Varus Stress Research Articles

Ligaments of the knee

The ligaments of the knee can be divided into four groups. Ventral reinforcements are the patellar retinaculae. The posteromedial complex stabilizes the valgus stress. It consists of the medial collateral ligament, the thickened posteromedial capsule and a branch of the tendon of the semimembranosus muscle as well as the oblique popliteal ligament. On the lateral side the posterolateral complex protects the knee against varus stress. Here the lateral collateral ligament, the tendon of the popliteus muscle and the so-called popliteofibular fibres work together. The cruciate ligaments control the contact between femoral condyles and tibial plateau during flexion-extension of the knee. They course between the two layers of the capsule, the membranous and the synovial layer.

Knee Dislocation with Lateral Side Injury

Background Knee dislocations with lateral side injury are rare and disabling if not treated. Hypothesis An en masse surgical technique to repair the lateral side will provide good stability, and the posterior cruciate ligament will heal when left in situ. Study Design Case series; Level of evidence, 4. Methods Twenty-three patients underwent an en masse lateral side repair after knee dislocation injury; all but 1 patient had anterior cruciate ligament reconstruction. Physical examination included the International Knee Documentation Committee score, isokinetic strength testing, KT-2000 arthrometer testing, radiography (including varus stress), and magnetic resonance imaging scan. Patients were evaluated subjectively with several surveys. Results Mean objective evaluation occurred for 17 patients at 4.6 years postoperatively, and 21 subjective evaluations occurred for 21 patients at 5.6 years postoperatively. The objective overall grade was normal for 10 patients and nearly normal for 7 patients. Lateral laxity was graded as normal in 15 patients and 1+ in 2 patients. The posterior drawer was normal in all but 3 patients, who had 1+ posterior laxity. The postoperative varus stress radiography demonstrated a mean increase of 1.1 ± 1.7 mm (range, —1.2-4.7) between knees. Magnetic resonance scans showed that the lateral side was thickened but intact in all patients. The posterior cruciate ligament was viewed as healed or intact in all patients but was sometimes seen as elongated or buckled. The mean subjective total scores were 91.3 points for the IKDC survey, 93.0 for the modified Noyes survey, and 8.0 for an activity score, but scores were higher for patients who underwent surgery within 4 weeks from the injury. Conclusions The en masse surgical technique to repair the lateral side combined with an anterior cruciate ligament reconstruction after knee dislocation provides excellent long-term stability. The repaired lateral side and untreated posterior cruciate ligament heal with continuity. Patients can return to high levels of activity.

ACOMPARISON OF LOWER-BODY FLEXIBILITY, STRENGTH, AND KNEE STABILITY BETWEEN KARATE ATHLETES AND ACTIVE CONTROLS

The purposes of this study were to compare the lower-body flexibility, strength, and knee stability of karate athletes against that of non-karate controls and to determine whether regular karate training results in adaptations that may result in an increased risk for knee injury. Flexibility measurements included knee flexion and extension, hip flexion and extension, hip internal and external rotation, and foot inversion and eversion. Nine karate athletes (4 women and 5 men, age = 24.3 ± 6.7 years) and 15 active, non-karate controls (7 women and 8 men, age = 22.1 ± 3.2 years) participated. No subjects reported recent knee surgery or chronic or acute knee pain. Concentric quadriceps and hamstrings strength and endurance were measured using a Biodex II isokinetic dynamometer at 60° ·s-1 and 180°·s-1. Eccentric strength was measured at 150°·s-1 and 250 ft-lb (339 N·m). Knee stability was measured via varus and valgus stress and anterior drawer testing. Karate athletes demonstrated a significantly greater right hip flexion (p ≤ 0.05). Isokinetic testing demonstrated a significantly greater concentric right and left hamstrings peak torque at 60°·s-1, right hamstrings to quadriceps torque ratio at both 60°·s-1 and 180°·s-1, and a significantly faster time to peak torque in the hamstrings at 60°·s-1 in the karate athletes (p≤ 0.05). Eccentric isokinetic testing showed a significantly higher peak torque at 60°·s-1 in both the right and left quadriceps and hamstrings in the karate group compared to the controls (p ≤ 0.05). There were no significant differences in bilateral movement of the knees between the karate and control groups. The results indicate that this group of karate athletes may have demonstrated sport-specific adaptations in certain flexibility and strength measurements, but they showed no increased risk for knee injury.

Osteochondritis dissecans of the knee

Summary Osteochondritis dissecans (OCD) characterises a disease process predominately affecting male teenagers and young adults which, as its end-product, yields the separation of osteochondral fragments from the joint surface. Although OCD may occur in many joints, the knee appears to be by far the most commonly involved. Hence painful locking in a teenage knee should always raise the suspicion of OCD. The cause of the disease remains unclear and many theories have been developed, none of which has received unequivocal agreement. A multifactorial aetiology including elements of repetitive trauma and vascular insufficiency is henceforth considered most likely. The fundamental principle in the treatment of OCD is the timely recognition of the condition as lesions in the early disease process are more likely to be treated successfully. Proper initial assessment and grading of the lesion will allow for the right treatment protocol to be chosen. MRI may help in the staging process and in determining the lesions healing potential. Most cases fair well with conservative measures. In more advanced stages of the disease, surgical intervention ranging from subchondral drilling to fragment refixation may be required. The primary aim of any intervention is to achieve healing of the subchondral bone, and preservation of the articular cartilage as fragment separation may pave the way for subsequent development of osteoarthritis.

A Comparison of Lower-Body Flexibility, Strength, and Knee Stability Between Karate Athletes and Active Controls

The purposes of this study were to compare the lower-body flexibility, strength, and knee stability of karate athletes against that of non-karate controls and to determine whether regular karate training results in adaptations that may result in an increased risk for knee injury. Flexibility measurements included knee flexion and extension, hip flexion and extension, hip internal and external rotation, and foot inversion and eversion. Nine karate athletes (4 women and 5 men, age = 24.3 +/- 6.7 years) and 15 active, non-karate controls (7 women and 8 men, age = 22.1 +/- 3.2 years) participated. No subjects reported recent knee surgery or chronic or acute knee pain. Concentric quadriceps and hamstrings strength and endurance were measured using a Biodex II isokinetic dynamometer at 60 degrees .s(-1) and 180 degrees .s(-1). Eccentric strength was measured at 150 degrees .s(-1) and 250 ft-lb (339 N.m). Knee stability was measured via varus and valgus stress and anterior drawer testing. Karate athletes demonstrated a significantly greater right hip flexion (p <or= 0.05). Isokinetic testing demonstrated a significantly greater concentric right and left hamstrings peak torque at 60 degrees .s(-1), right hamstrings to quadriceps torque ratio at both 60 degrees .s(-1) and 180 degrees .s(-1), and a significantly faster time to peak torque in the hamstrings at 60 degrees .s(-1) in the karate athletes (p <or= 0.05). Eccentric isokinetic testing showed a significantly higher peak torque at 60 degrees .s(-1) in both the right and left quadriceps and hamstrings in the karate group compared to the controls (p <or= 0.05). There were no significant differences in bilateral movement of the knees between the karate and control groups. The results indicate that this group of karate athletes may have demonstrated sport-specific adaptations in certain flexibility and strength measurements, but they showed no increased risk for knee injury.

Treatment of Chronic Ankle Lateral Instability using Modified Brostrom Procedure

Purpose : To analyze the results of modified Brostrom procedure for chronic ankle lateral instability. Materials and Methods : Twenty six patients were followed up for more than 1 year after performing the modified Brostrom procedure. The mean age was 35.3 years, and the mean follow-up period was 2.4 years. Anterior and varus stress radiographs were taken in all cases, and a preoperative MRI was taken in 22 cases. Clinically, the Karlsson scale and Sefton grading were used. The effects of age, injury pattern and associated injury such as osteochondral fracture on the clinical results were analyzed. Results : Radiologically the difference in anterior displacement between the affected side and contralateral side was 3.1 mm, and that of the varus tilt was 4.2o. At the last follow-up, the Karlsson scale had increased from preoperative 47.5 points to 90.3 points. There were 14 excellent, 8 good, 3 fair and 1 poor results according to the Sefton grading. The results were significantly worse in patients over 50 years of age. An osteochondral fracture or degenerative changes also lowered the level of patient satisfaction. Conclusion : The modified Brostrom procedure appears to be a safe and highly satisfactory procedure. However, a more careful approach is needed for patients over 50 years of age or with associated degenerative changes.

PR_093: The Effect of Anteromedial Coronoid Fracture, and Lateral Collateral Ligament and Posterior Bundle of the Medial Collateral Ligament on the Stability of the Elbow to Varus Stress

Objective: To test cadaveric elbow specimens before and after anteromedial coronoid fractures followed by serial disruptions of the lateral collateral ligament (LCL) and medial collateral ligament (MCL) in order to assess the role of these individual structures in the stability of the elbow under varus loading. Design: Randomized controlled trial. Setting: Biomechanics laboratory. Cadavers: 14 fresh cadaveric elbow specimens divided into 5 groups: intact elbow (n=14), anteromedial coronoid fracture (n=14), anteromedial coronoid fracture with LCL (n=7) or posterior bundle of MCL disruption (n=7), and anteromedial coronoid fracture with both ligaments disrupted (n=14).

Elevation of medial tibial condyle for severe tibia vara

Clinical and radiological evidence of knee instability was used as criteria for elevation of medial tibial condyle in severe tibia vara. Restoration of tension to the exposed medial collateral ligament was used as a guide for the required amount of elevation. A second-stage proximal tibial osteotomy was performed later for correction of the remaining varus deformity. External fixators were used in all instances. Elevation of the medial tibial condyle is indicated in severe tibia vara with arrest of the medial tibial physis, in which more than a 10 degrees difference exists between valgus and varus stress radiographs with the knee in extension as compared with an opposite normal knee.

Measurement and comparison of the difference in normal medial and lateral knee joint opening

This paper reports the amount of medial and lateral knee joint opening in the general population. Knee joint lateral and medial opening at 20 degrees knee flexion was quantified on manual varus and valgus stress test, respectively, with custom made device. One hundred men and women between the ages of 20-60 years were evaluated for their joint openings. Patients with previous knee surgeries or chronic knee pains were excluded from the study. Measurements were done twice by two different orthopedic surgeons who were blinded from each other. The mean age of the study group was 39 years (range 20-60 years) and 43 years for women (range 20-60 years) and 34 years for men (range 20-60). The mean lateral and medial knee joint space opening was 7.0 degrees (range 3-9 degrees ) and 4.1 degrees (range 2-7 degrees ), respectively, in the overall population; in the male population, it was 6.7 degrees (range 3-9 degrees ) and 3.9 degrees (range 2-7 degrees ), respectively, and in the female population, it was 7.2 degrees (range 3-9 degrees ) and 4.3 degrees (range 3-7 degrees ), respectively. Conversion to displacement in millimetres, the overall mean lateral and medial joint displacement was 9.3 mm (range 5.1-13.6 mm) and 4.8 mm (range 3.5-10.7 mm), respectively; for males, it was 9.1 (range 5.1-11.9 mm) and 4.6 mm (range 3.5-7.9 mm), respectively, for females, it was 9.8 mm (range 7.2-13.6 mm) and 4.9 mm (range 3.7-10.7 mm), respectively. The prevalence of the overall population that exceeds 6 mm or more lateral joint space opening was 91% (male 90% and female 92%) and medial joint space was 8% (male 4% and female 12%). Statistically, significant differences were seen between medial and lateral opening in male, female and the overall population (p<0.001). The female population exhibited wider opening in both medial and lateral joint opening than the male population (p<0.05). The interexaminer reliability showed no significant difference (p>0.05). More than 91% of the Korean population showed wide lateral joint space opening in the bilateral knee. However, none complained of functional instability or symptoms except for non-pathologic laxity detected by the physician. We strongly recommend bilateral comparison of the knee that has wide lateral joint opening.

Patellofemoral Pain Syndrome in Tibetan Buddhist Monks

Patellofemoral pain syndrome is a common diagnosis in athletes and especially runners. This article discusses 3 cases of patellofemoral pain caused by pronounced inactivity and prolonged knee hyperflexion at altitude in a unique population of Tibetan Buddhist monks. In this case, the monks responded well to a program of activity modification and exercises.

Asymmetry of mediolateral laxity of the normal knee

BackgroundUnderstanding the normal kinematics of the joints is important for reconstructive surgery. However, only a few extensive studies have been done on medial and lateral laxity of the normal knee. MethodsRadiographs of 50 normal knees were obtained under varus and valgus stress in both extension and flexion and the relative angle of the articular surface was measured. ResultsIn extension, the mean angle was 4.9° in varus stress and 2.4° in valgus stress. In flexion, the mean angle was 4.8° in varus stress and 1.7° in valgus stress. Lateral laxity was significantly greater than medial laxity in both extension and flexion. ConclusionsLateral laxity may be necessary for the medial pivot movement of the normal knee. There is some disagreement regarding the importance of pursuing the perfect rectangular gaps during total knee arthroplasty (TKA). The methods for measuring the tension of soft tissues during the operation are not accurate and do not always reflect the postoperative tensions of dynamic phases, such as walking and standing. Slight lateral laxity can be accepted with TKA, and further studies are necessary to determine whether prosthesis lift-off occurs in the replaced knee with slight lateral laxity similar to that in the normal knee.

Knee Pain - Acute on Chronic - Football Player

HISTORY A 14 year-old male presented to sports clinic with a complaint of left knee pain for five days. The patient is an offensive guard for his high school freshman football team. He stated that his injury occurred when he stepped on another player's foot while walking backwards which caused him to hyperextend his knee. At that point, he was unable to continue playing secondary to pain. He later felt the pain localized laterally across the knee. He also experienced swelling the following day, along with a sensation of locking or clicking. He had increased pain with stair climbing. The patient did report a previous hyperextension injury of the left knee six months prior to presenting to clinic with residual pain and swelling. These symptoms resolved and he had played without any problems. PMH/PSH: Negative Medications: Ibuprofen prn pain. No supplements, herbs, vitamins or prescription drugs Allergies: NKDA PHYSICAL EXAMINATION The patient was in no acute distress, walking with a nonantalgic gait. Vitals: Temp= 98.7 Pulse = 70 RR = 16 BP = 130/70 Weight = 260 Height =6′2″ Examination of lower extremities: Active ROM full at the hip and ankle bilaterally. The left knee was lacking full extension while prone with a heel height difference of 4cm. A mild effusion was present at the knee joint. The Patella was non-tender. Negative patellar apprehension and grind tests. Normal patellar tracking and good VMO strength. Mild anterolateral joint line tenderness. No tenderness at fibular head or IT Band. McMurray's, Anterior and Posterior drawer and Lachman's tests were negative. Negative valgus and varus laxity at 0 and 30 degrees. Positive pain at lateral joint line with varus stress. Negative external rotation recurvatum test. Negative Ober's. Positive difficulty with squatting. Differential Diagnosis Meniscal Injury Lateral Collateral Ligament Injury Posterolateral Corner Injury Osteochondral Defect (OCD) Patellar Subluxation TESTS AND RESULTS Xrays Left knee plain films read by Radiology as normal. However, in clinic reviewed and found to have a cortical disruption with OCD in the anterior lateral aspect of femoral condyle MRI left Knee Large OCD involving the anterior aspect of the lateral femoral condyle with a loose body noted anterior to the insertion site of the ACL most likely arising from the site of the OCD. ACL, PCL, LCL, MCL and menisci intact. FINAL WORKING DIAGNOSIS OCD of lateral femoral condyle with loose body TREATMENT AND OUTCOMES Nonweightbearing and orthopedic referral Scheduled arthroscopy with loose body removal. Possible microfracture, possible cartilage biopsy, possible internal fixation.

Medial Knee Pain - Recreational Swimmer

HISTORY: A 42-year-old male physician and recreational swimmer presented with right knee pain. He had presented with right knee pain 1 year earlier after he slipped carrying a box, fell, and hyperflexed his knee. At that time he had minimal swelling, VMO pain, and was limited by pain with walking, squatting, or sitting with his knees bent. He complained of instability of the knee and tenderness to the medial joint line. MRI at that time revealed medial meniscus tear. He underwent arthroscopy for partial medial menisectomy of the posterior horn. Afterwards, his joint line pain resolved, but he continued to have pain localized to the VMO region with numbness and burning. Symptoms were constant, aching, and worsened by whip-kick motion with breast stroke, standing, knee bending, biking, and resting a portable computer on this area. He noted no skin rash, mottling, or temperature change. PHYSICAL EXAM Right knee with full ROM. Quad atrophy, including right VMO being slightly smaller than left. No palpable mass. No tenderness at VMO quadriceps or patellar tendon insertion, but tender over the VMO 1 inch from the insertion. Normal lower extremity reflexes. Decreased sensation along the medial knee from the joint line up to 10 cm proximal. Positive Tinel's sign at the adductor canal. Positive saphenous nerve stretch test. Lower extremity strength is 5/5 and equal. Plica band not palpable. No tenderness of the medial patellafemoral ligament, medial joint line, medial femoral condyle, or patella. Negative grind, Clark's sign, and lateral apprehension. Negative McMurray's. Lachman's and posterior drawer were normal. Varus and valgus stress were normal. Normal posterior tibialis pulse. Normal skin color and temperature. Arthroscope portal scars present, but not near the location of symptoms. DIFFERENTIAL DIAGNOSIS VMO tendinosis, saphenous nerve entrapment soft tissue or bone tumor (osteochondroma) lumbar radiculopathy (L3/L4) TESTS AND RESULTS Previous MRI knee – medial meniscus tear Knee Radiographs, 4 view – normal MRI thigh – normal FINAL WORKING DIAGNOSIS Saphenous Nerve Entrapment TREATMENT AND OUTCOMES Traditional PT and Augmented Soft Tissue Molibization 50% improvement, still restricted in activity of daily living. Steriod Injection at the Adductor Canal Marked immediate relief of symptoms, but minimal long-term improvement. Surgical consultation Neurontin/NSAIDS for conservative management. Some benefit, but patient elected saphenous nerve decompression. Operative findings included an area of serous fluid and pale area of nerve consistent with compression at the adductor canal. After the adductor canal was released his symptoms resolved.

Tensioning of Remnant Posterior Cruciate Ligament and Reconstruction of Anterolateral Bundle in Chronic Posterior Cruciate Ligament Injury

Posterior cruciate ligament (PCL) injuries have potential for intrinsic healing and several magnetic resonance imaging studies have reported that the PCL healed with continuity but also with residual laxity. The goal of our study was to introduce a new method and investigate the outcome of tensioning of the remnant PCL and reconstruction of the anterolateral (AL) bundle of the PCL using modified inlay technique. Therapeutic study. Forty-nine patients who underwent tensioning of the remnant PCL and reconstruction of the AL bundle of the PCL were evaluated 45.7 months (range, 24 to 78 months) on average after surgery. Tensioning was performed by distal transfer of the tibial attachment. The AL bundle of the PCL was reconstructed with 4 bundles of hamstring tendon (34 cases), bone-patellar tendon-bone graft (7 cases), or Achilles tendon allograft (8 cases), arthroscopically at the femoral tunnel and by the modified inlay technique through a posteromedial approach in the supine position. In 35 patients who had a combined posterolateral rotatory instability, the posterolateral corner reconstruction was performed. Stability was assessed by stress radiographs with the Telos device and maximal manual testing with KT-1000 arthrometer. The clinical results were assessed by IKDC and OAK scores. Physical examination was performed using the posterior drawer test, varus stress test, posterolateral drawer test, and dial test in 30 degrees and 90 degrees flexion. The average side-to-side difference of posterior tibial translation on posterior stress radiographs decreased from 10.4 +/- 2.1 mm to 2.2 +/- 1.0 mm. The average side-to-side difference in maximal manual test with the KT-1000 arthrometer also decreased from 8.2 +/- 1.5 mm to 1.9 +/- 1.0 mm. The final IKDC score was A in 10 (20.4%), B in 33 (67.3%), and C in 6 (12.2%) patients. The average OAK score improved from 63.3 +/- 8.3 to 91 +/- 7.3. Good clinical results and very good posterior stability were achieved with tensioning of the remnant PCL and reconstruction of the AL bundle using the modified inlay technique in chronic PCL injuries. With this technique, the surgeon can operate without changing the patient's position during surgery. Level IV, therapeutic study.

Tensioning of Remnant Posterior Cruciate Ligament with a Reconstruction of the Anterolateral Bundle in Chronic PCL Injuries

Purpose : This report introduces a new method for tensioning the remnant PCL with a reconstruction of the anterolateral (AL) bundle of the PCL using a modified tibial inlay technique with an assessment of the outcome of this method in chronic PCL injury. Materials and Methods : From January 1998 to August 2003, eighty six patients was underwent tensioning of a laxed remnant PCL with a reconstruction of the anterolateral bundle of the PCL. Of these, fifty two patients who were followed up for more than 2 years were evaluated. Tensioning was performed using a distal transfer of the tibial attachment with the posteromedial approach in the supine position. The AL bundle of the PCL was reconstructed with 4 bundles of a hamstring autograft or tibialis anterior tendon allograft. The stability was assessed objectively using stress radiographs with the Telos® device and the maximal manual test with the KT-1000 arthrometer. The clinical results were assessed by the IKDC (International Knee Documentation Committee) and OAK (Orthopadische Arbeitsgruppe Knie) scores. The posterior drawer test, varus stress test, posterolateral drawer test and dial test in 30˚ and 90˚ flexion were performed for a physical examination. Results : The average side to side difference of the posterior tibial translation in stress radiographs with the Telos® device decreased from 10.4±2.0 mm to 2.2±1.0 mm. The average side to side difference in the maximal manual test with the KT-1000 arthrometer also decreased from 8.2±1.5 mm to 1.9±1.0 mm. The final IKDC score was A in eleven (21.2%), B in thirty-five (67.3%) and C in six (11.5%) patients. The average OAK score improved from 64.3±8.9 to 90.8±7.2. Conclusion : Tensioning of the laxed remnant PCL with a reconstruction of the AL bundle in chronic PCL injuries showed good clinical results and excellent posterior stability.

Segond Fracture Revealed by Ultrasonography

Segond fracture is an eponym that refers to an avulsion fracture of the anterolateral margin of the proximal tibia, just below the lateral plateau. This fracture was described originally in 1879 by French surgeon Paul Ferdinand Segond (1851-1912) in cadaveric experiments. 1 On the anteroposterior view of the knee, the Segond fracture characteristically appears as a small elliptical bone fragment with its long axis oriented vertically, parallel to the proximal tibia. 2 Recognition of this fracture is important because it has a high association with other knee injuries, including anterior cruciate ligament (ACL) tears (75%-100% of cases) and meniscal tears (53%-75% of cases). 2 - 7 The Segond fracture results from excessive internal rotation and varus stress, which cause abnormal tension on the middle portion of the lateral joint capsule (ie, the lateral capsular ligament [LCL] of the knee) and therefore produce an avulsion fracture of the lateral tibial plateau. 1 - 4 The Segond fracture is usually diagnosed on anteroposterior radiographs of the knee; however, some fractures have subtle findings, and the avulsed cortical fragment may be difficult to detect on routine views. 8 At magnetic resonance (MR) imaging, focal bone marrow edema may be seen at the lateral tibial rim, but the bony fragment itself may be overlooked.4 To our knowledge, there is no report of ultrasonographic findings in Segond fracture. We present a case of Segond fracture diagnosed ultrasonographically and confirmed by radiographs and MR imaging.

Reconstruction of the Posterolateral Corner of the Knee

To describe a technique for reconstruction of the posterolateral corner (PLC) of the knee and report the results of a prospective series of patients. Case series. Twenty-two patients with PLC injuries underwent reconstruction; 15 patients had multiligamentous knee injuries and 7 had isolated PLC injuries. We used the modified 2-tailed technique that reconstructs the popliteofibular ligament and fibulocollateral ligament. The technique includes use of an allograft tendon placed through transtibial and transfibular bone tunnels and around a screw on the lateral femoral condyle. All patients have been followed-up prospectively with clinical examinations, Lysholm knee scores, KT-2000 ligament arthrometer examinations, and evaluation of work and recreational functional status. There were 15 male and 7 female patients (mean age, 32 years; range, 17 to 55 years). Follow-up was a minimum of 24 months (mean, 29.5 months; range, 24 to 38 months). Mean range of motion is extension of 0.2 degrees (range, 0 degrees to 5 degrees) and flexion of 133.4 degrees (80 degrees to 144 degrees). The range of motion for the multiligamentous knees was 0.3 degrees to 129 degrees compared with 0 degrees to 143 degrees for knees with isolated corner injuries. Mean Lysholm knee scores were 90 for the entire group with a score of 92 for the multiligamentous knees and 88 for the isolated corners. Stability was clinically graded on a scale of 0 to 3 for both varus stress and external rotation, with a score of 2 or 3 indicating a failed PLC reconstruction. The mean score for varus stress was 0.2 for the whole group, with 0.3 in the multiligamentous knee and 0.1 for the isolated injuries. Similarly, the mean score for external rotation was 0.4, with a 0.5 for multiligamentous knee and 0.3 for isolated PLC injuries. There were 2 failures in the multiligamentous knee injury group (13%), compared with no failures in the isolated PLC group. The failure rate for the whole study was 9%. Reconstruction of the PLC using an allograft reconstruction of the popliteus, popliteofibular, and fibulocollateral ligaments yielded a stable reconstruction with excellent functional results. Predictably, range of motion and incidence of failure were both better for patients with isolated PLC injuries than for those with multiligamentous knees. Both groups, however, showed excellent overall functional results. Level IV, case series.

A Swollen Elbow In An Adolescent Throwing Athlete

HISTORY Patient is a 16 year old female, left-hand dominant outfielder, who plays softball for a local high school. She gives a history of an insidious onset of elbow discomfort. This discomfort progressed to pain over the past year. Over the past few weeks, the patient noted a new onset of swelling. Patient denies any trauma or inciting injury to this area. She localizes her pain to the posterior lateral aspect of her elbow. Patient denies locking or decrease motion at the elbow. Patient also denies numbness, tingling, or weakness. Her symptoms are aggravated by throwing and/or full extention of her elbow. She has had some relief of her symptoms with the use of ibuprofen. She has recently stopped playing softball secondary to discomfort with this activity. PHYSICAL EXAMINATION No acute distress. Afebrile vital sign stable. Left elbow demonstrates trace of effusion on palpatation with some local warmth. Range of motion is full, 0 to 104 degrees. No ligaments laxity is noted on varus or valgus stress testing, but has some mild reproduction of her pain with valgus stressing at 20 degrees of flexion. Patient has pain with valgus extension overload testing. Patient has diffuse tenderness noted over the lateral epicondyle as well as lateral capitelloradial joint. No tenderness noted with forced wrist extension or flexion. Mild tenderness noted with forced extension and flexion of the elbow. Examination of the right elbow reveals no effusion, non-tender, full range of motion, and no ligamentous laxity. Neurovascular status of the upper extremities are intact. DIFFERENTIAL DIAGNOSIS Stress fracture; Autoimmune disease, i.e. juvenile rheumatoid arthritis; Triceps strain; Infectious disease, i.e. lyme, syphilis; OCD elbow (osteochondral defect). TEST AND RESULTS X-ray; no fracture or deformity noted MR arthrogram with gadolinium; peripheral portion of the capitellum demonstrates a cartilaginous defect measuring 2 mm × 9mm, no noted bone edema, no contusion, no loose body, medial and lateral collateral ligaments are intact, marrow signal intensity within normal limits, no stress fracture noted. Diagnosis: OCD of the capitellum, left elbow. FINAL WORKING DIAGNOSIS OCD capitellum, left elbow TREATMENT AND OUTCOMES Patient placed on NSAID's. Patient had arthroscopy of the elbow with microabrasion to potentiate healing. Patient is currently not in a throwing program, but will begin physical therapy to progress to a throwing program as tolerated.

Total dislodgement of the femoral component following cemented total knee arthroplasty: a case report

Total dislodgement of the components, which is the most severe form of loosening, has hitherto been unreported following total knee arthroplasty. An eighty-four-year-old woman presented with complaints of pain and sensation of insecurity of her right knee after cemented total knee arthroplasty. On physical examination, a clunk was elicited during movements of the knee; however, radiographs appeared normal except for a separated fragment of the medial femoral condyle. Further examination with varus and valgus stress tests under fluoroscopic control showed dislodgement of the femoral component, which was only apparent on stress radiographs. She underwent revision cemented total knee arthroplasty and her complaints disappeared completely within a follow-up period of three years. This case illustrates the need for stress radiographs when standard radiographs are normal in the face of a high suspicion of loosening.

Management of Concomitant Posterolateral Rotatory Instability and Anterior Cruciate Ligament Injuries of the Knee

Purpose: Many failures of anterior cruciate ligament (ACL) reconstruction are due to a failure to treat concomitant posterolateral rotatory instability (PLRI). We report the results of reconstruction in cases of combined PLRI and ACL injury. Materials and Methods: From January 1998 to December 2002, 24 patients were followed-up for a mean of 25 months (range, 12 to 58), postoperatively. PLRI was treated using a biceps tenodesis or posterolateral comer sling (PLCS), through a proximal tibial or fibular head obliquely anteroinferiorly to posterosuperiorly. ACLs were reconstructed using autogenous hamstring 4 bundles with RIGIDfix™ on the femoral side and Intrafix™ with additional staple fixation on the tibial side. Clinical results were evaluated using the Orthopadishe Arbeitsgruppe Knie (OAK) and International Knee Documentation Committee (IKDC) knee scoring system. Stability was measured on pull varus stress radiographs using a Telos stress device and by using the manual maximum displacement test using a KT-1000™ arthrometer with 30 degrees of knee flexion. Results: The mean side-to-side difference in anterior displacement measured on the pull stress radiographs was reduced from a preoperative 7.9±3.4 to 2.1±0.8 ㎜ at the last follow-up, from 2.1±0.8 to 0.4 ±0.7㎜ on varus stress radiographs, and from 6.5±1.3 ㎜ to 2.3±1.3 ㎜ as measured using the KT-1000 arthrometer. The average OAK score improved from 64.1±11.9 to 84.4±9.2 points over the same period. At the final evaluation, 22 of the 24 patients (92%) had a satisfactory result according to the IKDC system. Conclusion: Based on our experience, we recommend arthroscopically assisted ACL reconstruction and the correction of concomitant PLRI in cases of combined ACL and posterolateral rotatory instability.