Varus Stress Research Articles

Posterolateral Instability of the Elbow in an Adolescent Boy with a Lateral Epicondyle Fracture: A Case Report

Posterolateral rotatory instability of elbow is considered to be due to the disruption of the ulnar part of the lateral collateral ligament (LUCL). This instability pattern may also be induced by a fracture of components of the lateral column. We present the case of a 16-year-old boy who fell on his left outstretched arm as he attempted to jump over a tennis net. On initial physical examination, the elbow had instability found on varus stress and the radial head could be felt posteriorly. With attempted valgus and supination force combined with axial loading, the elbow gapped open and the patient had a sense of increased instability. X-rays showed a fracture of the lateral humeral epicondyle and posterolateral subluxation of the elbow. In the operating room, the patient was found to have reproducible posterolateral instability of the elbow. The lateral epicondyle was found to be fractured off the humerus with the LUCL still attached to the fragment. The elbow was reduced, and the injury was stabilized with small screws and suture anchors. At 6-month follow-up, the patient was pain-free, and physical examination revealed 170° of flexion, full extension, 90° of pronation, and 65° of supination. X-rays showed healing of the fracture with concentric reduction of the elbow joint. In lateral epicondyle fractures, the affected elbow should be assessed for any signs of associated instability. If signs of clear instability are seen that would prohibit proper postinjury rehabilitation, then surgical reduction and fixation of the epicondyle with reinforcement of the LUCL is an effective method of treatment.

Fibular Collateral Ligament Anatomical Reconstructions

Background After the development and biomechanical validation of an anatomical fibular collateral ligament reconstruction using a semitendinosus graft, this technique has subsequently been applied clinically. Hypothesis An anatomical reconstruction of a grade III fibular collateral ligament tear using a semitendinosus graft restores the knee to near-normal lateral compartment stability and results in improved patient outcomes. Study Design Case series; Level of evidence, 4. Methods A prospective study of 20 patients with an average age of 24 years (range, 16-45 years) who had an anatomical reconstruction of the fibular collateral ligament using a semitendinosus graft was performed. All patients were preoperatively and postoperatively evaluated with the modified Cincinnati and International Knee Documentation Committee (IKDC) subjective scoring systems, with the IKDC objective subscores for lateral and posterolateral knee stability and with varus stress radiographs. The patients were followed for an average of 2 years. Results Sixteen patients were available for follow-up. Six of the patients had an isolated fibular collateral ligament reconstruction. The average preoperative modified Cincinnati score was 28.2, and the average IKDC subjective score was 34.7. Postoperatively, there was a significant improvement of both the modified Cincinnati score (to 88.5) and the IKDC subjective outcome score (to 88.1). The Cincinnati component symptom and functional subscores were also evaluated. The average preoperative symptom subscore was 9.1 and the functional subscore was 19.1. Postoperatively, there was a significant improvement in both scores; symptom subscores improved to 43.0 and functional subscores improved to 45.5. Preoperative varus stress radiographs demonstrated an average differential of 3.9 mm (range, 2.5-6.2 mm) of lateral compartment gapping between the injured and noninjured knee. At an average of 2 years postoperatively, varus stress radiographs demonstrated an average side-to-side lateral compartment gap differential of —0.4 mm. Conclusion An anatomical fibular collateral ligament reconstruction using a semitendinosus graft results in improved patient outcomes and near-normal lateral compartment stability in patients with grade III injuries of the fibular collateral ligament.

Stress radiography for osteoarthritis of the knee: a new technique

Stress radiographs have been used for several years to detect the amount of varus/valgus knee laxity and to evaluate the degree of compartmental involvement in degenerative osteoarthritis. However, the popularity of these radiographic methods has been affected by their technical limits due to the x-ray exposure for the personnel involved and the variability of the stress forces applied. A device was developed with the aim to create a constant varus or valgus stress force to the knee with the patient in a supine position. The device does not require personal assistance during the actual film taking. Sixty consecutive patients where included in the study and measured prior to their total knee replacement. All patients had standard weight-bearing AP and lateral views as well as stress views in varus and valgus. Both knees were examined in full extension and 30° of flexion. The joint space width in both the lateral and medial compartments were measured and subsequently compared with the standard weight-bearing films. A significant decrease in joint space distance in the affected compartment was found in the stress radiographs compared with the standard weight-bearing views. The medial compartment was best examined with the knee extended and varus stress force (P<0.001) and for the lateral compartment 30° of flexion proved to be more efficient (P<0.01). In conclusion, this stress radiographic device offers a possibility to enhance the varus/valgus force in a standardized way compared to standard weight-bearing views of the knee. The reliability and reproducibility is high. It is suitable for clinical practice and a valuable tool in research.

Long-Term Outcome of Patients Treated Surgically for Traumatic Knee Dislocation: Does the Injury Pattern Matter?

Aims: To examine the difference in outcomes of patients treated surgically for traumatic knee dislocation with regard to different injury patterns. Methods: All patients who underwent reconstruction/repair of the cruciates and primary complete repair of collaterals, posterolateral, and posteromedial corner structures were allocated to 3 groups (group A: bicruciate injury with associated medial side injury [n = 31]; group B: bicruciate injury with associated lateral injury [n = 20]; group C: bicruciate injury with associated medial and lateral injury [n = 23]). Outcome was assessed at a mean of 12 years postoperatively using the International Knee Documentation Committee (IKDC) score, Short Form-36 (SF-36) health survey, Lysholm score, Tegner score, visual analog scale (VAS) pain score, and Knee Society score. Anterior-posterior laxity was also measured (KT1000™ arthrometer; Medmetric Corp., San Diego, CA), and Pearson's correlation was used to compute associations between variables (P < 0.05). Results: The mean time to return to work was 6 ± 4 months in group A, 13 ± 19 months in group B, and 11 ± 12 months in group C. At final follow-up, 7 patients had a pain VAS of > 3 (group A: 6 patients; group B: 0 patients; group C: 1 patient). Seven patients could not flex their knee > 110° (group A: 4 patients; group B: 0 patients; group C: 3 patients). Eighteen patients (24%) presented with an extension deficit of > 5°. Valgus stress testing was > 3 mm in 12 patients (group A, 3 patients; group B, 4 patients; group C: 5 patients). Varus stress testing was > 3 mm in 9 patients (group A: 4 patients; group B: 3 patients; group C: 2 patients). The dial test at 30° showed < 6° (normal) and 6° to 10° (nearly normal) in 64 patients, and > 10° (abnormal) in 10 patients (group A: 4 patients; group B: 2 patients; group C: 4 patients). At 90° flexion, the difference was < 10° in 70 patients and > 10° in 4 patients (group A, 1 patient; group B: 1 patient; group C: 2 patients). Normal/nearly normal IKDC score values were found in 19 patients in group A, in 12 patients in group B, and in 14 patients in group C. There were no significant differences in outcome between the groups, except patients with an injury of the lateral collateral ligament and/or the peroneal nerve who had a greater need for workers compensation (P < 0.01). Conclusion: Early complete 1-stage reconstruction/repair showed good subjective and functional results with restoration of working capacity, independent from the location of associated injuries (medial, lateral, and medial and lateral). A peroneal nerve lesion resulted in significantly poorer outcome.

Clinical and radiological outcomes after management of traumatic knee dislocation by open single stage complete reconstruction/repair

BackgroundThe purpose of our study was to analyze the clinical and radiological long-term outcomes of surgically treated traumatic knee dislocations and determine prognostic factors for outcome.MethodsRetrospective consecutive series of patients treated surgically for traumatic knee dislocation with reconstruction/refixation of the anterior (ACL) and posterior cruciate ligaments (PCL) and primary complete repair of collaterals and posteromedial and posteromedial corner structures. 68 patients were evaluated clinically (IKDC score, SF36 health survey, Lysholm score, Knee Society score, Tegner score, visual analogue scale - VAS pain and satisfaction, Cooper test) and radiologically (weight bearing and stress radiographs) with a mean follow up of 12 ± 8 years. Instrumented anterior-posterior translation was measured (Rolimeter, KT-1000). Pearson correlation and stepwise regression analysis was used.Results82% of patients (n = 56) returned to their previous work. At final follow-up 6 patients (9%) suffered from pain VAS > 3. The mean side-to-side difference of anterior/posterior translation (KT-1000, 134N) was 1.6 ± 1.6 mm and 2.6 ± 1.4 mm. Valgus and varus stress testing in 30° flexion was <3 mm (normal) in 57 patients (86%). The IKDC score was normal/nearly normal in 38 (58%) patients and the mean Lysholm score 83 ± 17 (intact 98 ± 7). The median Tegner score decreased from 7 preinjury (range 3-10) to 5 at follow-up (range 0-10). The mean Knee Society score was 187 ± 15 (out of maximum 200). In 7 patients (10%) a secondary ligament reconstruction was performed. Three patients (4%) underwent a high tibial osteotomy and four (6%) received a primary unconstrained total knee replacement. According to the Kellgren Lawrence osteoarthritis score only mild degenerative changes were present. The stress radiographs showed stable results for anteroposterior translation. Injury of the lateral collateral ligament, refixation of the ACL/PCL and delayed surgery >40 days were significantly associated with worse outcome (p < 0.05).ConclusionsEarly complete reconstruction can achieve good functional results and patient satisfaction with overall restoration of sports and working capacity. Negative predictive factors for outcome were injury pattern, type of surgical procedure and timing of surgery.

Anterolateral Transtibial PCL Reconstruction Combined with Reconstruction of Posterolateral Corner Insufficiency: Comparison of Single-bundle vs Double-bundle PCL Reconstruction over a 2-6 Year Period (SS-45)

There is a paucity of clinical studies comparing single- and double-bundle posterior cruciate ligament (PCL) reconstruction combined with posterolateral corner reconstruction. The purpose of this study is to compare the clinical outcomes of single- and double-bundle transtibial PCL reconstruction combined with reconstruction of the lateral collateral ligament (LCL) and popliteus tendon for posterolateral corner insufficiency. The study population consisted of 42 patients who had undergone PCL reconstruction between March 2002 and July 2006, and for whom a minimum of two years of follow-up data were available. We compared clinical outcomes of two surgical techniques: a single-bundle technique with remnant preservation (23 patients, single-bundle group) or a double-bundle technique (19 patients, double-bundle group), each combined with reconstruction of the lateral collateral ligament and popliteus tendon for posterolateral corner insufficiency. There were no difference between the single- and double-bundle groups in the mean side-to-side difference of posterior translation measured with Telos stress radiography (4.2 ± 1.7 vs. 3.9 ± 1.6 mm, p = 0.628), and rates greater than 5 mm were 22% in single-bundle group and 21% in double-bundle group. Regarding the posterolateral rotatory laxity, there were no differences between the two groups in the mean side-to-side difference in the dial test. (5.3° ± 2.7° vs. 5.1° ± 2.4° at 30°, p = 0.801; 6.7° ± 2.7° vs. 6.7° ± 2.4° at 90°, p = 0.917), or in varus stress radiography (1.2 ± 1.2 mm vs. 1.3 ± 1.4 mm, p = 0.722). The Lysholm knee scores were 85.7 ± 7.6 in the single-bundle group and 87.7 ± 7.3 in the double-bundle group (p =0.392). There was a trend of no difference between the groups in IKDC knee score (p =0.969). The rates of abnormal and severely abnormal categories in IKDC were 30% in single-bundle group and 26% in double-bundle group. Double-bundle PCL reconstruction combined with posterolateral corner reconstruction does not appear to have advantages over remnant preserving single-bundle PCL reconstruction combined with posterolateral corner reconstruction with respect to the clinical outcomes or posterior knee stability.

Comparison of Posterolateral Corner Reconstructions Using Computer-Assisted Navigation

This study evaluated different fibular-based reconstruction techniques for grade III posterolateral corner (PLC) injuries. Seven fresh-frozen cadaveric knees were used in this study. A surgical navigation system was used to determine varus opening and external rotation at 0 degrees , 30 degrees , and 60 degrees with a 9.8-Nm varus stress and 5-Nm external rotation stress applied to the tibia. Intact and disrupted PLC knees were used as controls. Four different fibular-based reconstruction techniques were evaluated. The femoral attachments consisted of a single- or double-tunnel technique, and the fibula attachment consisted of an anteroposterior or oblique tunnel technique. Sectioning of the PLC resulted in an increase in varus and external rotation at all flexion angles. All reconstruction techniques restored varus and external rotation stability compared with the PLC-deficient state, but the single-femoral tunnel reconstruction with an anteroposterior fibular tunnel did not restore varus or external rotation stability at 30 degrees and 60 degrees . No reconstruction technique overconstrained the knee at any flexion angle. A double femoral tunnel with an oblique fibular tunnel best restored native knee kinematics to the lateral side of the knee. Although there are many different techniques to reconstruct the PLC-deficient knee, this study suggests that a single-graft, fibular-based reconstruction that replicates the femoral insertions of the lateral collateral ligament and popliteus will be able to restore varus and external rotation stability to the knee.

Posterolateral Corner Reconstruction of the Knee

Background: Injuries to the posterolateral corner of the knee remain a challenging problem and have been cited frequently as a reason for failure of anterior and posterior cruciate ligament reconstructions. Although several reconstructive techniques currently exist, there are relatively few clinical outcomes data after reconstruction of the posterolateral corner. Purpose: The study was undertaken to examine the clinical outcomes and provide objective data using arthrometry and stress radiography of a posterolateral corner reconstruction technique. Study Design: Case series; Level of evidence, 4. Methods: A retrospective cohort study of a consecutive series of patients who underwent posterolateral corner reconstruction of the knee was evaluated. The surgery featured dual femoral tunnels, a transfibular tunnel, and a free graft to reconstruct the posterolateral corner of the knee. All patients had concomitant reconstruction of one or both cruciate ligaments. Outcomes were assessed using the Short Form–12, Lysholm, and Tegner knee scores. A clinical examination, KT-2000 arthrometry measurements, single-legged hop quotient, and varus and posterior Telos stress radiographs were obtained and compared with results for the contralateral, uninjured knees. Results: Twenty-four (83%) of 29 consecutive patients were evaluated at a mean 39 months postoperatively (range, 24-81 months). The mean Lysholm and Tegner knee scores were 83 and 6, respectively. The mean difference (± standard deviation) in total anterior-posterior side-to-side KT arthrometry measurements was 1.4 ± 1.3 mm. The varus stress radiographic mean side-to-side difference measured at 20° of flexion was 0.2 ± 1.9 mm. The mean radiographic posterior tibial displacement with a 15-kg stress at 90° of flexion was 3.2 ± 4.5 mm in patients undergoing posterior cruciate ligament reconstruction. Conclusion: This reconstruction of the posterolateral corner of the knee with concomitant cruciate ligament reconstruction restores varus and rotational stability at a minimum of 2 years postoperatively.

Knee Injury- Football

HISTORY: An 11 yo middle school football player presented with complaints of right knee pain while playing football. He reported difficulty running secondary to inability to extend his knee fully. PMH was significant for injury four months ago, when a motorcross bike landed on the front of his knee after falling off during a jump. The patient was transported to ED at time of injury. X-rays of right knee reported as unremarkable. The patient also seen by an orthopedic surgeon later that week then ordered an MRI. The MRI reported as normal. The patient wore a brace initially, but had not worn it over the last few months. Although he had swelling at time of injury, patient denied swelling. Since initial injury, patient reported he had never regained full ROM of knee. He denies any radiating symptoms or hip pain. Initial MRI was unavailable for review. PHYSICAL EXAMINATION: (Right knee) No effusion was appreciated. Patient had tenderness to palpation along lateral femoral condyle, LCL, and lateral joint line. Patient reported pain in the posterolateral corner with passive knee extension. Patient had a loss of approximately 30 degrees of knee extension. The right knee was stable with valgus and varus stress at 30 degrees. Anterior and posterior drawer test were negative. Patient demonstrated guarding with McMurray's and Lachman's test. Sensation was intact. 2+ dorsalis pedis and posterior tibial pulses were palpated. Patient had full PROM of right hip. DIFFERENTIAL DIAGNOSIS: Lateral meniscus tear Posterolateral corner injury Articular cartilage injury Occult fracture Hip abnormality TEST AND RESULTS: AP/LAT/Sunrise radiographs of right knee: - Small bony avulsion noted adjacent to lateral femoral condyle MRI right knee: - Avulsion of the popliteus tendon from popliteal hiatus. - ACL,PCL, MCL, and LCL ligaments are intact - Popliteal fibular ligament is intact. - Medial and lateral meniscus are intact - Articular cartilage is intact - No effusion is present Final/Working Diagnosis Isolated popliteus tendon avulsion Treatment and Outcomes Activities restricted ROM exercises with Physical therapy started at 4 months post injury Patient regained full, painless ROM after 1 month of physical therapy. Patient released for full activity and return to play. Patient doing well five months post injury with all sports.

Locking Knee in a Football Player

HISTORY: 16 y.o. high school sophomore football player sustained a knee injury while running in a game. During the second quarter of a midseason football game, he suddenly experienced locking and pain of his left knee. No clear mechanism of injury known. After being escorted off the field he was examined by the team orthopaedic surgeon. His left knee was manipulated by fully flexing the knee and applying varus stress while extending the knee. There was an audible "clunk". The player successfully performed sideline drills pain free and he returned to the game. Repeat exam following the game revealed only lateral joint line tenderness. MRI of the knee was performed with normal findings. He was placed in a long hinged knee brace for play. Subsequently, during a regular practice session, he again experienced pain and locking of the same knee while running. He was re-examined by the orthopaedic surgeon, the left knee reduced with an audible "clunk", and returned to play. PHYSICAL EXAM: Exam on the sidelines revealed no swelling, effusion, or bruising. The left knee lacked 20 degrees of full extension. There was pain with forced extension. He had tenderness along the lateral joint line. Lachman negative. Anterior and Posterior Drawer were negative. Varus and Valgus stress at 0 and 30 degress were negative. Mcmurray negative. Neurovascularly he was intact. After manipulation of the knee by fully flexing the knee and then extending while applying varus stress to the knee, there was an audible "clunk" and the patient's pain resolved. Re-examination was within normal limits. Differential Includes: Meniscal Tear Hypermobile Meniscus Discoid Meniscus TEST AND RESULTS: MRI of the knee revealed intact medial and lateral meniscus, intact cruciate and collateral ligaments, and normal bony anatomy. Otherwise normal MRI of the knee. FINAL WORKING DIAGNOSIS: Hypermobile lateral meniscus Treatment: Conservative care including a hinged knee brace restricting motion between 0 and 90 degrees. He has continued to play in a hinged brace restricting his motion without further reoccurrence. Definitive treatment involves arthroscopic examination and manipulation to further define the problem and potentially secure the lateral meniscus.

Clinical Case Knee Injury - Football

HISTORY: A 19 year old male lacrosse and football athlete presented with a one year history of right knee pain. The pain started after playing pick-up basketball. He was running for general exercise the next day, when he came to an abrupt stop associated with severe pain, and he fell to the floor. Pain was located over the inferior aspect of the right patella and proximal patellar tendon. He denied any numbness, paresthesias, or weakness in the right lower extremity, or swelling of the right knee joint. He was treated with PTO brace and physical therpay without significant improvement. PHYSICAL EXAMINATION: On inspection, he has mild pes planus, the right patella is internally rotated. Full PROM, with anterior knne pain on full flexion. With single leg squat, he had valgum movement of the knees bilaterally. He was tender to palpation over the inferior pole of the patella and proximal patellar tendon. He was not tender to palpation over the quad tendon, medial/lateral joint lines, medial/lateral patellar borders, or tibial tuberosity. There was no laxity noted with valgus or varus stress testing. Mcmurray, Lachman, Anterior and Posterior Drawer tests negative. Muscle strength was full. Sensation intact through all dermatomes. Muscle stretch Reflexes symmetric in the patella and Achilles. DIFFERENTIAL DIAGNOSIS: 1.Patellar Tendinosis 2.Patellar tendon rupture 3.Chondromalacia patella/Patellofemoral pain 4.Prepatellar Bursitis TEST AND RESULTS: Ultrasound Exam: large partial intrasubstance tear of medial aspect of the proximal patellar tendon MRI Right Knee: Partial tear/tendonitis of the proximal patellar tendon with associated thickening and edema. On the axial images, the tear is almost full thickness centrally. There is mild edema within the inferior pole of the patella. FINAL WORKING DIAGNOSIS: Partial Tear Right Patellar Tendon. TREATMENT AND OUTCOMES: •Platelet Rich Plasma injection using ultrasound guidance to the right patellar tendon •Rest × 2 weeks, followed by gradual increase in activity. •Patient reported 90% improvement at 5 weeks, tolerating running, swimming, and squats pain free.

Results of isolated posterolateral corner reconstruction

BackgroundIsolated posterolateral corner (PLC) tears are relatively rare events. Various surgical techniques to treat posterolateral knee instability have been described; because surgical results are linked to cruciate reconstructions it has been difficult to date to define whether one surgical procedure has better prognosis than another. The goal of this study is to determine the clinical outcome of PLC reconstruction following fibular-based technique.Materials and methodsWe retrospectively evaluated a case series of patients who received isolated PLC reconstruction between March 2005 and January 2007. Ten patients were surgically treated for isolated injuries and were available for follow-up; average patient age was 27.4 years (range 16–47 years). All patients were treated following the fibular-based technique: double femoral tunnel was performed in six patients, while in the remaining four patients, the reconstruction of the PLC was performed with a single femoral tunnel. Six patients had semitendinosus allograft and four had semitendinosus autograft. All patients had the same evaluation and the same rehabilitation protocol.ResultsMean follow-up was 27.5 months (range 18–40 months). Mean range of motion (ROM) was 143.5° for flexion (range 135–150°) and 0.5° for extension (range 0–3°). Three patients showed 1+ on varus stress test, while on Dial test another three patients showed 10° reduction of external rotation compared with contralateral knee. The average Lysholm score was 94 points (range 83–100), and the mean International Knee Documentation Committee (IKDC) subjective result was 88.48 (range 74–96.5). Based on Lysholm score, the results were excellent in eight knees and good in two knees. On IKDC evaluation, two patients were grade A and eight were grade B. No significant difference in clinical results was observed between single and double femoral tunnel.ConclusionFibular-based technique showed good results in terms of clinical outcome, restoring varus and rotation stability of knees in treatment of chronic isolated PLC injury.

Medial Complex Elbow Dislocation: An Unusual Pattern of Injury

A 47-year-old man sustained a medial complex dislocation of the right elbow. After initial evaluation, closed reduction was performed. On examination under general anesthesia, the elbow was unstable under varus and valgus stress. Computed tomography scan showed a medial epicondyle and a coronoid fracture. Both medial and lateral approaches were used to fix the epicondylar fragment, the coronoid fragment, and the complex damage to the soft tissues. Immobilization in a cast for 1 week followed by early motion in a dynamic orthosis resulted in a good outcome. Follow up at 2 years showed a range of motion of 110 degrees of flexion-extension and 170 degrees of pronation-supination. Radiographs showed no significant arthritis or heterotopic ossifications.

Combined reconstruction for posterolateral rotatory instability with anterior cruciate ligament injuries of the knee

If posterolateral rotatory instability (PLRI) injury in patients with a torn anterior cruciate ligament (ACL) is not diagnosed and treated, ACL reconstruction can fail. We retrospectively evaluated the clinical outcome after reconstructions between 2002 and 2007 of both the ACL and the posterolateral corner (PLC) in 44 knees with combined ACL and PLC injuries. The median follow-up duration was 49 months (range, 24-68 months). ACL reconstruction employed autogenous hamstring grafts from the ipsilateral knee. For grade II PLRI, a posterolateral corner sling through the fibular head was placed obliquely from the anteroinferior aspect to the posterosuperior aspect using autogenous hamstring grafts of the contralateral knee. Clinical outcomes were evaluated using the OAK (Orthopadishe Arbeitsgruppe Knie) and IKDC (International Knee Documentation Committee) knee scoring systems. Anterior stability was measured on pull stress radiographs using a Telos stress device and the manual maximum displacement test using a KT-1000 arthrometer with the knee flexed 30 degrees. PLRI was classified according to varus and rotational instability preoperatively and at final follow-up. Median OAK scores improved from 71 points (range, 48-86) to 93 points (range, 75-100). Satisfactory IKDC results were achieved in 39 knees (89%). As for anterior stability, as measured by anterior stress radiography, mean side-to-side displacement difference dropped significantly from 6.9 +/- 1.9 preoperatively to 1.4 +/- 1.1 mm at final follow-up. Forty patients (91%) had the same or better rotational stability compared to the normal side. Varus stress radiographs showed mean side-to-side displacement differences dropped from 1.8 +/- 1.7 preoperatively to 0.4 +/- 0.8 mm at final follow-up. Thus, chronic ACL deficiency is often accompanied by grade II PLRI and can be treated successfully by arthroscopic ACL reconstruction paired with posterolateral reconstruction employing a single sling through the fibular tunnel and a hamstring tendon autograft.

Diagnostic Ultrasound Evaluation of Posterolateral Corner Knee Injuries

The purpose of this study was to determine whether dynamic ultrasound (US) would be able to differentiate posterolateral corner knee injuries that would require surgical intervention. This is a single-group cohort study. A knee sonogram was obtained in patients referred to us with suspected posterolateral knee injury. In addition to static US imaging, a dynamic US stress test was performed by placement of maximum varus stress on the knee at 30 degrees of flexion. The tibiofemoral separation was then measured with US. Results from US and surgery were then compared. Sixteen patients had US and underwent surgery, and twelve patients had surgical findings requiring surgical intervention to the posterolateral knee structures. With regard to static US images, the sensitivity, specificity, negative predictive value, positive predictive value, and accuracy were 92%, 75%, 92%, 75%, and 88%, respectively, for the lateral collateral ligament; 33%, 100%, 100%, 33%, and 50%, respectively, for the popliteus; and 67%, 75%, 67%, 75%, and 69%, respectively, for the popliteofibular ligament. The dynamic US stress test showing 10.5 mm of lateral joint space width or more during varus stress showed a sensitivity of 83% and specificity of 100% for injury to the lateral collateral ligament and posterolateral corner structures, with a positive predictive value of 100%, negative predictive value of 75%, and accuracy of 88%. A positive dynamic US stress test (>or=10.5 mm) positively predicted the need for posterolateral knee surgery in 100% of patients in this study who required posterolateral corner repair or reconstruction. Level I, testing of previously developed diagnostic criteria in series of consecutive patients with universally applied gold standard.

Outcomes of the Modified-Brostrom Procedure Using Suture Anchor for Chronic Lateral Ankle Instability: a Prospective, Randomized Comparison with the Bone Tunnel Technique

Purpose: This study was performed prospectively and randomly to compare the clinical outcomes of modified-Brostrom procedures using the suture anchor and the bone tunnel for chronic lateral ankle instability. Materials and Methods: Thirty patients were followed up for more than 1 year after the modified-Brostrom procedures. Fifteen procedures treated with a suture anchor and 15 procedures treated with a bone tunnel technique assigned randomly were performed by a single surgeon. The clinical evaluation was performed according to the VAS for pain, the Karlsson scale and Sefton grading system. Measurements of the talar tilt and anterior talar translation was performed using anterior and varus stress radiographs. Results: There were no significant differences in the pain VAS between the 2 techniques postoperatively. However, the pain VAS at postoperative 4th day was significantly higher in the bone tunnel group. The Karlsson scale had improved significantly from a preoperative average of 45.2 points to 90.1 points in the suture anchor group, and from 44.6 points to 88.3 points in the bone tunnel group. According to the Sefton grading system, 13 cases (86.7%) in the suture anchor group and 12 cases (80%) in the bone tunnel group achieved satisfactory results. The talar tilt angle and anterior talar translation had improved significantly from preoperative average of and 6.2 mm to and 4.5 mm in the suture anchor group, from and 6.4 mm to and 4.2 mm in the bone tunnel group. There were no significant differences between 2 techniques. Conclusion: The techniques for ligament reattachment produced similar clinical and functional outcomes except for earlystage postoperative pain. Both modified-Brostrom procedures using the suture anchor and bone tunnel appear to be effective treatment methods for chronic lateral ankle instability. However, the suture anchor technique has an advantage of less early-stage postoperative pain.

Posterior root tear of the medial meniscus in multiple knee ligament injuries

The purposes of the present study were to examine the frequency and characteristics of root tears of the medial meniscus associated with ligament injuries of the knee and to evaluate the effectiveness of pull-out repair for restoring meniscus function. We retrospectively analyzed the 9 patients (10 knees) with posterior root tears of the medial meniscus and ligament injuries of the knee treated between August 2004 and February 2007. All the patients were male, with average age of 29.8 years, and the mean follow-up period was 29.7 months. The pull-out suture technique was used to repair the root tears. Clinical outcomes were evaluated using the Lysholm, IKDC, and Tegner scores, as well as the McMurray and Apley tests. The mean follow-up period was 41.1 months (range, 30 to 63 months). The incidence of root tears of the medial meniscus with ligament injuries was 2.74% (10 cases in 365 ligament surgeries). All clinical results showed significant improvement. At the final follow-up, McMurray test showed one positive and nine negative cases, and the Apley test revealed two positive and eight negative cases. There were no positive findings in anterior drawer test, posterior drawer test, valgus and varus stress test, and posterolateral instability test. Healing of the root tear was confirmed by arthroscopy in five patients and by MR in four patients. Root tears of the medial meniscus may occur in multiple knee ligament injuries. It is important not to miss them. Our results indicate that pull-out repair provides satisfactory results and evidence of healing.

Imaging of the Medial and Lateral Ligaments of the Knee

The knee is an inherently unstable structure consisting of rounded femoral condyles articulating with a flat tibial plateau. Stability is provided by a complex system of intra-articular and extraarticular ligaments that resist anterior and posterior translation, abnormal tibial rotation, and varus and valgus stress. In this article, the anatomy and biomechanics of the medial and lateral stabilizers, as well as the mechanisms of injury, clinical examination, and radiographic and magnetic resonance imaging appearances of injury of these structures, are discussed.

Ten-Year-Old Boy with a Recurrent Knee Effusion

Ten-Year-Old Boy with a Recurrent Knee Effusion

The Effect of Anteromedial Facet Fractures of the Coronoid and Lateral Collateral Ligament Injury on Elbow Stability and Kinematics

It is postulated that fractures of the anteromedial facet of the coronoid process and avulsion of the lateral collateral ligament lead to posteromedial subluxation and arthritis of the elbow. It is not clear which injuries require internal fixation and whether repair of the lateral collateral ligament is sufficient. We hypothesized that increasing sizes and subtypes of anteromedial facet fractures cause increasing instability and that isolated lateral collateral ligament repair without fracture fixation would restore elbow stability in the presence of small subtype-I fractures. Ten fresh-frozen cadaveric arms from donors with a mean age of 66.3 years at the time of death were used in this biomechanical study. Passive elbow flexion was performed with the plane of flexion oriented horizontally to achieve varus and valgus gravitational loading. An in vitro unconstrained elbow-motion simulator was used to simulate active elbow flexion in the vertical position. Varus-valgus angle and internal-external rotational kinematics were recorded with use of an electromagnetic tracking system. Testing was repeated with the coronoid intact and with subtype-I, subtype-II, and subtype-III fractures. Instability was defined as an alteration in varus-valgus angle and/or in internal-external rotation of the elbow. All six coronoid states were tested with the lateral collateral ligament detached and after repair. In the vertical position, the kinematics of subtype-I and subtype-II anteromedial coronoid fractures with the lateral collateral ligament repaired were similar to those of the intact elbow. In the varus position, the kinematics of 2.5-mm subtype-I fractures with the lateral collateral ligament repaired were similar to those of the intact elbow. However, 5-mm fractures demonstrated a mean (and standard deviation) of 6.2 degrees +/- 4.5 degrees of internal rotation compared with a mean of 3.3 degrees +/- 3.1 degrees of external rotation in the intact elbow (p < 0.05). In the varus position, subtype-II 2.5-mm fractures with the lateral collateral ligament repaired demonstrated increased internal rotation (mean, 7.0 degrees +/- 4.5 degrees; p < 0.005). Subtype-II 5-mm fractures demonstrated instability in both the varus and valgus positions (p < 0.05). Subtype-III fractures with the lateral collateral ligament repaired were unstable in all three testing positions (p < 0.05). This study suggests that the size of the anteromedial coronoid fracture fragment affects elbow kinematics, particularly in varus stress. The size of an anteromedial coronoid fracture and the presence of concomitant ligament injuries may be important determinants of the need for open reduction and internal fixation.