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PubMed2005

Pedestrian injuries: viscoelastic properties of human knee ligaments at high loading rates.

OBJECTIVE: Accidents involving pedestrians are very common, and often lead to severe injuries to the lower extremities. In a large portion of pedestrian-automobile collisions, knee ligament injuries are sustained. In this study, the viscoelastic properties of the four major human knee ligaments were investigated at loading rates representative for pedestrian-automobile collisions. METHODS: Bone-ligament-bone specimens were tested in knee distraction loading. The collateral ligaments and the separate functional bundles of the cruciate ligaments were tested in the anatomical position corresponding to a fully extended knee. A series of step-and-hold tests and ramp tests at different rates were conducted to characterize the time-dependent behavior of the knee ligaments for deformation rates associated with the pedestrian impact loading environment. The quasi linear viscoelastic (QLV) theory was used to describe the structural response of the knee ligaments and averaged parameters for this model were determined. RESULTS: The QLV theory was found to be applicable for the time range that is relevant for pedestrian-automobile collisions. The structural behavior of the knee ligaments was found to be particularly rate-sensitive for high elongation rates, as occur during these collisions. The ligament stiffness was found to increase with age for both the collateral ligaments and with weight for the medial collateral ligament. CONCLUSIONS: For the loading conditions that are relevant for pedestrian-automobile collisions, the use of the QLV model for the description of the mechanical behavior of knee ligaments is appropriate. The rate-sensitivity is particularly important for these extreme loading conditions. The relaxation behavior was found to be consistent between different ligament types and samples. Variations due to donor anthropometry were found predominantly for the instantaneous elastic behavior.

Accidents, Traffic↗
PubMedDate not supplied

Elbow joint stability following experimental osteoligamentous injury and reconstruction.

Elbow joint dislocation was simulated in cadaveric specimens to quantify laxity induced by radial head and coronoid process lesions, either alone or in combination with collateral ligament insufficiency. The effects of lateral ligament reconstruction and radial head prosthesis replacement were also considered. Absence of the radial head and the coronoid process induced rotatory laxity of 145% and 128% (both P <.01), respectively, compared with the intact joint. When both were absent, the joints subluxated regardless of collateral ligament status. Isolated radial head prosthesis implantation prevented this subluxation, and laxity almost normalized. Lateral collateral ligament reconstruction prevented major laxity even in the absence of the radial head. Lateral collateral ligament reconstruction and radial head prosthetic replacement yielded restraint against gross instability in the maximal unstable situation (terrible triad). The lateral collateral ligament is the prime stabilizer to external rotation, and reconstruction of this alone, even with an absent radial head, is beneficial.

Aged↗
PubMedDate not supplied

Dynamic stability of the elbow: electromyographic analysis of the flexor pronator group and the extensor group in pitchers with valgus instability.

The medical collateral ligament is a common site of injury in baseball pitchers, causing substantial morbidity and loss of pitching time. Twenty-six skilled baseball pitchers with medial collateral ligament insufficiency were studied before surgery with high-speed cinematography and fine-wire electromyography of eight muscles around the elbow. Data from the pitchers with injured elbows were compared with data obtained from uninjured pitchers. The flexor carpi radialis muscle in the pitchers with medial collateral ligament deficiencies revealed significantly decreased firing during the acceleration and deceleration phase of the fastball when compared with that of the pitchers with normal elbows, and the flexor carpi radialis muscle was significantly depressed during the early cocking and deceleration phases. The extensor muscles revealed slightly increased activity in the injured elbows; however, this was not statistically significant. Although the muscles of the flexor pronator group (especially the flexor carpi ulnaris muscle and the flexor digitorum superficialis muscles) are anatomically positioned to provide dynamic stability of the elbow, they did not demonstrate increased electrical activity in pitchers with medial collateral ligament deficiencies. This finding suggests that the muscles on the medial side of the elbow do not supplant the role of the medial collateral ligament during the fastball pitch.

Baseball↗
PubMed1977

Post-traumatic instability of the metacarpophalangeal joint of the thumb.

Of eithty-six patients with collateral ligament instability of the metacarpophalangeal joint of the thumb, sixty-six (77 per cent) had ulnar and twenty (23 per cent) had radial instability, while in addition twenty-four had fractures and twenty-nine had volar subluxation of the proximal phalanx. Of the sixty-nine patients operated on, sixty-five had an abnormality of the ulnar or radial collateral ligament proper or of its attachment; two, subluxation of the extensor pollicis longus; and two, stretching of the adductor expansion. Stability was restored by collateral ligament repair or reconstruction, by fixation of a fracture fragment with a Kirschner wire, or by arthrodesis in all but five thumbs. Of the five patients who did not have stability of the metacarpophalangeal joint following surgery, three had had the collateral ligament sutured more than three weeks after injury and two had had reconstruction of the collateral ligament using a tendon graft. Early surgical treatment is recommended for all patients with post-traumatic instability of the metacarpophalangeal joint greater than 45 degrees and for those with volar subluxation of the proximal phalanx or a displaced fracture of the base of the proximal phalanx. Collateral ligament repair is indicated for patients operated on within three weeks of injury, and reconstruction of the ligament by means of a tendon graft is recommended for those treated more than three weeks after injury.

Adolescent↗
PubMed1984

Ligamentous structures of the metacarpophalangeal joint: a quantitative anatomic study.

The ligamentous structure of the metacarpophalangeal (MCP) joint of the index finger in human cadavers was studied by gross examination and quantitative measurement. Anatomically, the collateral ligament is separable into two layers, with the precise origin arising from the metacarpal head and inserting on the proximal phalanx. Quantitatively, the change in length of the collateral ligament was studied with biplanar radiographic techniques. The distance between the origin and insertion of the collateral ligament changed in different portions of the ligament when the joint was moved from a position of hyperextension to that of flexion. When the MCP joint was flexed from 0 degree to 80 degrees, the dorsal portions of both the radial and ulnar collateral ligaments were lengthened (3-4 mm). The middle portions of both ligaments were slightly elongated (0.4-1.0 mm), and the volar portions of the ligaments were shortened (1-2 mm). When the MCP joint extended into hyperextension, the dorsal portions of the ligaments shortened 2-3 mm, the middle thirds of the ligaments shortened slightly, and the volar thirds of the ligaments lengthened. The results of this study suggest that the dorsal and volar portions of the collateral ligament provide MCP joint constraint at the flexed and extended positions, respectively.

Biomechanical Phenomena↗
PubMed2004

Chronic finger joint instability reconstructed with bone-ligament-bone graft from the iliac crest.

Five patients with chronic instability of digital joints presented with instability and functional disability. Two patients had ulnar collateral ligament damage of the thumb metacarpophalangeal joint and another had chronic multidirectional instability due to radial collateral ligament, dorsal capsule and palmar plate laxity of the metacarpophalangeal joint of the thumb. The fourth patient had a lax radial collateral ligament and palmar plate of the proximal interphalangeal joint of the little finger and the fifth had chronic laxity of the ulnar collateral ligament of the interphalangeal joint of the thumb. All were reconstructed with bone-ligament-bone graft harvested from the iliac crest. The graft was fixed with screws and joint stability was achieved intra-operatively in all patients. All patients achieved a stable joint with improved functional performance at final follow-up.

Adult↗
PubMed2005

Effects of elbow flexion and forearm rotation on valgus laxity of the elbow.

BACKGROUND: Clinical evaluation of valgus elbow laxity is difficult. The optimum position of elbow flexion and forearm rotation with which to identify valgus laxity in a patient with an injury of the ulnar collateral ligament of the elbow has not been determined. The purpose of the present study was to determine the effect of forearm rotation and elbow flexion on valgus elbow laxity. METHODS: Twelve intact cadaveric upper extremities were studied with a custom elbow-testing device. Laxity was measured with the forearm in pronation, supination, and neutral rotation at 30 degrees, 50 degrees, and 70 degrees of elbow flexion with use of 2 Nm of valgus torque. Testing was conducted with the ulnar collateral ligament intact, with the joint vented, after cutting of the anterior half (six specimens) or posterior half (six specimens) of the anterior oblique ligament of the ulnar collateral ligament, and after complete sectioning of the anterior oblique ligament. Laxity was measured in degrees of valgus angulation in different positions of elbow flexion and forearm rotation. RESULTS: There were no significant differences in valgus laxity with respect to elbow flexion within each condition. Overall, for both groups of specimens (i.e., specimens in which the anterior or posterior half of the anterior oblique ligament was cut), neutral forearm rotation resulted in greater valgus laxity than pronation or supination did (p < 0.05). Transection of the anterior half of the anterior oblique ligament did not significantly increase valgus laxity; however, transection of the posterior half resulted in increased valgus laxity in some positions. Full transection of the anterior oblique ligament significantly increased valgus laxity in all positions (p < 0.05). CONCLUSIONS: The results of this in vitro cadaveric study demonstrated that forearm rotation had a significant effect on varus-valgus laxity. Laxity was always greatest in neutral forearm rotation throughout the ranges of elbow flexion and the various surgical conditions. CLINICAL RELEVANCE: The information obtained from the present study suggests that forearm rotation affects varus-valgus elbow laxity. Additional investigation is warranted to determine if forearm rotation should be considered in the evaluation and treatment of ulnar collateral ligament injuries of the elbow joint.

Aged↗
PubMed1978

Assessing ulnar instability of the metacarpophalangeal joint of the thumb.

Seven hundred and fifty normal thumbs were examined to determine the normal range of radioulnar mobility of the metacarpophalangeal joint with the joint in full extension, 15 degrees of flexion, and full flexion. Full flexion was the position of greatest stability. Twenty-five adult unembalmed cadaver thumbs were examined to determine the optimal position for testing the metacarpophalangeal joint for ulnar collateral ligament stability. When radial stress was applied to the metacarpophalangeal joint of 20 specimens after cutting the adductor aponeurosis and capsule, minimal ulnar instability was found. However, further sectioning of the ulnar collateral ligament revealed marked ulnar instability most significantly when the thumbs were examined in full metacarpophalangeal flexion. Finally, division of the adductor aponeurosis, dorsal capsule, ulnar collateral ligament, accessory collateral ligament, and volar plate resulted in complete instability of the metacarpophalangeal joint in all positions tested.

Biomechanical Phenomena↗
PubMed2004

Anatomical basis for functional treatment of dorsolateral dislocation of the proximal interphalangeal joint.

Dorsolateral dislocation of the proximal interphalangeal (PIP) joint is a common injury to the hand. Closed reduction of the dislocation anatomically realigns the avulsed ligaments; thus patients may be managed non-operatively. Standard treatment involves placement of a dorsal splint to prevent hyperextension and lateral stresses. This allows early active motion of the PIP joint while preventing a flexion contracture. In this fresh cadaver study, the PIP joint in 24 fingers was dorsolaterally dislocated. Four digits had to be excluded from the investigation due to a fracture dislocation with a bony fragment of >40% of the articular surface of the middle phalanx. After closed reduction, seven digits were further studied using the cryosection technique described by Kathrein et al. (1996, Clin. Anat. 9:227-231) to demonstrate the position of the avulsed palmar plate. In another 13 joints, the torn ligaments were examined by gross dissection. In 10 degrees of finger flexion, the avulsed palmar plate lay at its previous attachment to the base of the middle phalanx. The collateral ligament, ruptured at its attachment to the side of the head of the proximal phalanx, returned to its original position and was not interposed in the joint. The split between the collateral ligament and the accessory collateral ligament was also closed. Our data suggest that the ligamentous structures of the PIP joint, namely the palmar plate and collateral ligaments, typically return to their anatomic positions upon simple closed reduction of dorsolateral dislocations in fresh cadavers.

Aged↗
PubMedDate not supplied

Avulsion fracture of the ulnar sublime tubercle in overhead throwing athletes.

BACKGROUND: Injuries to the ulnar collateral ligament are relatively common in throwing athletes and result from either acute traumatic or repeated valgus stress to the elbow. Avulsion fracture of the sublime tubercle of the ulna is a rarely reported site of ulnar collateral ligament injury. PURPOSE: We retrospectively reviewed our cases of ulnar collateral ligament injuries to study avulsion fractures of the sublime tubercle of the ulna. STUDY DESIGN: Case series. METHODS: Data, including radiographs and magnetic resonance imaging scans, were obtained by review of hospital and office records and by follow-up examination. Of 33 consecutive patients treated for ulnar collateral ligament injuries, 8 had avulsion fractures of the sublime tubercle of the ulna. All eight were male baseball players with dominant arm involvement, an average age of 16.9 years, and an average follow-up of 23.6 months. RESULTS: Six of eight patients had failure of nonoperative treatment and required surgical repair. Two of the six underwent ulnar collateral ligament reconstruction and four had direct repair of the sublime tubercle avulsion with bioabsorbable suture anchors. At last follow-up, all eight had returned to their preinjury level of activity. No patient had residual medial elbow pain or laxity. CONCLUSIONS: Diagnosis of sublime tubercle avulsion fracture is made with history, physical examination, and radiographic studies. Magnetic resonance imaging can help identify an avulsion fracture not visible radiographically and can help determine whether direct repair or reconstruction is needed.

Adolescent↗
PubMed1979

[Comments on the lateral load capacity of the phalangeal joints (author's transl)].

The article compares the load capacity of the collateral ligaments of the metacarpo-phalangeal and interphalangeal joints exposed to a laterally applied force. The tests were performed in vivo with 50 each female and male volunteers. It was found that the average load capacity of the metacarpo-phalangeal and interphalangeal joints in women was 5.8 kp and in men 12.3 kp. Furthermore, the bones of the long fingers with the preserved joint capsules and collateral ligaments of ten corpses were also examined, and the collateral ligaments exposed to a load which was increased to the point of their destruction. The average values found in this manner were 26.5 kp for the metacarpo-phalangeal collateral ligaments and 15.4 kp for the interphalangeal collateral ligaments. This means that the pain threshold is usually below the destruction limit, so that generally there will be no spontaneous overloading. It is important for the construction of endoprostheses that their stability level should always be above that of the pain threshold and should attain at least the values of the tear tests, since otherwise these endoprotheses will not function properly. These basic prerequisites enable a comparative study of endoprostheses, the results of which will be presented at a later date.

Adult↗
PubMed2005

The use of knee braces, part 1: Prophylactic knee braces in contact sports.

Surrogate knee model biomechanical studies have indicated that off-the-shelf braces provide 20% to 30% greater resistance to a lateral blow when the knee is in full extension. Custom functional braces doubled the protective effects and proved effective with the knee in some flexion. Although functional performance studies are not consistent, preventive knee braces may slow straight-ahead sprint speed, cause early fatigue, and increase muscular relaxation pressures, energy expenditure, blood lactate levels, maximal torque output, oxygen consumption, and heart rate. Two epidemiologic studies have been performed. At West Point, a randomized control study of 71 injuries in 1396 cadets indicated knee brace effectiveness with a statistically higher rate of injury in the control group (3.4/1000 exposures) than in the braced group (1.5/1000 exposures), with the most significance for medial collateral ligament sprains in defensive players. The Big Ten Conference conducted a descriptive study of 100 medial collateral ligament sprains among 987 players in different positions, strings, and types of session. Brace-wear tendency varied directly with the unbraced player counterpart's risk of medial collateral ligament sprain, with the nonplayer linemen experiencing both the greatest risk of unbraced practice session injury (0.0801 injuries/1000 exposures) and the highest incidence of brace wear (85%). During practices, there was a nonsignificant but very consistent reduction in injury rate for braced players in every position and string. During games, there was also a reduced rate for linemen and the linebacker/tight end group. The study concluded that although the issue is not closed, preventive knee braces appear to offer some protection to the medial collateral ligament from a contact injury involving a valgus blow, but there may be negative effects on performance level, leg cramping, and fatigue symptoms.

Anterior Cruciate Ligament Injuries↗
PubMed2002

Biomechanical evaluation of the elbow using roentgen stereophotogrammetric analysis.

The medial collateral ligament complex is the primary constraint of the elbow to valgus forces and is composed of the anterior bundle, the posterior bundle, and a transverse part. Total and partial ruptures have been described. Clinical and radiologic examinations of medial or valgus instability of the elbow are difficult. The effect of different stages of medial collateral ligament ruptures on ulnohumeral movement in cadavers was determined to rationalize the use of physical and radiologic examinations in different stages of valgus instability in vivo. Using roentgen stereophotogrammetric analysis, motion is determined between the humerus and ulna under valgus load and between the humerus and radius during maximal pronation of the forearm after various dimensions of medial collateral ligament lesions. The increase in distance between the humerus and ulna under a 15 N valgus load varied from 2.7 mm to 9.8 mm. The increase in distance between the humerus and proximal radius with the forearm in pronation in an intact specimen and after transsection of the anterior medial collateral ligament and posterior medial collateral ligament in the anterior direction was 9.7 mm. These results suggest that detection of partial ruptures with clinical and radiologic examinations is difficult. Anterior movement of the radial head can be used as an additional parameter of valgus instability.

Aged↗
PubMedDate not supplied

Computed tomographic arthrography of the normal canine stifle.

Computed tomographic (CT) imaging of eight normal cadaveric canine stifles was performed before and after intra-articular administration of iodinated contrast medium. Transverse CT images were reconstructed in dorsal, parasagittal, and oblique planes. The following ligamentous structures were identified on transverse CT images in all stifles: cranial cruciate ligament, caudal cruciate ligament, medial meniscus, lateral meniscus, and the medial and lateral collateral ligaments. The following ligamentous structures were identified on transverse computed tomographic arthrography (CTA) images in all stifles: cranial cruciate ligament, caudal cruciate ligament, medial meniscus, lateral meniscus, meniscofemoral ligament, cranial meniscotibial ligaments, caudal meniscotibial ligaments, intermeniscal (transverse) ligament, and the medial and lateral collateral ligaments. The patellar tendon was identified on transverse and reconstructed dorsal and sagittal CT and CTA images in all stifles. Multiplanar reconstructions enabled further evaluation of the continuity of the cranial and caudal cruciate ligaments and menisci. The medial and lateral collateral ligaments were not clearly identified on CT or CTA multiplanar reconstructed images.

Animals↗
PubMed1992

Ligamentous reconstruction for posterolateral rotatory instability of the elbow.

Eleven consecutively seen patients who had posterolateral rotatory instability of the elbow joint were managed operatively. The radial collateral-ligament complex was advanced and imbricated in three of them. In seven patients, the ulnar band of the radial collateral ligament (the lateral ulnar collateral ligament) was reconstructed with the palmaris longus tendon and in two of the seven, the reconstruction was augmented with a prosthetic ligament. The ligament was reconstructed with the lateral one-third of the triceps fascia in the remaining patient. Stability was obtained in ten patients, and seven patients had an excellent functional result. There was one failure in one of the patients in whom the ulnar band of the radial collateral ligament had been reconstructed with the palmaris longus tendon and augmented with a prosthetic ligament.

Adolescent↗
PubMed1998

Total knee arthroplasty in morbidly obese patients.

We reviewed the clinical outcomes of fifty primary total knee arthroplasties that had been performed with cement in forty patients who were considered morbidly obese (a Quetelet index of more than forty). These results were compared with those of 1768 similar procedures, performed during the same time-period by the same surgeon, in 1539 patients who were not morbidly obese (controls). At a mean of approximately five years postoperatively, there was a significant difference between the morbidly obese patients and the control group with regard to the knee and functional scores (84 and 53 points compared with 92 and 67 points; p < 0.00005 for both scores). No significant difference was detected, with the numbers available, with regard to the range of motion or the radiographic score (p = 0.77). The rate of perioperative complications was significantly higher in the morbidly obese patients (p < 0.00005). Of the fifty knees in these patients, eleven (22 percent) had a wound complication, five (10 percent) had an infection, and four (8 percent) had an avulsion of the medial collateral ligament. The five infections developed within twenty weeks after the operation, and three were associated with a wound complication. In comparison, thirty-five (2 percent) of the 1768 knees in the control group had a wound complication, eleven (0.6 percent) had an infection, and none had an avulsion of the medial collateral ligament. We concluded that total knee arthroplasty in morbidly obese patients can be successful but is associated with an increased rate of perioperative complications, including problems with wound-healing, infection, and avulsion of the medial collateral ligament. Alterations in the operative technique for soft-tissue closure and protection of the medial collateral ligament have decreased the rates of complications related to wound-healing and the medial collateral ligament.

Arthroplasty, Replacement, Knee↗
PubMedDate not supplied

Kinematics of the lateral ligamentous constraints of the elbow joint.

Thirty osteoligamentous elbow joint specimens were included in a study of the lateral collateral ligament complex (LCLC). The morphologic characteristics of the LCLC were examined, and then three-dimensional kinematic measurements were undertaken after selective ligament dissections were performed. Isolated sectioning of the annular ligament (AL) or the lateral ulnar collateral ligament (LUCL) induced only minor laxity to the elbow joint with a maximum of 2.2 degrees and 4.4 degrees during forced varus and external rotation (supination), respectively. Transsection of the lateral collateral ligament (LCL) caused a maximal laxity of 15.4 degrees and 22.8 degrees during forced varus and external rotation (supination), respectively. Combined ligament dissections showed that total transection of the LCLC at the ulnar or the humeral insertion was important for joint laxity. Total transection of the LCLC at the humeral or the ulnar insertion induced a maximal laxity of 24.5 degrees and 37 degrees during forced varus and external rotation (supination), respectively. This study suggests the AL and the LUCL are of minor importance as constraints when cut separately, whereas the LCL is a significant preventer of elbow joint laxity. The LCLC was observed to be a complex structure of ligamentous fibers rather than discreet bands. The LCLC forms a ligamentous constraint between the lateral humeral epicondyle and the ulna, stabilizing the elbow joint and forming a base for radial head stability and rotation.

Aged↗