Imaging Findings of Knee Trauma on Magnetic Resonance Imaging

Background: Knee is one of the major joints involved in kinesis. With increasing involvement in sports related activities especially in young people, Trauma related knee pathologies have increased. An accurate diagnosis regarding the type and extent of injuries is essential for early operative as well as non-operative treatment. Methods:This prospective study included total of 82 cases. The patients were referred to the department of Radiodiagnosis from indoor and outdoor departments of Guru Nanak Dev Hospital, Amritsar with suspicion of internal derangement of the knee and with history of knee trauma.Results:The most common age group involved was young males between 15-34 years. In all age groups most of the patients were males. Most common ligament to be injured was Anterior Cruciate Ligament (ACL). Partial tears were more common than complete tears. Posterior Cruciate Ligament (PCL) tears were less common. Medial Collateral Ligament (MCL) tears outnumbered Lateral Collateral Ligament (LCL) tears and grade 2 tears were more common in both. Among the meniscal injuries Medial Meniscus (MM) tears were more common than LM and grade 3 signal was more common in both. Most of the patellar retinaculum injuries were associated with Anterior Cruciate Ligament ACL tears.Conclusions:Post-traumatic pre-arthroscopic MR imaging evaluation has proved to be cost-effective. MRI is an accurate imaging modality complementing the clinical evaluation and providing a global intra-articular and extra-articular assessment of the knee.

Ankle-Injury Patients Perform More Microadjustments during Walking: Evidence from Velocity Profiles in Gait Analysis

Introduction. We evaluated the velocity profiles of patients with lateral collateral ligament (LCL) injuries of the ankle with a goal of understanding the control mechanism involved in walking. Methods. We tracked motions of patients’ legs and feet in 30 gait cycles recorded from patients with LCL injuries of the ankle and compared them to 50 gait cycles taken from normal control subjects. Seventeen markers were placed on the foot following the Heidelberg foot measurement model. Velocity profiles and microadjustments of the knee, ankle, and foot were calculated during different gait phases and compared between the patient and control groups. Results. Patients had a smaller first rocker percentage and larger second rocker percentage in the gait cycle compared to controls. Patients also displayed shorter stride length and slower strides and performed more microadjustments in the second rocker phase than in other rocker/swing phases. Patients’ mean velocities of the knee, ankle, and foot in the second rocker phase were also significantly higher than that in control subjects. Discussion. Evidence from velocity profiles suggested that patients with ligament injury necessitated more musculoskeletal microadjustments to maintain body balance, but these may also be due to secondary injury. Precise descriptions of the spatiotemporal gait characteristics are therefore crucial for our understanding of movement control during locomotion.

Sequential Damage Assessment of the Posterolateral Complex of the Knee Joint: A Finite Element Study

Background. The posterolateral complex (PLC), which consists of the popliteus tendon (PT), lateral collateral ligament (LCL), and popliteofibular ligament (PFL), is an indispensable structure of the knee joint. The aim of this study was to explore the functionality of the PLC by determining the specific role of each component in maintaining posterolateral knee stability. Methods. A finite element (FE) model was generated based on previous material property data and magnetic resonance imaging of a volunteer’s knee joint. The injury order of the PLC was set as LCL, PFL, and PT. A 134 N anterior load was applied to the tibia to investigate tibial displacement (TD). Tibial external rotation (TER) and tibial varus angulation (TVA) were measured under bending motions of 5 and 10 Nm. The instantaneous axis of rotation (IAR) of the knee joint under different rotation motions was also recorded. Results. The TD of the intact knee under a 134 N anterior load matched the values determined in previous studies. Our model showed consistent increases in TD, TVA, and TER after sequential damage of the PLC. In addition, sequential disruption caused the IAR to shift superiorly and laterally during varus rotation, and medially and anteriorly during external rotation. In the dynamic damage of the PLC, LCL injury had the largest effect on TD, TVA, TER, and IAR. Conclusions. Sequential injury of the PLC caused considerable loss of stability of the knee joint according to an FE model. The most significant structure of the PLC was the LCL.

Surgical stabilization of traumatic elbow joint luxation and proximal ulnar fracture in a silvery langur (Trachypithecus cristatus)

CASE DESCRIPTION A 3-year-old 5-kg sexually intact female silvery langur housed in a single-species group at a zoological institution was presented because of acute trauma to the left forelimb. CLINICAL FINDINGS Radiography of the left forelimb revealed a type II Monteggia fracture (proximal ulnar fracture with cranial displacement and caudal luxation of the radial head). During surgery, disruption of the annular ligament and rupture of the lateral collateral ligament were noted. TREATMENT AND OUTCOME The langur underwent open reduction and internal fixation of the ulnar fracture and placement of a radioulnar positional screw, a prosthetic lateral collateral ligament, and a temporary hinged type 1A external skeletal fixator. The langur was returned to group housing, underwent behavioral training, and was periodically anesthetized for physical therapy sessions to improve range of motion of the left elbow joint. The external skeletal fixator was removed 4 weeks after surgery, and the radioulnar positional screw was removed 6 weeks after surgery. Three months after surgery, the range of motion of the langur’s left elbow joint was considered normal, and the animal returned to normal activity. CLINICAL RELEVANCE For the captive silvery langur of the present report, surgical stabilization and postoperative management of a type II Monteggia fracture of the left forelimb were successful with recovery of elbow joint function. These techniques may be applied to other captive nonhuman primates, including those that brachiate or are members of social species that must be housed with conspecifics in the postoperative period to maintain group dynamics.

The Influence of Medial Collateral Ligament and Lateral Collateral Ligament Pie Crusting in Primary Total Knee Arthroplasty on Patient Reported Outcomes

Background and Hypothesis: Pie-crusting of the collateral ligaments can help achieve balanced gaps in total knee arthroplasty (TKA) in knees with varus or valgus deformity. However, the effect of this technique on patient-reported outcome measures (PROMs) is unknown. The purpose of this study was to compare PROMs following primary TKA for patients with and without medial collateral ligament (MCL) or lateral collateral ligament (LCL) pie-crusting. Experimental Design or Project Methods: We retrospectively reviewed 1,305 primary TKAs. Intraoperative MCL or LCL pie-crusting was documented in all operative reports and recorded. Prospectively collected preoperative, 4-month postoperative, and minimum 1-year postoperative PROMs related to overall knee health, pain during functional activities, activity level, and overall satisfaction were compiled and compared between patients with and without MCL or LCL pie-crusting. Medians were evaluated with Kruskal-Wallis test adjusted for ties. Results: The cohort was 67% female with mean age 66 years and BMI 34.0 kg/m2. MCL or LCL pie-crusting was performed in 13.0% of the cohort. There were no intraoperative or postoperative ruptures of the MCL or LCL. 6.3% of conforming bearing TKAs required a collateral ligament pie crusting versus 21.5% of standard bearing TKA (p<0.001). No significant differences were found in preoperative, 4-month, minimum 1-year, or change from preoperative baseline to minimum 1-year PROMs with and without pie-crusting of the collateral ligaments (p≥0.095). However, the LCL pie-crusting group had slightly better PROMs at minimum 1-year. Conclusion and Potential Impact: These study results corroborate existing literature that pie-crusting of collateral ligaments is safe and effective to achieve a balanced TKA. Additionally, no significant outcome differences were found between groups with and without MCL or LCL pie-crusting. However, LCL pie-crusting for valgus knee correction had slightly better PROMs. Interestingly, conforming bearings may impart enhanced stability and mitigate the need for pie-crusting ligament releases in TKA.

Anatomic Measurement and Variability Analysis of the Anterior Talofibular Ligament and Calcaneofibular Ligament of the Ankle

Background: The anterior talofibular ligament (ATFL) and calcaneofibular ligament (CFL) contribute greatly to the overall stability of the ankle joint; however, ATFL and combined ATFL-CFL sprains are common. Anatomic reconstruction of the lateral collateral ligament with grafts has been proposed for patients with poor tissue quality or inadequate local tissue. Anatomic reconstruction of the lateral ankle ligaments requires a good understanding of their anatomic location. Purpose: To describe the anatomy of the ATFL and CFL ligaments quantitatively and qualitatively and explore the relationship of some morphological parameters. Study Design: Descriptive laboratory study. Methods: A total of 66 adult ankle specimens were analyzed for ATFL band type, origin, length, width, thickness, and angle between the ATFL and CFL, and 73 adult ankle specimens were used for measuring the origin of the CFL. The coefficient of variation was used to describe and compare the respective variability of angle, length, width, and thickness. The origin of the ATFL was labeled as point A, and the leading edge of the CFL intersection with the articular surface of the calcaneus was considered point B. Results: The ATFL had a variable number of bands. A high degree of variability (coefficient of variation >0.2) was seen for most morphological measurements of the ATFL. In addition, the length of distance AB also varied. The CFL originated at the tip of the fibula in only 9% of specimens. It was found more commonly at the anterior border of the lateral malleolus (4.94 ± 1.70 mm from the tip). The angle between the ATFL and CFL was consistent at 100° to 105º. Conclusion: A fair amount of variability of ATFL length, width, and thickness were found in our study, with less variability in the ATFL-CFL angle. Most CFLs attached anterior to the tip of the fibula. Clinical Relevance: Providing relevant anatomic data of ATFL and CFL is important in ensuring proper surgical treatment of ankle joint injuries.

Ultrasonographic Measurement of Elbow Varus Laxity With a Sequential Injury Model of the Lateral Collateral Ligament–Capsular Complex

Background: There is no consensus how to determine the varus laxity due to the LCL injury using the ultrasonography. There is a risk of lateral collateral ligament injury during or after arthroscopic extensor carpi radialis brevis release for tennis elbow. The equator of the radial head has been suggested as a landmark for the safe zone to not increase this risk; however, the safe zone from the intra-articular space has not been established. Hypothesis: Increased elbow varus laxity due to lateral collateral ligament–capsular complex (LCL-cc) injury could be assessed reliably via ultrasound. Study Design: Descriptive laboratory study. Methods: Eight cadaveric elbows were evaluated using a custom-made machine allowing passive elbow flexion under gravity varus stress. The radiocapitellar joint (RCJ) space was measured via ultrasound at 30° and 90° of flexion during 4 stages: intact elbow (stage 0), release of the anterior one-third of the LCL-cc (stage 1), release of the anterior two-thirds (stage 2), and release of the entire LCL-cc (stage 3). Two observers conducted the measurements separately, and the mean RCJ space in the 3 LCL-cc injury models (stages 1-3) at both flexion angles was compared with that of the intact elbow (stage 0). We also compared the measurements at 30° versus 90° of flexion. Results: At 30° of elbow flexion, the RCJ space increased 2 mm between stages 0 and 2 (95% confidence interval [CI], 1-3 mm; P < .01) and 4 mm between stages 0 and 3 (95% CI, 2-5 mm; P < .01). At 90° of elbow flexion, the RCJ space increased 1 mm between stages 0 and 2 (95% CI, 1-2 mm; P < .01) and 2 mm between stages 0 and 3 (95% CI, 2-3 mm; P < .01). Conclusion: Elbow varus laxity under gravity stress can be reliably assessed via ultrasound by measuring the RCJ space. Clinical Relevance: Because ultrasonographic measurement of the RCJ space can distinguish the increasing varus laxity seen with release of two-thirds or more of the LCL-cc, the anterior one-third of the LCL-cc, based on the diameter of the radial head, can be considered the safe zone in arthroscopic extensor carpi radialis brevis release for tennis elbow.

Reconstruction of the Lateral Collateral Ligament Using a Suture Tape Anchor for Iatrogenic Hallux Varus

Iatrogenic hallux varus is a difficult complication of hallux valgus surgery. Although tendon transfer combined with bony correction is performed for hallux varus, tendon transfer has several disadvantages, such as the complicated nature of the procedure and the donor site morbidity. We describe the case of a 70-year-old woman with iatrogenic hallux varus treated by lateral collateral ligament (LCL) reconstruction using a suture tape anchor with bony correction. Tarsometatarsal joint arthrodesis was performed to correct the narrow intermetatarsal angle (IMA), and the varus deformity of the great toe at the metatarsophalangeal joint was corrected by anatomical reconstruction of the LCL using the suture tape anchor. One year postoperatively, the Japanese Society for Surgery of the Foot Hallux Metatarsophalangeal-Interphalangeal Scale had improved from 37 to 90 points. Radiography confirmed that the hallux valgus angle had been corrected from -24° to 4° and the IMA from 0° to 8°. Reconstruction of the LCL using suture tape anchor is an easy procedure for iatrogenic hallux varus which can achieve good stabilization.