Valgus Angulation Research Articles

Coronal plane stability of cruciate-retaining total knee arthroplasty in valgus gonarthrosis patients: A mid-term evaluation using stress radiographs.

Total knee arthroplasty (TKA) using implants with a high level of constraint has generally been recommended for patients with osteoarthritis (OA) who have valgus alignment. However, studies have reported favorable outcomes even with cruciate-retaining (CR) implants. To evaluate the coronal plane stability of CR-TKA in patients with valgus OA at the mid-term follow-up. Patients with primary valgus OA of the knee who underwent TKA from January 2014 to January 2021 were evaluated through stress radiography using a digital stress device with 100 N of force on both the medial and lateral side. Gap openings and degrees of angulation change were determined. Descriptive statistical analysis was performed for both continuous and categorical variables. Inter-rater reliability of the radiographic measurements was evaluated using Cronbach's alpha. This study included 25 patients (28 knees) with a mean preoperative mechanical valgus axis of 11.3 (3.6-27.3) degrees. The mean follow-up duration was 3.4 (1.04-7.4) years. Stress radiographs showed a median varus and valgus gap opening of 1.6 (IQR 0.6-3.0) mm and 1.7 (IQR 1.3-2.3) mm and varus and valgus angulation changes of 2.5 (IQR 1.3-4.8) degrees and 2.3 (IQR 2.0-3.6) degrees, respectively. No clinical signs of instability, implant loosening, or revision due to instability were observed throughout this case series. The present study demonstrated that using CR-TKA for patients with valgus OA of the knee promoted excellent coronal plane stability.

An ex vivo sequential ligament transection model of flatfoot

BackgroundThe ligaments implicated in the earliest stages of developing a progressive collapsing foot deformity are poorly understood. Commonly employed cadaveric flatfoot models are created from simultaneous transection of multiple ligaments, making it difficult to assess early changes in pressure distribution from ligaments critical for maintaining load distribution. A serial transection of ligaments may provide insight into changes in pressure distribution under the foot to identify a potential combination of ligaments that may be involved in early deformities. MethodsSpecimens were loaded using a custom designed axial and tendon loading system. Plantar pressure data for the forefoot and hindfoot were recorded before and after six sequential ligament complex transections. FindingsSectioning the plantar fascia (first) and short/long plantar ligaments (second) failed to generate appreciable differences in load distribution. Dividing the spring ligament (third) led to changes in hindfoot load distribution with a shift towards the lateral column indicative of hindfoot valgus angulation. All subsequent conditions resulted in similar patterns in hindfoot plantar load distribution. An anterior shift in the center of pressure only occurred after transection of all six ligament complexes. InterpretationLoss of the plantar fascia and short/long plantar ligaments are not critical in maintaining plantar load distribution or contact area. However, the additional loss of the spring ligament caused notable changes in hindfoot load distribution, indicating the combination of these three ligament complexes is particularly critical for preventing peritalar subluxation. Minimal changes in load distribution occurred when performing additional transections to reach a complete flatfoot deformity.

Chronic Deltoid Insufficiency in Stage IV Adult Acquired Flatfoot Deformity: Do We Have a Good Answer?

Stage IV adult acquired flatfoot deformity (AAFD) with secondary chronic deltoid ligament insufficiency is a challenging deformity to treat, with minimal consensus in the literature concerning its surgical management. Many surgical treatment options have been described, including joint-sparing techniques, fusions, osteotomies, and even arthroplasties. However, questions remain as to what, if any, treatment is optimal. This contribution reviews studies on surgical treatments for stage IV AAFD with deltoid ligament failure and provides a critical analysis regarding the quality of outcomes reported for those different treatment options. PubMed and Google Scholar databases were searched between June 1, 2022, and August15, 2022, for studies published between 1990 and 2022 that describe the treatment of stage IV AAFD with deltoid ligament insufficiency. Articles included in the study focused on subjects with stage IV AAFD and associated deltoid ligament insufficiency undergoing surgical correction. Exclusion criteria included stage I, II, and III AAFD, as well as deltoid ligament repair following acute injury/rupture. Nine studies covering five different treatment options for patients with stage IV AAFD and chronic deltoid insufficiency were included, with minimal overlap in outcome measures used to assess the efficacy of the procedure. Triple arthrodesis with deltoid ligament reconstruction resulted in a 62.5% (5/8) success rate with a residual tibiotalar (TT) angulation of 2°(success defined as <3°). Tibiotalar arthrodesis of four patients resulted in an average post-operative tibiotalar angulation of 4.8°with all patients showing progressive destabilization of the hindfoot complex at 12-18 year follow-ups. Deltoid arthroscopic laminoplasty (Brostrom) resulted in an increased American Orthopaedic Foot and Ankle Society (AOFAS) score from 49.7 pre-op to 91.9 post-op. There was no long-term follow-up of these patients. Deltoid ligament reconstruction using autografts of the peroneus longus resulted in a post-operative valgus of 2.1°in one study and <5°in another. Deltoid ligament reconstruction using an anterior tibial tendon autograft resulted in a gain of 126.4 + 40.2% in stiffness compared to an intact ligament. Twinfix suture anchors resulted in a post-operative hindfoot angle averaging 5.3°. Combined deltoid and spring ligament reconstruction resulted in a 5.1°valgus angulation. There is currently no standard of care or clinical consensus regarding surgical treatment for stage IV AAFD with deltoid insufficiency. Several studies imply that mild valgus malalignment around the tibiotalar joint can result in satisfactory outcomes. A few studies even deemed <5°of valgus tilt post-operatively successful. However, it has been described that any imbalance in tibiotalar tilt is a significant risk factor for progressive arthritis and future ligamentous failure. No treatment option was able to correct valgus tilt to an anatomical standard (i.e., to normal anatomy). These varied findings, along with the lack of consensus on post-surgical measures to assess efficacy, are worrisome and emphasize the need for better surgical options. Moreover, there is a critical need for additional research on the long-termoutcomes following stage IV AAFD and deltoid insufficiency repair, particularly, as over five million people in the United States and 10% of the geriatric population are affected by AAFD with a risk of progressing to stage IV.

432 Ligament Engagement and In-Situ Force During Multiplanar Loading of the Medial Knee Ligaments

OBJECTIVES/GOALS: Load sharing across the arc of knee flexion of the medial knee ligaments (MKLs) is not well understood. The goal of this research is to characterize ligament engagement and in-situ force within the deep and superficial medial collateral ligament (dMCL, sMCL) and the posterior oblique ligament (POL) in response to externally applied multiplanar loads. METHODS/STUDY POPULATION: Ten human cadaveric knees, 5 male and 5 female, age 32±7 (25-42) [mean±SD (range min-max)] years, were mounted to a force sensor and a 6-degree-of-freedom robotic arm. Knee kinematics, before and after serial dissection of the sMCL, dMCL, and POL, were recorded from 0-30 degrees during applied isolated external rotation, valgus angulation, and anterior tibial moments, and the force (Newtons, N) borne by each structure was measured via the principle of superposition. Loads in the dMCL, sMCL, and POL will be compared across each knee and at each flexion angle with paired t-tests and repeated-measures analysis of variance with Tukey post hoc testing. Ten knees will provide &gt;99% power to detect differences of 5N ± 3% at p=0.05, which is considered the threshold for clinically meaningful force differences. RESULTS/ANTICIPATED RESULTS: Our anticipated results include characterization of the means and standard deviations of the in-situ forces within the dMCL, sMCL, and POL in response to externally applied valgus angulation, tibial external rotation, and anterior-directed tibial loading at 0, 15, and 30 degrees of knee flexion. Our statistical analysis will determine if there are clinically meaningful differences (5N ± 3%) in the loads within each ligament at different knee flexion angles and will also provide data regarding differential relative ligament engagement for each applied force scenario, which is an indication of the percentage of contribution that each structure contributes to knee stability during application of forces and torques to the knee. DISCUSSION/SIGNIFICANCE: Data on ligament engagement and in-situ forces will help clinicians better diagnose potentially injured ligaments when they observe pathological knee laxity in an injured patient. Our results will also inform future computer modeling studies on injury mechanisms, individual anatomical variability, and surgical planning.

The lateral stability of the knee, A review of the clinical Anatomy of the Popliteal hiatus and its clinical pathologies

As a modified hinge joint, the knee joint facilitates the erect posture and greater mobilization of the human body. Varusvalgus angulation, external-internal rotation, and anteriorposterior stability are primarily maintained by the tibial bony eminences, menisci, and the congruencies of the femoral and tibial articular surfaces. The primary restrainer for the valgus angulation is the medial collateral ligament (MCL). The primary restrainer for varus angulation is the lateral collateral ligament (LCL). Even though the LCL is the principal lateral stabilizer for the knee, it is supported by the surrounding ligaments, muscles, and tendons. Non -uniformity in the nomenclature of these structures and complexity in the anatomical arrangements lead to complexity of understanding and clinical interpretation. The popliteus is a very small muscle but a unique muscle to the knee with specialized functions. It is highly vulnerable to injuries during trauma with posterior lateral corner injuries of the knee. Proper history of the injury and clinical assessment will help in a proper diagnosis. However acute pain in the knee may interfere with a proper clinical diagnosis. During total knee arthroplasty, special care should be taken to minimize the iatrogenic popliteal ligament injuries during bone cuts and lateral release in soft tissue gap balancing.

Demographic heterogeneity in valgus angulation of the proximal ulnar canal in relation to the flexion-extension axis.

The long-term outcome of total elbow arthroplasty remains unsatisfactory because of loosening and polyethylene wear, which could be caused by malpositioning of the ulnar component. When introducing an ulnar component, 2 different angles should be considered in the coronal plane: the valgus angulation of the proximal ulna in relation to the flexion-extension axis (FE-axis) and the intramedullary varus angulation in relation to the FE-axis. Currently, available TEA designs may not always be able to reconstruct the FE-axis because of the morphologic variability of the ulna. This study aimed to determine the demographic variability of the ulna and the relation between the 2 angulations in the frontal plane based on 3-dimentional computed tomography (CT) reconstructions of the elbow joint of healthy volunteers. Computed tomography scans of 36 left elbows of healthy volunteers were obtained (20 men and 16 women). The scans were segmented and analyzed using the Mimics Research 20.0 software. A local coordinate system was created based on the FE-axis of the elbow and the ulna's longitudinal axis. The measurements were conducted using the 3-Matic Research 12.0 software. The valgus angulation of the proximal medullary canal was on average 16° in men but 12° in women and ranged between 5° and 21°. The varus angulation of the medullary cavity could be determined at 57 mm in men and 64 mm in women from the FE-axis. This angulation was on average 10° in men and 7° in women. There was no significant correlation between this angle and the length of the ulna or the point of varus angulation. This study found a wide range of valgus angulation of the proximal ulnar canal in relation to the FE-axis. The available elbow implant designs are discordant with the mean valgus angulation of the proximal ulna found in this study, and the valgus laxity of the implants does not cover the variability in the population.

Posterior-stabilized versus mid-level constraint polyethylene components in total knee arthroplasty.

Mid-level constraint designs for total knee arthroplasty (TKA) are intended to reduce coronal plane laxity. Our aims were to compare kinematics and ligament forces of the Zimmer Biomet Persona posterior-stabilized (PS) and mid-level designs in the coronal, sagittal, and axial planes under loads simulating clinical exams of the knee in a cadaver model. We performed TKA on eight cadaveric knees and loaded them using a robotic manipulator. We tested both PS and mid-level designs under loads simulating clinical exams via applied varus and valgus moments, internal-external (IE) rotation moments, and anteroposterior forces at 0°, 30°, and 90° of flexion. We measured the resulting tibiofemoral angulations and translations. We also quantified the forces carried by the medial and lateral collateral ligaments (MCL/LCL) via serial sectioning of these structures and use of the principle of superposition. Mid-level inserts reduced varus angulations compared to PS inserts by a median of 0.4°, 0.9°, and 1.5° at 0°, 30°, and 90° of flexion, respectively, and reduced valgus angulations by a median of 0.3°, 1.0°, and 1.2° (p ≤ 0.027 for all comparisons). Mid-level inserts reduced net IE rotations by a median of 5.6°, 14.7°, and 17.5° at 0°, 30°, and 90°, respectively (p = 0.012). Mid-level inserts reduced anterior tibial translation only at 90° of flexion by a median of 3.0 millimetres (p = 0.036). With an applied varus moment, the mid-level insert decreased LCL force compared to the PS insert at all three flexion angles that were tested (p ≤ 0.036). In contrast, with a valgus moment the mid-level insert did not reduce MCL force. With an applied internal rotation moment, the mid-level insert decreased LCL force at 30° and 90° by a median of 25.7 N and 31.7 N, respectively (p = 0.017 and p = 0.012). With an external rotation moment, the mid-level insert decreased MCL force at 30° and 90° by a median of 45.7 N and 20.0 N, respectively (p ≤ 0.017 for all comparisons). With an applied anterior load, MCL and LCL forces showed no differences between the two inserts at 30° and 90° of flexion. The mid-level insert used in this study decreased coronal and axial plane laxities compared to the PS insert, but its stabilizing benefit in the sagittal plane was limited. Both mid-level and PS inserts depended on the MCL to resist anterior loads during a simulated clinical exam of anterior laxity.

EFFECT OF DYNAMIC HINDFOOT VALGUS DEFORMITY FOLLOWING INTRAMEDULLARY FIXATION OF TIBIA AND CONSERVATIVELY MANAGED PROXIMAL AND MIDDLE 1/3RD FIBULAR FRACTURES ON ANKLE FUNCTION RETROSPECTIVE STUDY

Objective: Evaluate Effect of dynamic hindfoot valgus deformity following intramedullary xation of tibia and conservatively managed proximal and middle 1/3rd bular fractures on ankle function Retrospective study The study involve Design: Materials and methods : d 20 patients who had undergone conservative management for proximal to middle one-third (except distal one-third level) bular fracture and who had unilateral middle and distal one-third tibial fractures treated by anatomic reduction and interlocking intramedullary nail xation. The Outcome Measures: Knee Injury and Osteoarthritis Outcome Score (KOOS) and the Foot and Ankle Disability Index Score were used to calculate functional outcome ratings for each patient. In addition, Mean Length of bula and Mean hindfoot valgus was observed. 20 patients were studied The mean Results: KOOS score was 86.5, and the mean FADI score was 89.4. [8,9] The statistical difference in FADI and KOOS in cases of operated side and the contralateral side were statistically insignicant leading to the conclusion that the occurrence of the hindfoot valgus angulation does not cause any functional impairment of the ankle. The increase in calcaneal valgus on the clinical hindfoot examination was a mean of 6 compared to that of the other extremity. Fibular shortening was identied in 14 cases and mean bular shortening was found to be 1.1 cm. Dynamic hindfoot Conclusions: valgus deformity is a foreseen complication in cases of distal diaphyseal fractures of tibia treated with intramedullary nailing along with conservatively managed concurrent proximal and middle third bular fractures. This deformity is predominantly seen in cases where bular shortening occurs but its effect on the ankle function is almost unhindered.

Emerged donor limb growth morbidity and malalignment after combined ipsilateral tibial and fibular cortical harvest graft in children. Early follow-up report.

The quantity of bone grafts required in certain pediatric conditions is sometimes substantial. This retrospective study details the radiological changes occurring in the donor leg and ankle following the simultaneous harvest of large diaphyseal cortical grafts from the tibia and fibula in 14 children (16 legs). The following preoperative and follow-up radiological parameters were measured and compared for donor legs: the longitudinal continuous regeneration of fibula, distal fibular station, medial proximal tibial angle, lateral distal tibial angle, posterior proximal tibial angle (PPTA), anterior distal tibial angle and interphyseal angle (tibia diaphyseal angulation) in both coronal and sagittal planes. Additionally, the impact of fibular regeneration in combined harvests was separately analyzed. Children were operated at the mean age of 52 months. Mean follow-up of 25.2 months was available. At follow-up, the donor tibia healed completely in all legs whereas fibular regeneration was complete only in 10 legs (62.5%). At follow-up, ankle valgus was present in 6 out of 16 legs (37%) and tibia valga increased in all legs except one (94%). Procurvatum was present in 7 legs. The fibular nonregeneration group was prone to ankle valgus deformity ( P = 0.014), valgus angulation of tibial diaphysis ( P = 0.0076) and lower mean PPTA ( P = 0.026) when compared to the regenerate group. There was a complication of stress fracture in one donor tibia. Combined tibial and fibular harvest is a major surgical undertaking in children. The donor limbs have their share of complications postharvest, more so when the fibula remains nonregenerated. Serial monitoring of donor sites is emphasized.

Trilogy of Covid-19 pandemic inactivity, Vitamin D deficiency and Genu Valgus knee deformation: Indolent manifestation of concern in preadolescents

The Covid-19 pandemic has affected the health in myriad ways. The direct affection may lead to respiratory infection. An indirect effect of Covid-19 has manifestations on the physical, mental and behavioural attributes in majority of the age groups. The forced restrictions, limited activities, and changed lifestyle have aggravated the deleterious effects of the sedentary lifestyles. The management of the physical activity for all age groups especially pre-adolescents took a relative back-seat during the Covid-19 restrictions with no immediate suggestions for an active treatment protocol strategy. The clinicians in general, emphasised on the conservative measures to manage the increased incidence of vitamin deficiency and osteopenia majorly with consultations based on telecommunication without clinical evaluation. The subsequent delayed assessment showed a profound negative impact amongst the pre-adolescents with significant progression of knee deformation and increased outpatient clinic presentation of genu valgus for management in later phase of pandemic. This has posed a unique Covid-19 post-pandemic manifestation of concern.The trilogy of Covid-19 restrictions induced poor physical activity, vitamin-D deficiency, and deformation of knees to valgus angulation have crippling effect in the pre-adolescent age-group. The delay in timely identification and medical management for the pre-adolescents has aggravated the joint deformation compromising the functional outcomes. The orthopaedic surgeons are now challenged and burdened to manage pre-adolescents knee deformity for corrective medical and surgical measures. On literature review, the guidelines are sparse for the paediatric orthopaedic management. The silent worsening with increased morbidity presents a matter of substantial concerns.An individualized management strategy for pre-adolescents is strongly recommended to manage this “silent” morbidity.

Talar Arthroscopic Reduction and Internal Fixation (TARIF): A Novel All-Inside Soft-Tissue-Preserving Technique.

Talar Arthroscopic Reduction and Internal Fixation (TARIF): A Novel All-Inside Soft-Tissue-Preserving Technique.

A method for measuring muscle strength in restraining valgus joint angulation: Elbow varus muscle strength against valgus loading

Skeletal muscle works as a dynamic joint stabilizer, assisting the underlying ligaments in restricting joint angulation by actively resisting external loads. Despite its clinical importance, little is known about the muscle strength required to produce torque to help ligaments restrict joint angulation within the physiological range permitted by the joint structure. In this study, we introduce a method for measuring the strength of the elbow musculature in restraining valgus angulation and present the values obtained in 20 healthy young men. Each participant was fastened to a Biodex dynamometer, with the elbow joint flexed to 90° and the varus-valgus axis aligned to the dynamometer’s rotation axis. Maximal voluntary isometric ramp contraction of shoulder internal rotators was performed while the humeroulnar joint gap was monitored with an ultrasound apparatus. The largest torque recorded while the humeroulnar joint gap did not exceed a predetermined individualized threshold was considered to be the elbow varus strength of the participant. The elbow varus strength of the dynamic stabilizer was found to be 41 ± 12 Nm, which agreed with the value estimated by our musculoskeletal model. The inter-operator reliability test indicated excellent reliability (ICC (2,1) = 0.91). These findings suggest that the present method is valid for measuring the strength of the elbow musculature in restraining the valgus angulation. Measurements of this aspect of strength are expected to provide insights for understanding and preventing elbow injuries.

Predictive factors for the development of Gartland type IV supracondylar humerus fractures: a prospective clinical study.

This study aimed to identify the preoperative predictive factors for the development of Gartland type IV supracondylar humerus fracture based on the patient characteristic, fracture mechanism, and preoperative radiographic fracture characteristics. This prospective study included the data of 120 patients with Gartland type III and IV supracondylar humerus fractures treated in a single center from 2020 to 2021. Patients' age, gender, height/weight percentile values, injury mechanisms, the proximity of fracture fragment to the skin (i.e., dimple sign), and time from trauma to surgical treatment were recorded. In the preoperative radiographs, the degree of extension or flexion deformity between fracture fragments in the sagittal plane, varus/valgus angulation between fracture fragments in the coronal plane, the amount of translation (medial or lateral) in the coronal plane, and the amount of osseous apposition between fracture fragments in the coronal plane were evaluated. With the authors' consensus, the patients were divided into 2 groups based on the presence of multidirectional instability during the intraoperative reduction: group 1 (Gartland type III; 99 patients) and group 2 (Gartland type IV; 21 patients). Fixation of the fractures was then completed. Significant differences were observed between groups in the valgus/varus angle and amount of osseous apposition (P < .001). Although no significant difference was found in terms of translation amount between the groups (P=.088), there was a significant correlation with medial translation in type IV fractures (P < .001). The correlation between the results and the groups was checked with Spearman's test. Medial translation (r=0.352), varus or valgus angulation (r=0.616), and osseous apposition (r=0.433) exhibited a positive correlation. The probability of type IV fracture was modeled for the preoperative parameters using binary logistic regression. The regression analysis showed that the diagnosis of type IV supracondylar fractures could be predicted, if varus or valgus angulation was more than 25.5° (81% sensitivity, 85% specificity, odds ratio=1.725; 95% CI=1.170-2.541, P=.001, r=0.616) and if the amount of osseous apposition was more than 9.5 mm (85% sensitivity, 81% specificity, odds ratio=1.471; 95% CI=0.714-3.029, P=.001, r=0.433) in the preoperative radiographs. There was also a significant correlation between medial translation (varus angulation) (P < .001, r=0.352), age (P=.019, r=0.255), and patients with more than 90 height/weight percentile values (P < .001, r=0.508) with the possibility to have Gartland type IV fractures. This study has found some preoperative factors that may be relevant for type IV Gartland fractures. Height/weight values greater than the 90 percentile, varus or valgus angulation greater than 25.5°, bone apposition values greater than 9.5mm, medial translation values greater than 11mm, and older than eight years patients type IV fractures were more common in such patients. If surgeons can more accurately diagnose a Gartland type IV fracture preoperatively, the surgeon can more accurately inform the patient and plan better treatment. Level II, Diagnostic Study.

Treatment of High Energy Tibial Plateau Fractures with Hybrid External Fixation

Objective: The current study aimed to assess the treatment results of high energy tibial plateau fractures with hybrid external fixation. Methodology: It included 20 adult patients (17 males and 13 females). At emergency rooms, patients were clinically and radiologically evaluated according to standard protocols, then the assessment was completed and treatment was started in the inpatient department. Preoperative preparation was completed according to standard protocols. Then, the surgical fixation was performed and the patient scheduled for postoperative evaluation. Radiological evaluation had been achieved by anteroposterior and lateral X-ray of the knee and leg. Computed tomography and Doppler ultrasound were requested for specific patients when indicated. Routine laboratory investigations were carried out. All operations carried out under spinal anesthesia. The 1st follow up visit was at the 2nd week postoperative, and follow up was done every 2 weeks. In each visit, patient was assessed clinically and by radiological investigations. Results: Five patients (25 %) had excellent, 8 patients (40%) had good, 2 patients (10 %) had fair, 5 patients (25%) had poor final result. In addition, 13 patients (65%) had no varus or valgus angulation, 18 patients (90 %) had 0-5mm limb shortening, 14 patients (70 %) had normal knee range of motion, 12 patients (60 %) had no pain and 14 patients (70 %) had normal gait. Two patients had non-union treated by removal of Ilizarov, proximal tibial locked plate, autologous iliac bone graft. 6 patients had multiple degrees of stiffness treated by physiotherapy and had fair, good outcomes, 3 patient had Pin track infection treated by surgical debridement with good outcome, 1 patient had deep vein thrombosis DVT treated by anticoagulant medication. Conclusion: Hybrid external fixation is a safe and effective treatment modality for tibial plateau fractures.

Stabilizing effect of an elbow orthosis with an adjustable hinge axis after lateral collateral ligament injury: A biomechanical study.

Current commercial elbow braces have a straight hinge that does not account for the native carrying angle of the elbow. The objective of this study was to determine the effectiveness of a custom-designed hinged elbow orthosis (HEO) with variable valgus angulations in stabilizing a lateral collateral ligament (LCL) deficient elbow. Eight cadaveric upper extremities were mounted in an elbow motion simulator in the abducted varus gravity-loaded position. The specimens were examined before and after simulated LCL injury and then with the addition of the custom-designed HEO with 0°, 10°, and 20° of valgus angulation. Kinematic data were recorded using an electromagnetic tracking system. The LCL injured state with or without the brace resulted in significant increases in varus angulation of the elbow compared to the intact state in both pronation and supination (P < 0.05). There were no significant differences in varus-valgus angulation or ulnohumeral rotation between any of the brace angles and the LCL injured state with the forearm pronated and supinated. The custom-designed HEO did not provide any additional stability to the LCL injured elbow. The varus arm position should be avoided during the rehabilitation of an LCL injured elbow even when an HEO is used.

A Biomechanical Comparison of the LaPrade Technique Versus a Novel Technique for Reconstruction of Medial-Sided Knee Injuries

Background: Medial-sided knee injuries can lead to symptomatic valgus laxity or anteromedial rotatory instability and may require surgery, particularly in the setting of cruciate tears and tibial-sided medial collateral ligament (MCL) avulsions. The LaPrade (LP) technique utilizes 2 free grafts to reconstruct the superficial MCL (sMCL) and the posterior oblique ligament (POL). An alternative MCL reconstruction devised by the senior author comprises an anatomic single-bundle reconstruction using a free graft to reconstruct the sMCL with advancement and imbrication of the posteromedial capsule/POL (MCL anatomic reconstruction with capsular imbrication [MARCI] technique). These techniques have not been biomechanically compared with one another. Purpose: To identify if one of these reconstruction techniques better restores valgus and rotational medial knee stability throughout the range of motion. Study Design: Controlled laboratory study. Methods: A total of 20 fresh-frozen, male (mean age, 43.7 years [range, 20-63 years]), midfemur-to-toe-matched cadaveric knees were utilized. All reconstructions were performed by a single fellowship-trained sports medicine surgeon. Left and right specimens within matched pairs were randomized to 1 of the 2 treatment groups: LP or MARCI. Each specimen was tested in 3 phases: (1) intact knee, (2) destabilized (MCL and POL completely severed), and (3) reconstructed (post-LP or post-MARCI reconstruction). We quantified valgus angulation defined by medial joint line opening, as well as internal and external tibial rotation at 0°, 20°, 30°, 60°, and 90° of knee flexion under applied external moments/torques at each phase. Results: There were significant differences between the MARCI and LP reconstruction groups in valgus stability compared with the intact state (P = .021), with the MARCI reconstruction more closely approximating the intact knee. There was no overall difference between the MARCI and LP reconstruction techniques for internal rotation (P = .163), with both closely resembling the intact state. For external rotation, the effect of the reconstruction technique was dependent on the knee flexion angle (P < .001). At the highest angles, there were no differences between reconstructions; however, for lower knee flexion angles, the MARCI technique more closely resembled the intact state. Conclusion: Although both techniques improved knee stability compared with destabilized conditions, the MARCI technique better approximated intact stability during valgus at knee flexion angles from 0° to 90° and external rotation loads at knee flexion angles ≤30° in a cadaveric model. Clinical Relevance: The MARCI technique provides an alternative option to improve valgus stability throughout the range of motion. It utilizes a POL advancement without the potential limitations seen in the LP technique, such as multiple tunnel complexity and collision, particularly in the multiple ligament–injured knee.

Minimally invasive plate osteosynthesis via posterior approach for type B and C fractures of distal humeral shaft: surgical tactics and a clinical series.

The optimal technique and implant for fixation of multifragmentary fractures of the distal humeral shaft remain inconclusive. We describe the use of minimally invasive plate osteosynthesis (MIPO) via posterior approach and extra-articular distal humerus locking compression plate (LCP-EADH) fixation for 18 such fractures. All fractures were united with a mean union time of 17.6weeks (range 12-20). Transient radial nerve palsy was demonstrated in 2 patients. Six patients had 5° varus angulation and 1 had 5° valgus angulation. Triceps power was Grade 5 in all patients. The mean arc of elbow motion was 127.5 degrees (range 115-140). Six patients had an excellent MEP score and 12 had a good MEP score. As the results, posterior MIPO and LCP-EADH fixation could be an alternative for multifragmentary fractures of the distal humeral shaft, particularly for fractures with a very short distal fragment.

Demographic Heterogeneity In Valgus Angulation Of The Proximal Ulnar Canal In Relation To The Flexion-Extension Axis

The aim of this study was to determine the relation and the demographic variability of three angulations of the ulna in the coronal plane (the valgus angulation of the proximal ulna in relation to the flexion-extension axis, the intramedullary varus angulation, and the valgus angulation of the complete ulna in relation to the FE axis).

Stable internal fixation with dual plate technique for osteoporotic distal femur fractures

BackgroundOsteoporotic distal femur fractures are difficult in terms of fracture treatment and recovery. We hypothesized that the minimally invasive plate osteosynthesis (MIPO) with dual plate technique increased fixation stability and encouraged early mobilization and return to pre-fracture activity. Material and methodsBetween 2016 and 2019, 22 patients were treated with the dual plate technique for osteoporotic distal femur fractures. To evaluate the clinical outcome, the modified Western Ontario and McMaster Universities (WOMAC) score, Tegner activity score, knee range of motion (ROM), time to pain free full weight bearing from operation and patient satisfaction score were used. To evaluate the radiological outcome, the time to radiological union and varus or valgus angulation were measured. ResultsThe mean modified WOMAC score was 37.0 ± 6.5 (range, 26–42). There was no significant difference between preoperative and postoperative Tegner activity score (p = 0.436). Among 22 patients, 16 patients (72.7%) achieved preoperative activity level. The mean knee ROM was 106.1° ± 16.8° (range, 80–135). The time to pain free weight bearing was 7.4 ± 1.5 (range, 5–10) weeks. In patient satisfaction, 20 patients (90.9%) were very satisfied or somewhat satisfied. Bone union was achieved in all patients at 16.4 ± 4.3 (range, 13–22) weeks. The final follow-up valgus angle was 3.6° ± 4.0° (range, −2.5° - 10.9). ConclusionMIPO with the dual plate technique can provide rigid fixation for osteoporotic distal femur fractures. This stable and rigid fixation may allow early mobilization and return to pre-fracture activity.

Lateral Patellar Luxation and Ehlers Danlos Syndrome (EDS) in a Dog

Background: Ehlers Danlos Syndrome (EDS) is a rare genetic disease characterized by a deficiency in collagen synthesis, which can result in joint laxity. Patellar luxation is one of the main orthopedic conditions that affect the canine knee joint, with limited descriptions of its association with EDS in dogs. The purpose of this report is to describe the surgical management and postoperative evolution of a 1-year-old Chow Chow dog with grade II patellar luxation, tibial valgus and EDS.Case: A 1-year-old Chow Chow dog was referred to the University Veterinary Hospital due to lameness of the left pelvic for 3 months. At the orthopedic examination were verified severe lameness and lateral deviation of the left stifle joint during the ambulation of the animal. Additionally, it was verified bilateral hyperextension of the tibiotarsal joint and grade II patellar luxation of both pelvic limbs with painful hyperextension of the left stifle joint. Radiographic evaluation showed lateral displacement of the patella from both femoral trochlear groove, and a valgus deviation of the proximal left tibial shaft. In addition, it was verified cutaneous hyperextensibility and an extensibility index suggestive of EDS. The animal was submitted to trochlear block resection technique and medial imbrication, followed by corrective tibial osteotomy. Furthermore, skin biopsies of the scapular and lumbar folds were performed during the corrective tibial osteotomy. The samples were sent for histopathological examination, which revealed fragmented and unorganized collagen fibers in the dermis. Histopathological findings were compatible with EDS. The absence of lameness and correct positioning of the patella in the trochlear sulcus were verified in the post-surgical follow-up. Complete bone consolidation of the closing wedge osteotomy to correct the tibial valgus was verified at 90 days postoperatively.Discussion: The clinical signs, cutaneous extensibility index, and histopathological abnormalities in the present case were consistent with EDS. In the present study, this congenital collagen abnormality syndrome may have been a contributing factor of patellar luxation as EDS can result in hypermobility of ligaments and joints, due to metabolic and structural abnormalities of the collagen in connective tissues, and consequently may promote patellar luxation and other orthopedic abnormalities. A variant of EDS in humans has been implicated in the development of skeletal abnormalities such as short stature and bone deformities. This corroborates the possibility that EDS is correlated with valgus angulation of the proximal portion of the tibia in the present case. However, in-depth genetic studies are required to confirm this correlation. Corrective osteotomy in conjunction with block recession sulcoplasty and medial imbrication seem to have enabled patellofemoral stability and alignment of the quadriceps mechanism, ensuring that the patella remained in the trochlear sulcus, even in the presence of EDS. In addition, this syndrome does not seem to affect the surgical outcome of the treatment of patellar luxation associated with closed wedge osteotomy for tibial valgus correction. Medium-term follow-up can be considered excellent in this case report since there was a rapid resolution of lameness and adequate corrective osteotomy healing despite persistent hyperextension of the tibiotarsal joint. Ehlers Danlos Syndrome did not contraindicate the surgical treatment of patellar luxation. However, further studies are needed to assess the influence of the syndrome on long-term patellar luxation. The findings of this case report can help in the diagnosis and treatment of other animals affected by this rare syndrome and associated orthopedic diseases.Keywords: patellar luxation, bone, collagen diseases.