The TOAST (Traction on Ankle Stress Test): A Supplemental Clinical and Dynamic Ultrasound Examination Approach for Focal Assessment of Axial Ankle Joint Instability.

Ankle drawer and varus-valgus stress tests have evolved to examine for excessive joint displacement in the sagittal and coronal planes which may correlate to ligament instability. However, there appear to be no formal manual test(s) assessing for axial plane (longitudinal) instability of the mortise joint. In keeping with Cartesian and Cyriax principles, The TOAST (Traction On Ankle Stress Test) was developed to dynamically assess for 3rd vector axial strain pain generation and long-axis mortise joint gapping. The test is easy to learn as longitudinal manual traction of the mortise joint and applied counterforce hand positions are similar to emergent ankle fracture dislocation reduction technique. The TOAST may also be performed under dynamic ultrasound control.

Overcoming the Technical Challenges of Total Knee Arthroplasty in Patients Affected by Hereditary Multiple Exostoses: Our Experience Managing the Bone Deformities

Introduction: Hereditary multiple exostoses (MHE), also known as familiar osteochondromatosis or diaphyseal aclasis, is an autosomal dominant inherited genetic pathology that is characterized by the presence of multiple benign osteochondromas (exostoses). Knee deformity is common in patients with HME, with nearly a third of patients developing genu valgus. Total knee arthroplasty (TKA) has been used to correct valgus deformities with advanced knee osteoarthritis (OA). However concomitant limb deformities and altered anatomy of the knee make this surgery particularly challenging.Case presentation: We present the case of a 50 years old Caucasian woman, affected by multiple hereditary exostoses, who came to our attention for progressive pain in the right knee. Upon further examination the knee had a prominent valgus alignment, concomitant valgus instability and flexion contraction. The patient was treated with one stage total knee arthroplasty using a semi-constrained design. The patient was re-evaluated at 24 months follow-up and there were no signs of implant loosening, the knee function improved significantly and the patient was very satisfiedConclusions: We also present a mini-review of the literature on this topic. Given the recurring technical difficulties of such procedure in these patients, we describe our experience as well as the need for preoperative planning, the use of appropriate constrain when required, the high frequency of ligament instability, bony defects, and patellar maltracking. TKA must be considered when necessary, in these patients, as good to excellent clinical results can be achieved and maintained, allowing for significant improvements in quality of life.

Multiligamentary Reconstruction in a Below-Knee Amputation Patient

Multiligament injuries in below-knee amputation patients are a severe condition, and its treatment is controversial. Its incidence is unknown, and it is highly underdiagnosed, representing a challenge for the physician. The case presented is about a patient with a left transtibial amputation secondary to a severe crushing of the ipsilateral lower limb to which during the process of physiotherapy, a multiligament injury was diagnosed. The patient underwent a tibiofibular fixation with a multiligament reconstruction with good functional results. In this complex situation, delay in diagnosis is frequent, ligament instability should always be suspected and explored further, allowing for proper rehabilitation and early treatment.

Perspectives and Risk Factors in the Return-to-Sports Decision After Knee Surgery in a Male Elite Handball Player: A Case Report

We present the case of 28 years old male elite Handball Player with a first ACLR (Anterior Cross Ligament reconstruction) under surgery on the 21st of January 2019 in Hungary and a posterior surgery on January 22th 2020 in Barcelona-Spain with Re-tensing and reconstruction of the popliteus tendon and lateral collateral ligament. The reason of the second surgery was the ligament instability of the lateral and collateral posterior of the right knee and a residual laxity of the anterior-posterior cross Ligaments. After 6 months of the first post-operative rehabilitation in Amsterdam the handball Player visited our clinic in Bucharest in August 27th 2019 by petition of the Dinamo Hanball team manager to be re-evaluated and complete his rehabilitation until he will be able to reach the level to return to competition and play the national and European league with the Dinamo handball team Bucharest. The main objective of our Case report is to show the importance to provide further screening and prevention programs to find possibles inter-individual presence of risk factors” in the context of the return-to-sports decision after injury.

QUADRICEPS AUTOGRAFT IN ANTERIOR CRUCIATE LIGAMENT RECONSTRUCTION: A LITERATURE REVIEW

ABSTRACT Introduction: Anterior cruciate ligament injury is one of the most prevalent musculoskeletal injuries. Therefore, several surgical techniques and graft types have been described for its reconstruction. Autologous hamstring tendon graft is one of the most frequently used, but use of the quadriceps tendon graft has gained prominence in recent years. Objective: To review the literature to compare the outcomes of patients undergoing anterior cruciate ligament reconstruction (ACLR) with quadriceps tendon (QT) autograft versus hamstring tendon (HT) autograft. Methods: A literature review was conducted through PubMed to locate studies (Level of evidence I-III) comparing the outcomes of the QT autograft vs. the HT autograft in patients undergoing primary ACL reconstruction. Patients were assessed on the basis of re-rupture rate, ligament instability, patient-reported outcome scores, previous pain, and isokinetic tests. Results: Six studies were selected according to inclusion criteria. A total of 481 patients were evaluated, 243 in the QT group and 238 in the HT group. The total re-rupture rate was 1.6% (8 of 481), with 6 in the HT group and 2 in the QT group, but with no statistical difference between groups. One study found increased ligament instability in the HT group and another study found greater instability in the QT group, both with statistical significance. Regarding the patient-reported functional scores, only 01 study found statistical difference, with better results in the QT group. There was no difference in previous pain between groups in the selected studies. Regarding the isokinetic test, one study found a difference in flexor force in the HT group (p <0.01), with no difference in extensor force, while another two studies found an increased extensor force deficit in the QT group within up to 01 year of follow-up. The flexor/ extensor muscle strength ratio was higher in the QT group in both studies. Conclusion: ACL reconstruction with QT graft presents re-rupture rates, ligament instability, functional scores and donor site morbidity that are similar to the HT graft, in addition to preserving greater flexor force in proportion to extensor force. Level of evidence: IV; Review study.