Does Transection of the Superficial MCL During HTO Result in Progressive Valgus Instability?

Background: During high tibial osteotomy (HTO), the superficial medial collateral ligament (sMCL) is cut or released at any degree to expose the osteotomy site and achieve the targeted alignment correction according to the surgeon’s preference. However, it is still unclear whether transection of sMCL increases valgus laxity. Purpose: We aimed to assess the outcomes and safety of sMCL transection, especially focusing on iatrogenic valgus instability. Study Design: Case series; Level of evidence, 4. Methods: Seventy-two patients (89 knees) who underwent medial open wedge HTO (MOWHTO) with transection of the sMCL between October 2013 and September 2018 were retrospectively investigated. Clinical evaluations, including the International Knee Documentation Committee (IKDC) score, Knee injury and Osteoarthritis Outcome Score (KOOS), and Tegner and Lysholm scores, were performed preoperatively and at 2 years postoperatively. The radiographic parameters hip-knee-ankle (HKA) angle, joint line convergence angle on standing radiographs (standing JLCA), and weightbearing line (WBL) ratio were assessed preoperatively and at 3 months, 6 months, 1 year, and 2 years postoperatively. To evaluate valgus laxity, we assessed the valgus JLCA and medial joint opening (MJO) at the aforementioned time points using valgus stress radiographs. Results: All clinical results at the 2-year follow-up were significantly improved compared with those obtained at the preoperative assessment ( P < .001). The postoperative HKA angle significantly differed from the preoperative one, and no significant valgus progression was observed during follow-up (preoperative, 8.5°± 2.7°; 3 months, –3.5°± 2.0°; 6 months, –3.2°± 2.3°; 1 year, –3.1°± 2.3°; 2 years, –2.9°± 2.5°; P < .001) The mean WBL ratio was 62.5% ± 9.0% at 2 years postoperatively. The postoperative valgus JLCA at all follow-up points did not significantly change compared with the preoperative valgus JLCA (preoperative, –0.1°± 2.1°; 3 months, –0.2°± 2.4°; 6 months, –0.1°± 2.5°; 1 year, 0.1°± 2.5°; 2 years, 0.2°± 2.2°) The postoperative MJO at all follow-up points did not significantly change compared with the preoperative MJO (preoperative, 7.1 ± 1.7 mm; 3 months, 7.0 ± 1.7 mm; 6 months, 6.9 ± 1.9 mm; 1 year, 6.7 ± 1.8 mm; 2 years, 6.8 ± 1.8 mm). Conclusion: Transection of the sMCL during MOWHTO does not increase valgus laxity and could yield desirable clinical and radiographic results.

Changes in elbow joint contact area in symptomatic valgus instability of the elbow in baseball players

The aim of this study was to evaluate the joint contact area of the dominant side and that of the non-dominant side without valgus instability in symptomatic pitchers. Ten symptomatic elbow medial ulnar collateral ligament (UCL) deficient baseball pitchers participated in this study. Computed tomography (CT) data from the dominant and non-dominant elbows were obtained with and without elbow valgus stress. The CT imaging data of each elbow joint were reconstructed using a 3D reconstruction software package, and the radiocapitellar and ulnohumeral joint contact areas were calculated. The center of the contact area and the translation from the position without stress to the position with valgus stress were also calculated. With elbow valgus stress, the contact area changed, and the center of the radiocapitellar joint contact area translated significantly more laterally in the dominant elbow than in the non-dominant elbow (p = 0.0361). In addition, the center of the ulnohumeral joint contact area translated significantly more posteriorly in the dominant elbow than in the non-dominant elbow (p = 0.0413). These changes in contact areas could be the reason for cartilage injury at the posterior trochlea in pitchers with UCL deficiency.

Anatomic reconstruction of the medial collateral ligament in multi-ligaments knee injury using achilles allograft : a modification of Marx’s technique

Medial Collateral Ligament (MCL) injury may require operative treatment. Marx et al. described the latest technique for reconstruction of MCL. While good results have been reported using the Marx technique, some issues have been observed. To address the mentioned issues, a modification to the Marx technique has been devised. Eleven patients were enrolled and their ligaments were repaired by the fixation of allograft on the proximal and distal attachment footprints of the superficial MCL. For preventing loss of knee ROM, MCL and other ligaments were reconstructed in 2 separate stages. At the last follow up the ROM, knee ligament laxity and functional outcome scores, subjective (IKDC) and Lysholm score were evaluated and recorded. Knee motion was maintained in all cases. Two cases demonstrated 1+ valgus instability at 30 degrees of knee flexion. Both were treated for combined MCL and PCL tear, the rest were stable. The average IKDC-subjective score was 93 ± 4 and the average Lysholm score was 92 ± 3. All patients were satisfied and returned to their previous level of activity. In this technique, the superficial MCL was recon- structed closer to its anatomical construct. Patients didn’t have any complaints of hardware under the skin and the need for a second surgery for hardware removal was avoided. Patients didn’t have any complaints of hardware under the skin and the need for a second surgery for hardware removal was avoided. Also reconstructing the ligaments in 2 stages helped to preserve the knee motion.

Changes in Elbow Joint Contact Area in Symptomatic Valgus Instability of the Elbow in Baseball Players

The aim of this study was to evaluate the joint contact area of the dominant side and that of the non-dominant side without valgus instability in symptomatic pitchers. Ten symptomatic elbow medial ulnar collateral ligament (UCL) deficient baseball pitchers participated in this study. Computed tomography (CT) data from the dominant and non-dominant elbows were obtained with and without elbow valgus stress. The CT imaging data of each elbow joint were reconstructed using a 3D reconstruction software package, and the radiocapitellar and ulnohumeral joint contact areas were calculated. The center of the contact area and the translation from the position without stress to the position with valgus stress were also calculated. With elbow valgus stress, the contact area changed, and the center of the radiocapitellar joint contact area translated significantly more laterally in the dominant elbow than in the non-dominant elbow (P = 0.0361). In addition, the center of the ulnohumeral joint contact area translated significantly more posteriorly in the dominant elbow than in the non-dominant elbow (P = 0.0413). These changes in contact areas could be the reason for cartilage injury at the posterior trochlea in pitchers with UCL deficiency.

Distal Tibiofibular Syndesmotic Widening in Progressive Collapsing Foot Deformity

Background: Lateral overload in progressive collapsing foot deformity (PCFD) takes place as hindfoot valgus, peritalar subluxation, and valgus instability of the ankle increase. Fibular strain due to chronic lateral impingement may lead to distraction forces over the distal tibiofibular syndesmosis (DTFS). This study aimed to assess and correlate the severity of the foot and ankle offset (FAO) as a marker of progressive PCFD with the amount of DTFS widening and to compare it to controls. Methods: In this case-control study, 62 symptomatic patients with PCFD and 29 controls who underwent standing weightbearing computed tomography (WBCT) examination were included. Two fellowship-trained blinded orthopedic foot and ankle surgeons performed FAO (%) and DTFS area measurements (mm2). DTFS was assessed semiautomatically on axial-plane WBCT images, 1 cm proximal to the apex of the tibial plafond. Values were compared between patients with PCFD and controls, and Spearman correlation between FAO and DTFS area measurements was assessed. P values of less than .05 were considered significant. Results: Patients with PCFD demonstrated significantly increased FAO and DTFS measurements in comparison to controls. A mean difference of 6.9% ( P < .001) in FAO and 10.4 mm2 ( P = .026) in DTFS was observed. A significant but weak correlation was identified between the variables, with a Þ of 0.22 ( P = .03). A partition predictive model demonstrated that DTFS area measurements were highest when FAO values were between 7% and 9.3%, with mean (SD) values of 92.7 (22.4) mm2. Conclusion: To our knowledge, this was the first study to assess syndesmotic widening in patients with PCFD. We found patients with PCFD to demonstrate increased DTFS area measurements compared to controls, with a mean difference of approximately 10 mm2. A significantly weak positive correlation was found between FAO and DTFS area measurements, with the highest syndesmotic widening occurring when FAO values were between 7% and 9.3%. Our study findings suggest that chronic lateral impingement in patients with PCFD can result in a negative biomechanical impact on syndesmotic alignment, with increased DTFS stress and subsequent widening. Level of Evidence: Level III, retrospective comparative study.

The Influence of Posterior Cruciate Ligament Resection on Tibiofemoral Joint Gap in Varus Osteoarthritic Knees

Posterior cruciate ligament (PCL) resection during posterior-stabilized total knee arthroplasty (PS-TKA) has been reported to preferentially increase the tibiofemoral joint gap in flexion compared with extension. However, previous assessments of the joint gaps have been performed after bone resection and medial soft tissue release. Thus, these procedural steps may have the potential to influence soft tissue balance. In native knees, soft tissue laxity is generally greater in the lateral compartment than in the medial compartment both with the knee in extension and in flexion. Some surgeons may retain this natural soft tissue balance with less aggressive medial release during TKA. We performed this study to evaluate the impact of the PCL resection on the extension and flexion gaps in the absence of bone resection or medial soft tissue release. Tibiofemoral joint gaps for 41 patients (10 males and 31 females) in full extension and at 90 degrees of flexion both before and after the resections of both the anterior cruciate ligament (ACL) and PCL were assessed using a ligament tensioner device. The statistical analyze was performed using the Mann–Whitney U test. The results showed that medial gap in extension and flexion were 6.7 ± 1.0 and 7.3 ± 0.9 mm, and lateral gap in extension and flexion were 7.6 ± 1.1 and 8.4 ± 1.6 mm, respectively. Thus, physiological tibiofemoral gaps just after knee arthrotomy were trapezoidal and asymmetric shape with the significantly wider gaps in lateral and flexion, compared with the medial and extension, respectively (p < 0.05). However, the increases of the gaps with the ACL and PCL resections were less than 1 mm under the existence of medial soft tissues. As the medial collateral ligament is the primary restraint for the valgus instability, it was also considered to prevent the increase of the flexion gap although the PCL—which is the secondary restraint for the valgus instability—was resected. This finding is critically important for orthopedic surgeons applying PS-TKA implants, particularly for preserving soft tissues to achieve natural knee kinematics postoperatively.

Posteromedial Ligament Repair of the Knee with Suture Tape Augmentation: A Biomechanical Comparison with Posteromedial Ligament Reconstruction

Aims and Objectives: ACL ruptures combined with injuries of the superficial medial collateral ligament and posterior oblique ligament (= posteromedial ligament complex; PMC) are common. In acute cases with high-grade valgus and rotatory instability, primary repair of the PMC with suture tape augmentation may be a reasonable alternative to standard reconstruction techniques, in order to stabilize the knee and to protect the reconstructed ACL. The aim of the present study was to biomechanically examine the rotational and valgus stability, as well as the influence on ACL strain, following PMC repair with suture tape augmentation in comparison with posteromedial ligament reconstruction using tendon grafts. Materials and Methods: Ten cadaveric knee specimens were tested with the tibia fixed and the femur mobile on an X-Y-table. Each specimen was tested in four different conditions according to the state of the PMC: 1) native, 2) femoral avulsion, 3) repaired with suture tape augmentation, 4) reconstructed with tendon allografts. Valgus instability was tested with 40 N force applied in the lateral direction of the femur and rotational motion was tested with 5 N torque applied to the tibia. An optical 3D motion tracking system captured the valgus angle and the internal and external rotation. Additionally, the strain on the ACL during valgus stress was measured with a DVRT. Each condition was tested in 0°, 15°, 30°, 45° and 60° of knee flexion. Results: Femoral avulsion of the PMC led to a significant increase in valgus instability in all flexion angles and to a significant increase on ACL strain at 30° (Native 1.37 ± 2.33 vs. deficient 7.49 ± 7.00; p<0.001) and 45° (0.88 ± 1.66 vs. 2.82 ± 2.59; p<0.001) knee flexion. Additionally, a significant increase of internal rotation in 0° (p=0.018) and 30° (p=0.005) knee flexion and a significant increase of external rotation in 15° (p<0.001), 30° (p=0.016), 45° (p=0.006) and 60° (p=0.012) knee flexion was seen after dissection of the PMC. PMC repair with suture tape augmentation demonstrated similar valgus and rotational stability compared to intact specimens, with the exception of increased internal rotation at 30° (16.2 ± 6.3° vs. 19.3 ± 6.9°; p=0.005). PMC reconstruction with tendon grafts led to a significantly increased valgus opening at a 45° degree of knee flexion (7.5 ± 2.9° vs. 8.9 ± 2.1°; p=0.048) and significantly increased internal rotation at 30° (16.2 ± 6.3° vs. 20.1 ± 7.3°; p<0.001) compared to the native state. Direct comparison between both surgical techniques showed no significant differences. Conclusion: At time zero, ligament repair of the posteromedial knee with suture tape augmentation restored close to native valgus and rotatory stability, as well as native ACL strain for cases of complete PMC avulsion. Posteromedial ligament repair with suture tape augmentation may be a reasonable alternative to tendon reconstruction techniques in acute cases of combined posteromedial and ACL injuries with high-grade valgus and rotatory instability.

Medial-Sided Injuries in the Multiple Ligament Knee Injury

Multiligament knee injuries (MLKI) are complex and challenging to treat. The posteromedial corner (PMC) structures are commonly torn in MLKI. A thorough and systematic evaluation is imperative to avoid a missed diagnosis and for planning treatment. With several structures injured, the treatment method (operative vs. nonoperative, repair vs. reconstruction), availability of allografts, timing of surgery, and rehabilitation are some of the factors that have to be considered in the decision-making. Persistent valgus instability because of untreated or not healed medial collateral ligament (MCL) tears will increase graft forces on the cruciate ligament grafts, thus increasing the risk of reconstruction graft failure. In recent years, there has been a growing body of literature on the anatomy and biomechanics of the medial structures that has aided in the development of biomechanically and clinically validated anatomic PMC reconstructions. Despite good healing potential of the MCL, in MLKI, surgical treatment is recommended for grade III PMC injuries to aid early rehabilitation and reduce the risk of surgical failure. Several studies have reported satisfactory outcomes after surgical treatment of MLKI involving the medial side. Early functional rehabilitation is imperative to reduce the risk of arthrofibrosis.

Severe traumatic valgus instability of the elbow: pathoanatomy and outcomes of primary operation

Background The objective of the study was to depict the pathoanatomy of traumatic valgus instability of the elbow and to report clinical outcomes of primary operation. Methods Thirty-one patients presented with traumatic valgus instability of the elbow without dislocation. Thirty-one patients underwent surgical intervention of radial head fractures (28 open reduction and internal fixation and 3 radial head resection) and anatomical repair of the anterior bundle of medial collateral ligament (AMCL) with suture anchors. Twenty patients with disruption of the flexor-pronator tendon (FPT) and 14 patients with tears of the anterior capsule had primary repair of the FPT and anterior capsule simultaneously. Clinical outcomes were evaluated with the Mayo Elbow Performance Score (MEPS), modified hospital for special surgery assessment scale (HSS), and Disabilities of the Arm, Shoulder, and Hand (DASH) score. Results The median follow-up was 37.3 months (range, 15–53 months). Radial head fractures and complete avulsion of the medial collateral ligament (MCL) from its humeral footprint were confirmed in all patients intraoperatively. Intraoperative findings indicated disruption of the FPT in 20 patients and tears of the anterior capsule in 14 patients. Twenty-nine of 31 patients returned to previous activity and work levels within 6 months after surgery. The MEPS, modified HSS, and DASH score were 94 ± 4, 91 ± 5, and 8 ± 2 at the latest follow-up. Conclusions Radial head fractures with avulsion of the MCL can lead to severe valgus instability of the elbow. Primary operation to repair these disrupted structures, especially repair of the AMCL, can effectively restore valgus stability.