Proper Collateral Ligaments Research Articles

Shifting the paradigm: ankylosis arthroplasty for the proximal interphalangeal joint with a novel collateral ligament reconstruction.

Silicone arthroplasty for proximal interphalangeal joint ankylosis is rarely performed, partly due to the potential for lateral joint instability. We present our experience performing proximal interphalangeal joint arthroplasty for joint ankylosis, using a novel reinforcement/reconstruction technique for the proper collateral ligament. Cases were prospectively followed-up (median 13.5 months, range 9-24) and collected data included range of motion, intraoperative collateral ligament status and postoperative clinical joint stability; a seven-item Likert scale (1-5) patient-reported outcomes questionnaire was also completed. Twenty-one ankylosed proximal interphalangeal joints were treated with silicone arthroplasty, and 42 collateral ligament reinforcements undertaken in 12 patients. There was improvement in range of motion from 0° in all joints to a mean of 73° (SD 12.3); lateral joint stability was achieved in 40 out of 42 of collateral ligaments. High median patient satisfaction scores (5/5) suggest that silicone arthroplasty with collateral ligament reinforcement/reconstruction should be considered as a treatment option in selected patients with proximal interphalangeal joint ankylosis.Level of evidence: IV.

Morphometric Evaluation of Collateral Ligaments of the First Metacarpophalangeal Joint

Introduction The collateral ligaments of the first metacarpophalangeal (MCP) joint provide stability to the thumb. Injury to these collateral ligaments occurs more commonly in sports accidents leading to joint instability, weakness in pinch and grip strength. Normal morphometric measurements of collateral ligaments are essential for primary repair or reconstruction of the injured ligament. Hence, the objective of the study is to give the detailed morphometric profile of the proper collateral ligaments of the MCP joint of the thumb.Materials and Methods A total of 55 adult cadaveric hands were included in the study taken from 18 male (36 hands) and 10 female (19 hands) cadavers. Out of 55 hands, 28 belonged to the left side, while 27 were of the left side. The MCP joints were dissected to expose the collateral ligament complex. The length and width of the proper ligaments were measured.Results Both the proper collateral ligament attachments and the direction of the fibers were defined. Overall length and the width of both the proper collateral ligaments showed no statistically significant difference of mean between the left and the right sides. However, the length of both the proper collateral ligaments is significantly less in females compared with the males.Conclusion The morphometric details of the proper collateral ligaments obtained from this study would be useful for hand surgeons during surgical correction of the injured collateral ligaments either by primary repair or reconstruction with a tendon graft.

Rotational stability test for the diagnosis of radial collateral ligament rupture in the fingers: Anatomical study

Diagnosing rupture of the radial collateral ligament (RCL) of the finger metacarpophalangeal (MCP) joints is difficult. The aim of this cadaver study was to validate a rotational test for the MCP after RCL transection. With the MCP and proximal interphalangeal joints in flexion, rotation along the axis of the proximal phalanx was applied through an extended distal interphalangeal joint to 36 cadaver fingers. Each finger's pulp described an arc of pronation and supination that was noted on the palm. The test was repeated three times: before transection, after transection of the proper collateral ligament (CL) and after transection of both the proper and accessory CLs. Rotational arcs were measured in pronation and supination. Mean length of the pronation arc after transection of the main RCL was 17.53mm, while it was only 12.41mm before transection for the supination arc. Mean length of the pronation arc after transection of both CLs was 22.83mm compared to only 11.93mm before transection. Our results show a significant difference in pronation stability of the MCP joint after transection of the RCL proper. We can conclude that this rotational stability test is a valid test for diagnosing RCL rupture in MCP joints.

In Vivo Length Changes of the Proximal Interphalangeal Joint Proper and Accessory Collateral Ligaments During Flexion

To investigate the length changes in proper collateral ligament (PCL) and accessory collateral ligament (ACL) during flexion of the proximal interphalangeal (PIP) joint invivo and how portions of the PCL and ACL stabilize the PIP joint. We obtained computed tomography scans of the index, middle, and ring fingers of one hand from 6 volunteers at 0°, 30°, 60°, 90°, and full flexion of the PIP joint. Radial and ulnar PCL and ACL were measured and analyzed with computer modeling. The data showed that during flexion the average length of the dorsal portion of the radial and ulnar PCL increased significantly and reached a maximum at 90°. The volar portion of the radial and ulnar PCL and the distal portion of the radial and ulnar ACL shortened continuously from extension to full flexion. The proximal and middle portions of each ACL are nearly isometric, the dorsal portion of each PCL becomes taut only in flexion, and the volar portion of PCL and the distal portion ofACL become taut only in extension. The current findings indicate that the dorsal portion of PCLis the most stabilizing structure during flexion of the PIP joint, and that the volar portion of PCL and the distal portion of ACL provide the crucial lateral stability to the joint at extension. The results may provide information relevant to the ligaments of PIP joint reconstruction and rehabilitation.

Anatomic double-bundle reconstruction with free tendon graft for chronic ulnar instability of the thumb metacarpophalangeal joint.

Failed primary treatment of thumb metacarpophalangeal ligament injuries may lead to chronic instability. Different treatments have been described such as secondary ligament suture, fusion, dynamic or static procedures. Techniques to restrain the joint stability with various grafts of different configurations have been published, but most of these address only the proper collateral ligament. Experimental data revealed the importance of the accessory collateral ligament in stabilizing the metacarpophalangeal joint. In a former, true anatomic ligament reconstruction a bone-tendon graft was used; the tendon was split longitudinally to reconstruct both parts of the collateral ligament. This technique was modified by the author: a resorbable interference screw was used to fix a free tendon graft double in the metacarpal head, creating 2 identical bundles for reconstruction of both the proper and the accessory collateral ligament. The results of the first 10 patients with chronic ulnar instability in their otherwise intact thumb are reported. The mean follow-up was 15 months. Eight patients had excellent result and 2 patients had good result according to the Glickel grading system. The mean loss of motion in the metacarpophalengeal joint was 9% and the mean loss of pinch strength was 9% compared with the contralateral thumb. The technical details, pitfalls, complications, and rehabilitation are described in this paper.

Role of Collateral Ligaments in Metatarsophalangeal Stability: A Cadaver Study

Lesser metatarsophalangeal joint (MTPJ) instability is a common complaint. The role each of the collateral structures play in maintaining joint stability is unknown. Twenty-six fresh-frozen cadaver lesser MTPJ's were tested for instability with the amount of force necessary to translate the joint 3 mm dorsally. Specimens were tested with 1) intact collateral ligaments, 2) transected accessory collateral or proper collateral ligaments (ACL or PCL), 3) repaired ACL or PCL, 4) transected ACL and PCL, 5) repaired ACL and PCL, and 6) transferred interosseous (IO) tendon. Student t-tests were performed to test for statistical significance (p value less than 0.05). The mean force required for 3 mm of dorsal displacement was 25 ± 13 N (range, 11 to 52 N) in the 26 specimens. Transecting either the ACL alone or the ACL and PCL led to the most instability versus transecting the PCL alone. Repairing both ligaments improved stability. The IO tendon transfer was comparable to the direct repair of the PCL but was inferior to the direct repair of the ACL. Both ACL and PCL have a stabilizing effect on the MTPJ. However, the ACL was more important since primary transection of the ACL led to more instability and additional transection of the PCL in an ACL deficient model did not lead to significantly more instability. Direct repairs of both structures improved the stability of the joint but not back to normal. IO tendon transfer is a possible adjunct to collateral ligament repairs, but in itself is not sufficient to restore stability.

Anatomy of the Thumb Metacarpophalangeal Ulnar and Radial Collateral Ligaments

To describe the origin and insertion of the ulnar (UCL) and radial collateral ligaments (RCL) of the thumb metacarpophalangeal (MCP) joint. We dissected 18 UCLs and 18 RCLs from fresh-frozen human cadaveric thumbs. We removed all soft tissue overlying the MCP joint, isolating the proper collateral ligaments. We detached the collateral ligaments from the bone while marking their origin and insertion points and measured these attachment sites in relation to bony landmarks by digital photo analysis. The center of the UCL origin at the metacarpal was 4.2 mm from the dorsal surface and 5.3 mm from the articular surface. The dorsal aspect of the metacarpal origin site was 2.1 mm from the dorsal edge of the metacarpal. The center of the phalangeal insertion was 2.8 mm from the volar surface and 3.4 mm from the articular surface. The volar aspect of the phalangeal insertion site was 0.7 mm from the volar edge of the phalanx. The center of the RCL origin at the metacarpal was 3.5 mm from the dorsal surface and 3.3 mm from the articular surface. The dorsal aspect of the metacarpal origin site was 1.5 mm from the dorsal edge of the metacarpal. The center of the phalangeal insertion was 2.8 mm from the volar surface and 2.6 mm from the articular surface. The volar aspect of the phalangeal insertion site was 0.5 mm from the volar edge of the phalanx. Our study accurately defined the origin and insertion sites of the UCL and RCL of the thumb MCP joint. An accurate definition of the anatomical origin and insertion points of the thumb MCP UCL and RCL may allow for more successful surgical repair and reconstruction.

Anatomy of the Collateral Ligaments of the Proximal Interphalangeal Joint

To study and clarify the anatomy of the proper collateral ligaments and accessory collateral ligaments of the proximal interphalangeal joint. The collateral ligaments of 8 proximal interphalangeal joints were dissected under an operating microscope to gain an appreciation of their fiber direction and the anatomy of their origin and insertion. Two undissected joints were studied histologically. The proper collateral ligament was found to arise widely from dorsal and proximal to and from the fovea on the side of the head of the proximal phalanx and insert for some distance on most of the side of the base of the middle phalanx. The ligament is stout and its fibers are oriented parallel to the middle phalanx in all positions of the joint. The accessory collateral ligament was found to be a less substantial structure lying between the proper collateral ligament and the volar plate. The anatomy shown by this study is quite different from that shown in most of the anatomic and hand surgery literature, particularly in line drawings.

THUMB COLLATERAL LIGAMENT INJURIES

This anatomic and clinical study leads to the following conclusions: 1. The ulnar and radial proper collateral ligaments are the critical lateral stabilizers of the thumb MP joint; both are highly vulnerable to complete disruption, with resultant disabling joint instability. 2. The intrinsic anatomy of the radial side of the MP joint is not a mirror image of the ulnar aspect. Significant anatomic differences account for distinctive patterns of instability. Whereas disruption of the ulnar collateral ligament in conjunction with dorsal capsular tears is apt to result in combined radiovolar subluxation, disruption of the radial collateral ligament, coupled with the unopposed dynamic force of the adductor pollicis, characteristically is prone to a rapid pathologic sequence of profound joint instability, with progressive ulnar and volar subluxation and, ultimately, degenerative joint disease. 3. Optimal management of the complete collateral ligament lesion requires prompt diagnosis, most accurately confirmed with physical and radiographic stress testing, and precise surgical repair. Immobilization alone is insufficient treatment for these serious ligament disruptions, characterized by considerable displacement with wide separation of torn ends. 4. Although early direct repair affords the best opportunity for restoration of joint integrity with a highly favorable functional recovery, secondary repair and free tendon grafting, prior to joint deformity, provide consistently successful options for chronic instability.

High resolution magnetic resonance imaging of the proximal interphalangeal joints: Correlation with histology and production of a three-dimensional data set

The magnetic resonance imaging appearance of the proximal interphalangeal joints of cadavers was correlated with histology of the same specimen allowing many small-scale features to be identified that might otherwise have been misinterpreted. It enabled the magnetic resonance signal to be understood at a tissue and cellular level, allowing identification of synovial folds extending from the extensor tendon and volar plate, the entheses of the proper collateral ligament, the epitenon of the flexor tendons and the presence of osteophytes and sites of cartilage erosion. The main difficulties in matching two-dimensional magnetic resonance images with histology were the differing section thicknesses of the two methods and shrinkage of histological specimens. There are many advantages in producing high resolution three-dimensional datasets-the magnetic resonance section thickness is reduced and the individual components of the joint can be viewed simultaneously in two or more planes. A unique magnetic resonance atlas of three dimensional joint structure is presented.

Injuries of the Ulnar Collateral Ligament of the Thumb Metacarpophalangeal Joint

In an effort to determine whether valgus stress testing of the thumb metacarpophalangeal joint is predictive of a torn and displaced ulnar collateral ligament, anatomic and prospective clinical studies were performed and the results correlated. In the anatomic study on autopsy specimens, dividing the proper collateral ligament resulted in a significant increase in valgus instability of the flexed metacarpophalangeal joint. Significantly less laxity was noted when the joint was tested in extension. When the accessory collateral ligament/palmar plate complex was also divided, valgus instability in extension increased to the extent that it no longer differed significantly from the values obtained when the joint was tested in 30 degrees flexion. In the clinical study, valgus instability of greater than 35 degrees when the joint was positioned in extension and then stressed consistently indicated the presence of tears of the proper and accessory collateral ligaments: A Stener's lesion was present in 15 of 17 such cases (87%). Values on valgus stress testing of the metacarpophalangeal joint in extension and 30 degrees flexion are highly predictive of both disruption and displacement of the ulnar collateral ligament of the thumb.