Anatomical reconstruction of the anterior inferior tibiofibular ligament in elite athletes using InternalBrace suture tape

Aims The ideal management of acute syndesmotic injuries in elite athletes is controversial. Among several treatment methods used to stabilize the syndesmosis and facilitate healing of the ligaments, the use of suture tape (InternalBrace) has previously been described. The purpose of this study was to analyze the functional outcome, including American Orthopaedic Foot & Ankle Society (AOFAS) scores, knee-to-wall measurements, and the time to return to play in days, of unstable syndesmotic injuries treated with the use of the InternalBrace in elite athletes. Methods Data on a consecutive group of elite athletes who underwent isolated reconstruction of the anterior inferior tibiofibular ligament using the InternalBrace were collected prospectively. Our patient group consisted of 19 elite male athletes with a mean age of 24.5 years (17 to 52). Isolated injuries were seen in 12 patients while associated injuries were found in seven patients (fibular fracture, medial malleolus fracture, anterior talofibular ligament rupture, and posterior malleolus fracture). All patients had a minimum follow-up period of 17 months (mean 27 months (17 to 35)). Results All patients returned to their pre-injury level of sports activities. One patient developed a delayed union of the medial malleolus. The mean return to play was 62 days (49 to 84) for isolated injuries, while the patients with concomitant injuries returned to play in a mean of 104 days (56 to 196). The AOFAS score returned to 100 postoperatively in all patients. Knee-to-wall measurements were the same as the contralateral side in 18 patients, while one patient lacked 2 cm compared to the contralateral side. Conclusion This study suggests the use of the InternalBrace in the management of unstable syndesmotic injuries offers an alternative method of stabilization, with good short-term results, including early return to sports in elite athletes. Cite this article: Bone Joint J 2022;104-B(1):68–75.

Correlation between Morphological Features of the Anterior Cruciate Ligament: A Quantitative Study Using a Porcine Model

Background: Inadequate restoration of the rotational knee stability is often reported after ACL reconstruction, mainly due to insufficient restoration of the morphology of the ACL. This study aimed to explore the quantitative correlation between morphological features of the ACL, thus to provide useful information for improving anatomical reconstruction techniques and designing artificial ligaments. Methods: Porcine model was used in this study mainly because the morphology and function of porcine ACLs have been reported to be similar to those of the human ACL. 19 porcine knees (1 year, male) were fixed at full extension using 10% formalin and were dissected to expose the ACL. ACL lengths were measured using a caliper. Mid-substances of the ACL were cut and scanned using X-ray microscopy, and the cross-sectional area (CSA) was measured at the isthmus. Margins of direct and indirect bone insertion sites were distinguished and marked. Measurements were performed on digital photographs to obtain the areas of bone insertions. Statistical analysis using nonlinear regression was used to identify potential correlations among the measurements. Results: The results showed large individual differences on all of the measurements (e.g. the CSA at ACL isthmus ranged from 44.7 to 87.2 mm2, when the area of its femoral and tibial insertion sites ranged from 188.1 and 233.6 mm2 to 258.4 and 412.0 mm2, respectively). The CSA at the isthmus was significantly correlated with the total area of the bone insertion sites and the area of tibial insertion. The area of the tibial insertion was significantly correlated with the area of its direct insertion site. In contrast, the area of the femoral insertion was significantly correlated with the area of its indirect insertion site. The area of the indirect tibial insertion showed a weak correlation with the length of ACL, whereas the length of the ACL was not able to predict or be predicted by any other parameters.Conclusions: The CSA at the ACL isthmus might be more suitable for assessing the morphology of the ACL. However, ACL length has little correlation with the CSA of the isthmus or bone insertion sites, thus should be evaluated independently before surgery.

Is Stem Revision Necessary for Vancouver B2 Periprosthetic Hip Fractures? Analysis of Osteosynthesis Results from 39 Cases

Although stem revision is recommended for Vancouver B2 periprosthetic hip fractures (PPHFs), there has recently been a debate whether, under certain conditions, they could be treated by osteosynthesis alone. This study aimed to describe the medium-term clinical and radiological results of several patients with V-B2 fractures treated via osteosynthesis. A retrospective study of patients with V-B2 PPHF treated by osteosynthesis without stem revision, operated on between 2009 and 2019, was performed. The type of arthroplasty, type of stem, ASA, Charlson Comorbidity Index (CCI), medical and implant complications, reoperation rate, first-year mortality, radiological results (consolidation time), and functional results were analyzed. Thirty-nine patients were included. Their average age was 78.82 years. Most of the patients presented ASA ≥ 3 (35/39) and CCI ≥ 5 (32/39). Radiological consolidation was achieved in 93.5% of patients, with an average consolidation time of 92.93 days. The average Parker test score before admission was 5.84 while the current one was 4.92 (5.16 years follow-up). Osteosynthesis without stem revision is a valid surgical alternative in certain types of patients with V-B2 PPHF, depending on previous mobility, fracture pattern (anatomical reconstruction possible), anesthetic risk, comorbidities, and previous hip pain.

More Conservative Rehabilitation Strategy within Postoperative 6 Month for All-Inside Reconstruction Compared with Anatomical Reconstruction of Anterior Cruciate Ligament may be able to Achieve Better Stability: Based on the Study of Graft Maturity

Background: Individualized rehabilitation based on graft maturity is necessary to optimize patient function and prevent graft re-injury. But there is a lack of studies on graft maturity in the all-inside single-bundle anterior cruciate ligament reconstruction.Hypothesis/Purpose: Compared to the difference in graft maturity, functional scores, and stability between all-inside and anatomical single-bundle anterior cruciate ligament reconstruction, it was assumed that the stability of all-inside reconstruction is relatively insufficient, and its graft maturity is worse than the anatomical reconstruction.Study Design: Randomized controlled clinical trial.Methods: Fifty-four patients were recruited in this study and randomly assigned to the all-inside reconstruction group (n = 27) and the anatomical reconstruction group (n = 27) using the same rehabilitation strategy. The Tegner, International Knee Documentation Committee, and Lysholm score were recorded at postoperative 3rd, 6th, and 12th month to assess functional recovery. Magnetic resonance imaging was conducted to measure the Signal/Noise quotient (SNQ) of the intra-articular graft to observe the maturity. Stability was assessed using GNRB relaxation measuring instrument at the postoperative 12th month.Results: The graft SNQ of the all-inside group was significantly higher than that in the anatomical group during the postoperative 6th month (p < 0.05). There was no statistical difference in graft SNQ between the two groups at postoperative 3rd and 12th month (p > 0.05). Both groups exhibited the graft’s highest SNQ in the middle region, followed by the proximal region, and the lowest was the distal region. Functional scores improved significantly in both groups and had no statistical difference (p > 0.05). The stability recovered well in both groups during the postoperative 12th month, but the GNRB relaxation was higher in the all-inside group (p < 0.05). There was no correlation between functional scores and graft maturity in the two groups (p > 0.05).Conclusions: All-inside reconstruction graft maturity is inferior to the anatomical reconstruction during postoperative 6th month, which may cause relatively insufficient stability of all-inside reconstruction compared with anatomical reconstruction under the same rehabilitation strategy. A more conservative rehabilitation strategy for all-inside reconstruction around the postoperative 6th month may achieve better stability.

Clinical Impact of Pelvic Malrotation on X-ray based Preoperative Planning for Total Hip Arthroplasty: A Proof-of-concept and Prudent Prediction of Acceptable Rotation

IntroductionPelvic rotation (PR) on preoperative X-ray templating can affect various critical measured acetabular angles and potentially outcomes of successful total hip arthroplasty (THA). Optimising anatomical reconstruction of the joint is essential to achieve function, longevity and prevention of complications following surgery. There is limited literature that standardises the degree of acceptable PR on X-ray or its effects on the fitting of acetabular prostheses. ObjectiveThis study aimed to develop a proof-of-concept that quantifies how PR can affect various acetabular angles used in pre-operative THA templating and to formulate a practicable method of determining if the preoperative PR is acceptable. Materials and MethodsComputerised tomography (CT) models from three control and two THA patients were generated and manipulated in various degrees of PR. CT slices were thickened to simulate X-rays and acetabular angles measured. ResultsThe acetabular anteversion distance (AAD) and lateral opening angle (LOA) demonstrated a linear and quadratic relationship with good correlation (R2=0.923, R2=0.710 respectively, p<0.0001) in relation to PR. Change in area of prosthesis (AOP) demonstrated a good linear correlation (r2=0.774 and r2=0.875, p<0.0001) with PR. Two novel measurements were used to estimate the degree of PR from a pelvic X-ray; the horizontal distance between pubic symphysis and middle of sacrococcygeal joint (PSSC) and the simplified pelvic rotation ratio (SPRR). A strong correlation between PSSC and SPRR with change in PR was observed (R2=0.970, R2=0.953, p<0.001). ConclusionPreliminary results suggests that an SPRR >2.0 correlates to PR>20° with potential to have a clinical impact on preoperative measurements.

The Influence of Acetabular Morphologic Variations on the Cup Position in Total Hip Arthroplasty for Crowe type III Dysplastic Hip

Background: We aimed to (1) evaluate the acetabular morphologic variations of Crowe III hips; (2) study the influence of different morphologies on the cup position in total hip arthroplasty.Methods: From November 2008 to February 2019, we retrospectively evaluated 101 patients (110 hips) with Crowe III developmental dysplasia of the hip. We classified Crowe III hips into two subtypes, the IIIA when the acetabular roof was extensively deficient and the junction between the false and the true acetabulum was indistinct, and the IIIB when there is a significant crest between the false and the true acetabulum. Based on the radiographs, we measured the morphological characteristic of the acetabulum and the postoperative cup position.Results: The false acetabulum of IIIB hips had larger Tonnis angle and smaller center-edge angle than the IIIA hips. The width of true acetabular roof in the IIIB hips was thicker than the IIIA group. Fifty-one (100%) IIIA hips and 48 (81.4%) IIIB hips were reconstructed using high hip center while 11 (18.6%) IIIB hips were reconstructed anatomically. The mean vertical distance of center of rotation in the IIIA group was 33.5±4.5 mm while it was 31.2±6.3 mm in the IIIB group (p=0.040). The vertical distance of the hip center was positively correlated with the height of dislocation in the IIIA group (r=0.493, p<0.001). According to the four-zone system, in the IIIA group, 5 hips were located in the inferomedial zone, 23 hips in the superomedial zone, 22 hips in the superolateral zone and 1 hip in the inferolateral zone. In the IIIB group, the corresponding numbers were respectively 15, 17, 1 and 5. Compared with the IIIA group, there were more IIIB hips located in the inferomedial zone (p=0.008) and less in the superolateral zone (p=0.033).Conclusions: There are distinct morphologic subtypes based on the relationship between the false and the true acetabulum. More bone stock located in the superior wall of the true acetabulum can bring more possibilities for anatomical reconstruction, and lower the height of center of rotation when using high hip center.

Clinical Analysis of Adult Severe Open-Globe Injuries in Central China

Purpose: To describe the characteristics, management, and outcomes of adult severe open-globe injured (OGI) eyes.Methods: Retrospective chart review of inpatients with initial visual acuity (VA) of light perception (LP) or no light perception (NLP) associated with OGI between 2017 and 2020 at Department of Ophthalmology, Henan Eye Institute, Henan Eye Hospital, Henan provincial People's Hospital.Results: Six hundred twenty-five eyes of 622 adult patients with initial VA of LP or NLP associated with open-globe injuries (OGIs) were included. The mean age was 47.8 ± 14.1 years with the range from 18 to 91 years. Significant male predominance was noted (81.5%). The most common type of these severe OGIs was rupture (65.8%). Traffic accidents accounted for 13.5% followed by fall/tumble (10.9%) and nail/wire (10.9%) of all the severe OGIs. Almost half of the injuries happened at workplace (47.2%). Initially, 78.7% eyes just received primary debridement and wound closure, while 8.5% eyes with no possible of anatomical reconstruction received evisceration. After initial management, 350 eyes received subsequent operation, including 239 eyes underwent vitrectomy + silicone oil/(+cataract remove). Finally, over 6 months follow-up, 137 eyes (21.9%) were eviscerated, 150 eyes (24.0%) got atrophied, while 132 eyes (21.1%) retain some VA. Fifty-three eyes (8.5%) got VA of 0.3–1.5.Conclusion: Severe OGIs are most seen in the young, middle-aged, and male working population and remain a serious public health problem, resulting in significant vision loss or Evisceration of eyes. Effective preventive measures should be taken for the individuals in these groups.

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.

Kommerell's diverticulum of retroesophageal aberrant brachiocephalic artery with right aortic arch in an adult

A retroesophageal aberrant brachiocephalic artery is a very rare congenital aortic arch anomaly. We herein presented a 29-year-old man with right aortic arch, retroesophageal aberrant left brachiocephalic artery, left ligamentum arteriosus, and absent left internal carotid artery. Graft replacement of the descending aorta and anatomical reconstruction of left brachiocephalic artery was successfully performed using a midline sternotomy approach without blood transfusion. We discuss the surgical management for Kommerell's diverticulum.