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PubMed2000

The efficacy of magnetic resonance imaging in acute knee injuries.

OBJECTIVE: To evaluate the clinical efficacy of magnetic resonance imaging (MRI) of the knee in acute injuries with indeterminate clinical findings, using arthroscopy as a gold standard. DESIGN: A prospective double-blind study was performed. All patients underwent MRI on a 1.5 T magnet using dual spin echo pulse sequences. This was followed by arthroscopy. SETTING: Tertiary care referral center. PATIENTS: Twenty-three patients with an average age of 26 years satisfied the study criteria. Patients had to have been seen by one of two orthopaedic surgeons within 6 weeks of sudden trauma to the knee complicated by a hemarthrosis, clinical assessment of which was equivocal. RESULTS: The respective sensitivity and specificity for MRI of the knee were 90% (18/20) and 67% (2/3) for detecting any anterior cruciate ligament injury, 50% (1/2) and 86% (18/21) for detecting medial meniscal tears, and 88% (7/8) and 73% (11/15) for detecting lateral meniscal tears. MRI also identified injuries that could not be assessed on arthroscopy, including 14 bone bruises, five posterior cruciate ligament tears, nine medial collateral ligament tears, and one lateral collateral ligament tear. The detection of composite injury requiring surgical intervention yielded a sensitivity of 100% (16/16) and a specificity of 71% (5/7). Prospective use of MRI evaluation of the knee could have prevented 22% (5/23) of diagnostic arthroscopic procedures. CONCLUSION: Equivocal clinical findings in patients with acute knee injury should lead to use of MRI in an appropriate clinical setting. To our knowledge a prospective study of the efficacy of MRI of the knee in this patient population has not been reported. In the presence of such inclusion criteria, the results of our study support the use of early MRI to guide further surgical management.

Acute Disease↗
PubMed1995

Anatomy of the plantar plate and its attachments in the lesser metatarsal phalangeal joint.

The plantar plate is a rarely seen, yet central structure to the lesser metatarsal phalangeal (MP) joint. Thirty cadaver lesser MP joints were studied to obtain a detailed description of the plate, including its dimensions, connections, and histology. The plate was found to be made of fibrocartilage with fiber orientation which suggests that it withstands tensile loads in line with the plantar fascia as well as the compressive loads from the metatarsal head. The plantar plate was the most substantial distal insertion of the plantar fascia. Impressive plantar plate attachments were noted to the proximal phalanx, the major longitudinal bands of the plantar fascia, and the collateral ligaments. The plate and collateral ligaments formed a substantial soft tissue box connected to the sides of the metatarsal head. From the dissections, it is apparent that malposition of the toe at the MP joint is likely over time to be associated with pathology in both the collateral ligaments and the plate. Because of these attachments and a close association with the flexor tendons to the lesser toe, the plate can be compared with the sesamoid mechanism of the first MP joint.

Adult↗
PubMed2006

Characteristics of displaceable and nondisplaceable meniscal tears at kinematic MR imaging of the knee.

PURPOSE: To prospectively determine if kinematic magnetic resonance (MR) imaging of the knee may demonstrate displacement of menisci with tears and, if so, to characterize displaceable and nondisplaceable meniscal tears. MATERIALS AND METHODS: The study was approved by the hospital's review board, and informed consent was obtained. Forty-two patients (30 men, 12 women; mean age, 36.9 years) with 43 arthroscopically documented meniscal tears visible at 1.5-T MR imaging underwent kinematic MR imaging with an open-configuration 0.5-T MR imager with their knees in supine neutral, supine with 90 degrees flexion and external or internal rotation, and upright weight-bearing positions. Analysis of meniscal movement was performed in different knee positions in the coronal MR imaging plane. Meniscal displacement--that is, meniscal movement of 3 mm or more (in the medial direction for the medial meniscus, in the lateral direction for the lateral meniscus)--was compared with the patient's pain level as assessed with a visual analog scale by using analysis of variance. RESULTS: Between the different knee positions, meniscal displacement of 3 mm or more (displaceable meniscal tears) was noted in 18 (42%) of 43 menisci with tears. Simultaneous occurrence of grade II or III ipsilateral collateral ligament lesions was present in all 18 displaceable meniscal tears, whereas a normal-appearing collateral ligament or collateral ligament lesion (grade I) was present in 22 of 25 nondisplaceable tears (P < .05). Displaced menisci most commonly had complex, radial, or longitudinal tear configurations (16 of 18, 89%). Patients with displaceable meniscal tears had significantly more pain than did patients with nondisplaceable meniscal tears (P < .001), independent of the concomitant knee abnormalities. CONCLUSION: Displaceable meniscal tears usually have longitudinal, radial, or complex configurations; such tears are associated with substantial ipsilateral collateral ligament lesions and pain.

Adolescent↗
PubMed1997

[Anatomy of the fetlock joint in horses by means of joint casts].

The equine fetlock joint cavity shows ten pouches. The dorsal recess, which is oriented to the proximal side, is separated from those three pouches, which show to the distal direction, by several capsular folds. These folds are documented by means of sagittal sections through the fetlock joint. A medial/lateral recess is covered by the deep part of the collateral ligament of the fetlock joint. The collateral ligaments as well as the sesamoidean collateral ligaments are closely connected with the joint capsule, from which two capsular folds are separated. Between the part of the sesamoidean collateral ligament, that inserts to the metacarpus/metatarsus and the part that inserts to the proximal phalanx, the fetlock joint cavity pouches as Recessus palmaris/plantaris distalis medialis/lateralis. The palmar/plantar distal pouch, which lies in the median line, is covered by the Ligamentum sesamoideum rectum. This recess is narrowed down by the cruciated sesamoidean ligaments. The dominant palmar/plantar proximal recess is subdivided into several small pouches by strings or bands of the joint capsule, which can already be seen with an unaided eye.

Animals↗
PubMed2000

Medial instability of the elbow: findings on valgus load radiography and MRI in 16 athletes.

Medial discomfort of the elbow in athletes can be due to valgus instability after acute ligament rupture or attenuation of the medial collateral ligament caused by repetitive microtrauma during overhead throwing. We studied 16 athletes with medial instability of the elbow due to insufficiency of the medial collateral ligament. 4 patients had sensory ulnar nerve symptoms, of whom 2 had abnormalities of the ulnar nerve on electromyography. 13 showed an increase in the ulno-humeral joint space on dynamic radiography under valgus load. MRI of 10 of these 13 elbows revealed rupture of the medial collateral ligament or avulsion of the medial collateral ligament. Dynamic radiography under valgus load seems to be of value for the diagnosis of chronic medial collateral ligament insufficiency.

Adult↗
PubMedDate not supplied

The effect of arthroscopic sectioning of the lateral ligament complex of the elbow on posterolateral rotatory stability.

This study evaluates the relative roles of the radial collateral ligament, the lateral ulnar collateral ligament, and the overlying musculature in posterolateral rotatory instability of the elbow. Fourteen cadaveric upper limbs underwent sequential arthroscopic sectioning of the lateral collateral ligament complex. After sectioning, arthroscopic and fluoroscopic evaluation of a lateral pivot shift test was done. Minimal instability was noted after the first section, but no difference between radial collateral or lateral ulnar collateral ligament sectioning was found. A greater degree of instability was seen between the first and second cut ( P = .0001), but no significant difference was seen between sectioning the 2 groups ( P = .61). Complete instability occurred only after sectioning the overlying musculature. On the basis of this study, injury to both the radial collateral and lateral ulnar collateral ligaments is necessary to cause significant posterolateral rotatory instability of the elbow. Furthermore, the overlying musculature plays an important role in overall stability.

Arthroscopy↗
PubMed2004

The MRI appearance of cystic lesions around the knee.

This review presents a comprehensive illustrated overview of the wide variety of cystic lesions around the knee. The aetiology, clinical presentation, MRI appearances and differential diagnosis are discussed. Bursae include those related to the patella as well as pes anserine, tibial collateral ligament, semimembranosus-tibial collateral ligament, iliotibial and fibular collateral ligament-biceps femoris. The anatomical extension, imaging features and clinical significance of meniscal cysts are illustrated. Review of ganglia includes intra-articular, extra-articular, intraosseous and periosteal ganglia, highlighting imaging findings and differential diagnoses. The relationship between proximal tibiofibular joint cysts and intraneural peroneal nerve ganglia is discussed. Intraosseous cystic lesions, including insertional and degenerative cysts, as well as lesions mimicking cysts of the knee are described and illustrated. Knowledge of the location, characteristic appearance and distinguishing features of cystic masses around the knee as well as potential imaging pitfalls such as normal anatomical recesses and atypical cyst contents on MR imaging aids in allowing a specific diagnosis to be made. This will prevent unnecessary additional investigations and determine whether intra-articular surgery or conservative management is appropriate.

Bone Cysts↗
PubMed2000

The medial crosssover toe: a cadaveric dissection.

UNLABELLED: The development of a medial crossover second toe (second toe crossing over the first toe) is not a rare clinical condition. It often occurs in the setting of hallux valgus, although not exclusively so. The resulting displacement of the second toe can cause pain in shoes, with surgical correction being problematic. The pathologic anatomy of this condition has not been fully described. In an effort to better understand it, dissection of a cadaveric specimen with a full crossover toe is presented. The dissection revealed findings not previously documented. They include medial displacement of the flexor tendons and plantar plate along with deformity of the plate itself. These changes are in addition to contracture of the medial collateral ligaments and the previously described rupture of the lateral collateral ligaments. Both the plantar plate and the collateral ligaments, the two major static soft tissue stabilizers of the lesser MP joint, were found to be significantly involved. Pull on the flexor tendons only accentuated the malalignment of the toe. CLINICAL SIGNIFICANCE: The extensive soft tissue changes explain the difficulty in achieving a successful long term correction of a full medial crossover toe with a soft tissue procedure. With attenuation of the plantar plate and medial displacement of the flexor tendons, there is an imbalance of muscle forces across the MP joint. This muscle imbalance would not be corrected by release of the medial collateral ligament, dorsal capsular release or extensor tendon lengthening. Reconstruction of the collateral ligament is at risk for incomplete correction since it is unlikely to resolve deformity in the plate if already present.

Cadaver↗
PubMed2003

The biomechanical properties of the finger metacarpophalangeal joints to varus and valgus stress.

PURPOSE: The purpose of this study was to determine the normal biomechanical properties of the passive capsuloligamentous structures about the finger metacarpophalangeal (MCP) joints subjected to dynamic varus/valgus loading and to equate these findings to the clinical situation. METHODS: The finger MCP joints from 9 fresh-frozen cadaver hands were tested in a custom-designed testing apparatus that applied a varus/valgus force in each direction. Testing was performed at 0 degrees, 30 degrees, 60 degrees, and 90 degrees of MCP joint flexion. Load-displacement curves were generated for each specimen. A nonlinear hysteresis curve was apparent on loading and unloading. A region of collateral ligament laxity was identified whereby minimal torque (< 0.5 Nm) caused progressive joint angulation. Subsequently incremental load was required to produce further joint angulation. The slope of this region was used to calculate early and late collateral ligament stiffness. RESULTS: The index and long fingers showed a significant decrease in the region of collateral ligament laxity between 0 degrees and 90 degrees. The long finger collateral ligament laxity also diminished significantly between 30 degrees and 90 degrees. The collateral ligament laxity did not significantly change in the ring and small digits throughout MCP joint flexion. The early or late phase of collateral ligament stiffness was not affected by the amount of MCP joint flexion across any of the digits, except in late radial collateral ligament stiffness of the long finger between 0 degrees and 60 degrees. CONCLUSIONS: The additional stability and clinical observation of tightening of the MCP in flexion appears related to the decreased laxity of the collateral ligaments and not to alterations in the biomechanical properties of the collateral ligaments.

Biomechanical Phenomena↗
PubMed1991

Biomechanical study of ligaments around the elbow joint.

The ligamentous contribution to elbow joint stability is a product of morphology and biologic parameters of each of the collateral ligaments. Better understanding of these characteristics is of paramount importance for successful ligament reconstruction in the surgery for joint replacement and traumatic injury. Two experiments were performed. In the first, the arc of elbow flexion where the individual ligament was either taut or slack was measured; in the second, the structural properties of each collateral ligament were determined by using bone-ligament-bone preparations. The anterior medial collateral ligament (AMCL) and radial collateral ligament (RCL) were taut throughout most of the entire arc of flexion. The posterior medial collateral ligament (PMCL) was taut only when the elbow was in a flexed position. Among the collateral ligaments, the AMCL was the strongest and stiffest with an average failure load of 260 N. The palmaris longus tendon, the most frequently used graft for elbow ligament reconstruction, was similar in strength (357 N).

Biomechanical Phenomena↗
PubMed2000

Functional medical ligament balancing in total knee arthroplasty.

Function of the anterior and posterior oblique portions of the medial collateral ligament and the posterior capsule in flexion and extension was evaluated in eight knee specimens after posterior cruciate retaining total knee arthroplasty. The posterior oblique portion of the medial collateral ligament was released subperiosteally in four specimens, and the anterior portion was released in four specimens. The medial posterior capsule was released in each group, then the remaining portion of the medial collateral ligament was released. Release of the posterior oblique portion produced moderate laxity at full extension and at 30 degrees flexion, and posterior capsule release produced additional laxity in full extension. Release of the anterior portion produced major laxity at 60 degrees and 90 degrees flexion. Complete medial collateral ligament release increased laxity significantly in both groups in flexion and extension. This rationale was tested in a clinical study of 82 knees (76 patients) in which 62 (76%) required medial collateral ligament release to correct varus deformity during posterior cruciate retaining total knee arthroplasty. Twenty-two knees (35.5%) were tight medially in extension only, and were corrected by releasing the posterior oblique portion. Thirty-one knees (50%) were tight medially in flexion only, and were corrected by releasing the anterior portion. Nine knees (14.5%) were tight medially in flexion and extension and required complete medial collateral ligament release, but three knees (4.8%) remained tight in extension and required medial posterior capsule release to correct flexion contracture and medial ligament contracture. Seventeen (27%) had partial posterior cruciate ligament release to correct excessive rollback of the femoral component on the tibial surface.

Arthroplasty, Replacement, Knee↗
PubMed2000

Rehabilitation of the medial collateral ligament-deficient elbow: an in vitro biomechanical study.

The purpose of this study was to determine the relative contribution of muscle activity and the effect of forearm position on the stability of the medial collateral ligament (MCL)-deficient elbow. Simulated active and passive elbow flexion with the forearm in both supination and pronation was performed using a custom elbow testing apparatus. Testing was first performed on intact specimens, then on MCL-deficient specimens. Elbow instability was quantified using an electromagnetic tracking device by measuring internal-external rotation and varus-valgus laxity of the ulna relative to the humerus. Compared with the intact elbow, transection of the MCL, with the arm in a vertical orientation, caused a significant increase in internal-external rotation during passive elbow flexion with the forearm in pronation, but forearm supination reduced this instability. Overall, following MCL transection the elbow was more stable with the forearm in supination than pronation during passive flexion. In the pronated forearm position simulated active flexion also reduced the instability detected during passive flexion, with the arm in a varus and valgus gravity-loaded orientation. The maximum varus-valgus laxity was significantly increased with MCL transection regardless of forearm position during passive flexion. We concluded that active mobilization of the elbow with the arm in vertical orientation during rehabilitation is safe in the setting of an MCL-deficient elbow with the forearm in a fully supinated and pronated position. Splinting and passive mobilization of the MCL-deficient elbow with the forearm in supination should minimize instability and valgus elbow stresses should be avoided throughout the rehabilitation period.

Aged↗
PubMed1999

An irreducible knee dislocation: a case report.

An 8-year-old man presented after sustaining an injury during a fall. A closed reduction attempt failed, and after several tests, an open reduction was performed. With posterolateral dislocation of the knee, there can be anterior cruciate ligament, posterior cruciate ligament, and medial collateral ligament disruption. At the 6-month (final) follow-up, the patient had no subjective pain or instability. With this type of injury, the approach can be conservative monitoring or repair of all of the ligaments. Because of the age and activity level of our patient, we opted for repair of the medial collateral ligament initially with the possibility of late anterior cruciate ligament and/or posterior cruciate ligament reconstruction.

Aged↗
PubMed1991

Epidemiology of acute knee injuries: a prospective hospital investigation.

During a 1-year period, data on all acute injuries treated at emergency departments were entered into a registry; of these injuries, 6% involved the knee joint. The patients were followed until a definite diagnosis was established. The rate of anterior cruciate ligament injuries and meniscus tears was, respectively, 0.3 and 0.7 (injuries per 1,000 inhabitants per year). The rate of dislocations of the patellofemoral joints was equal to the rate of anterior cruciate ligament injuries. Ten percent of the cases involved ligament injuries, and isolated ruptures of the anterior cruciate ligaments were twice as common as combined lesions of this ligament. Injuries of both the collateral ligament and the meniscus represented 6% of the cases. In most age groups male patients predominated, but the frequency of anterior cruciate ligament injuries was similar in both sexes, while the frequency of collateral ligament injuries and meniscus tears varied according to both gender and age. Only 27% of the injuries were associated with sports activities, but they were found twice as often among athletes than people injured in nonathletic accidents. Ruptures of the collateral ligament and anterior cruciate ligament were four and seven times more common among athletes, respectively, while athletes sustained fewer meniscus tears than people involved in nonathletic activities. Half of the patients needed further care after primary treatment, and 18% were primarily (65%) or secondarily (35%) admitted to in-patient care. Operative treatment, including arthroscopic examination, was performed in 20% of cases.(ABSTRACT TRUNCATED AT 250 WORDS)

Acute Disease↗
PubMed1991

Vascular assessment of the periarticular ligaments of the rabbit knee.

While the rabbit is being extensively utilized in animal models for orthopaedic research, the vascular anatomy of the knee ligaments has not been thoroughly described in this species. This study demonstrates the blood supply to the infrapatellar fat pad, the cruciate ligaments, the medial collateral ligament (MCL), and the menisci, such that the effects of manipulating these tissues may be properly interpreted. Vascular injection with India ink and iodinated i.v. contrast dye was performed in 11 New Zealand white rabbits, and routine histology done on six. The large vessel anatomy is similar to that described for humans and dogs, with a descending geniculate artery, medial and lateral superior and inferior geniculate arteries, a posterior geniculate artery, and a recurrent anterior tibial artery. The microvascular anatomy is also similar in that the infrapatellar fat pad and synovial membrane are highly vascular, the menisci are vascularized from their periphery (being avascular centrally), and the medial collateral ligament is relatively well vascularized. A difference from dogs and humans is present in the anterior cruciate ligament (ACL), which is poorly vascularized, with a single artery on its anterior aspect. High magnification histologic evaluation reveals numerous capillaries in the substance of the MCL, while the ACL is nearly devoid of such vessels. The interspecies variation in vascular anatomy is a variable that must be taken into consideration in any surgical or traumatic animal model investigation of knee pathology.

Animals↗
PubMed1992

Reconstruction of the bones and joints of the upper extremity by vascularized free fibular graft: report of 46 cases.

The vascularized free fibular graft was applied in reconstructing bone and joint structures of the upper extremity in 46 cases between August, 1977 and December, 1989. Among these, 30 were grafts of the fibular shaft and 16 were grafts of the fibular head. There were 19 bony defects after trauma or osteomyelitis, 18 bony or articular defects after resection of tumors, five congenital deformities or defects, and four replacements for fibrous dysplasia. The longest grafted fibula was 22 cm and the shortest, 5 cm. Thirty-one cases were followed for more than two years, and these were evaluated for functional ability in daily living, roentgenologic appearance, and 99mTc scan during follow-up. The results revealed quite sufficient functional restoration, solid bone healing, and adequate blood supply, in most cases. The vascularized free fibular head graft appears to be an ideal procedure for the reconstruction of defects of the lower end of the radius or the upper humerus, including the humeral head. The stability of the reconstructed wrist or shoulder joint was maintained by suturing the lateral collateral ligament, the palmar collateral ligament around the wrist, or by passing the long head of the biceps brachii through the grafted fibula at the shoulder. Methods for fixation of the fibular shaft to the recipient bone and the selection of vessels for anastomoses, both in the graft and at the recipient site, are discussed. The importance of postoperative functional exercise is emphasized.

Adult↗
PubMed1993

The functional anatomy of the elbow complex.

The functional anatomy of the elbow joint complex is unique in orientation and configuration. Three bones, the ulna, radius, and humerus, articulate to form four articulations: the humeroulnar, humeroradial, superior radioulnar, and inferior radioulnar joints. This unique osseous structure provides the elbow excellent static stabilization, which is enhanced by the ulnar collateral ligament, the lateral collateral ligament, and the elbow joint capsule. Twenty-three muscles are directly associated with the elbow joint and can be classified into four main groups: the elbow flexors and extensors and the flexor-pronator and extensor-supinator groups. These muscles provide dynamic stabilization to the elbow and enable the hand to perform skilled, precise motions. The purpose of this review article is to provide the clinician with an understanding of the unique anatomy at the elbow joint and to enhance the clinician's knowledge of the biomechanics, clinical examination, and rehabilitation of the elbow complex.

Elbow Joint↗
PubMed2001

Revision total knee arthroplasty: how much constraint is enough?

Revision total knee arthroplasty is a complex situation that requires meticulous technique to restore a functional outcome. The surgical objective is the same as primary total knee arthroplasty: restore the original anatomy, restore function, and provide a stable joint. To this point of stability, it is preferable to implant the prosthesis with the least degree of constraint. Therefore, in the majority of patients undergoing revision surgery, a posterior-stabilized articulation is used. However, if there is functional loss of the medial collateral ligament or lateral collateral ligament, inability to balance the flexion and extension spaces, or a severe valgus deformity, then a constrained condylar prosthesis is necessary.

Arthroplasty, Replacement, Knee↗