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PubMed2005

MR imaging of the metacarpophalangeal joints of the fingers: evaluation of 38 patients with chronic joint disability.

OBJECTIVE: To report the MR imaging findings of painful injured metacarpophalangeal (MCP) joints of the fingers. DESIGN AND PATIENTS: MR imaging of 39 injured MCP joints in 38 patients was performed after a mean delay of 8.8 months. The MR images were obtained with the fingers in extended and flexed positions using T2-weighted and T1-weighted sequences before and after intravenous injection of a gadolinium compound. Ten patients were treated surgically. Mean clinical follow-up was 1.8 years. RESULTS: Tears of the collateral ligaments were the most common lesion (30/39), most being radial in location. Contrast-enhanced axial T1-weighted images with the MCP joint in a flexed position showed these lesions optimally. Ten tears were partial and 20 were complete. In 13 patients, MR images showed 17 associated lesions including injuries of the extensor hood (10/17), interosseous tendon (3/17), palmar plate (3/17), and an osteochondral lesion (1/17). Sagittal MR images were essential to highlight palmar plate tears. CONCLUSION: Partial or complete tears of the collateral ligaments are prevalent MR imaging findings in patients with chronic disability resulting from injuries to the MCP joints. Although conservative treatment generally is sufficient for isolated injuries of the collateral ligaments, surgical repair is often required in cases of more extensive injuries. MR imaging may clearly delineate associated lesions of and about the MCP joints.

Adolescent↗
PubMed2001

Sonographic examination of lateral epicondylitis.

OBJECTIVE: The purpose of this study was to describe the sonographic appearance of the common extensor origin in cadavers and asymptomatic volunteers, and to relate this appearance to the findings in patients with lateral epicondylitis. SUBJECTS AND METHODS: Seventy-two elbows in 71 patients with lateral epicondylitis were examined on sonography. Most of the patients (60/71) gave a history of repetitive microtrauma. The injuries were evaluated with respect to location and severity. Focal areas of degeneration, discrete cleavage tears, and involvement of the lateral collateral ligament were identified. Calcification and bony changes were noted. The appearance of the normal common extensor tendon was described, and cadaveric specimens were dissected. Twenty-one patients subsequently underwent surgery. RESULTS: The normal common extensor origin is composed of longitudinal fibrils bound closely with the extensor carpi radialis brevis constituting most of the deep fibers, with the extensor digitorum making up the superficial part. The lateral collateral ligament can be identified as a discrete and separate band. The most common appearance of lateral epicondylitis is a focal hypoechoic area in the deep part of the tendon (46/72). These focal areas were identified at surgery and corresponded histologically to collagen degeneration with fibroblastic proliferation. Often discrete cleavage planes traversing the tendon were manifest as partial (18/72) and complete (2/72) tears. The lateral collateral ligament was involved in eight of 72 elbows. CONCLUSION: Sonography of the common extensor origin can be used to confirm lateral epicondylitis in patients with lateral elbow pain and provide information about the severity of the disease.

Adult↗
PubMed1987

Valgus stability of the elbow.

The valgus stabilizers of the elbow have been identified anatomically, but their relative importance has not been quantified. The purpose of this study was to analyze the acute changes of the torque-displacement curve to valgus stress following (a) section of the posterior portion of the medial collateral ligament; (b) excision of the radial head; (c) prosthetic replacement of the radial head; and (d) excision of the anterior portion of the medical collateral ligament. Thirty cadaver specimens underwent load-displacement testing in three positions: 0 degrees, 45 degrees, and 90 degrees of flexion. The anterior portion of the medial collateral ligament was the primary stabilizer of the elbow to valgus stress. The relative contribution of the posterior ligament was minimal. After excision of the radial head alone, the slope of the load-displacement curve decreased an average of 30%. Silicone rubber radial head replacement did not significantly improve the stability to valgus stress after radial head excision.

Biomechanical Phenomena↗
PubMed2003

Application of screw displacement axes to quantify elbow instability.

OBJECTIVES: To determine if screw displacement axis patterns describing elbow joint motion: (1) change after ligament transection in vitro; (2) can reflect subtle changes in stability as a function of forearm position; (3) can reflect dynamic stabilization of the ligament insufficient elbow provided by muscle activity.Design. An in vitro kinematic study of eighteen cadaveric specimens tested in a joint simulator. BACKGROUND: In the elbow joint, screw displacement axes have been employed for proper positioning and design of endoprostheses. The effect of instability on screw displacement axes has not been previously reported. METHODS: Passive and simulated active flexion, with the forearm maintained in both pronation and supination, was performed on eighteen intact and ligament insufficient elbows. Instability was produced by transection of the medial collateral or lateral collateral ligament complexes. Kinematics were recorded using an electromagnetic tracking device and analyzed with a repeated measures design. RESULTS: During passive motion, division of either ligament caused deviation of screw displacement axes compared to the intact state (P<0.05). Transection of the medial/lateral collateral ligament generated greater instability with the forearm maintained in pronation/supination compared to supination/pronation (P<0.05). Muscle activation increased stability similar to the intact state (P>0.05). CONCLUSIONS: These results are consistent with observations determined using traditional kinematic descriptors. Screw displacement axes can readily detect changes in stability due to ligament sectioning. RELEVANCE: Clinicians can employ the screw displacement axis technique as a succinct descriptor of motion to readily detect elbow instability.

Aged↗
PubMedDate not supplied

Radial head fractures: MRI evaluation of associated injuries.

The purpose of this study was to evaluate the incidence of combined osteochondral and ligamentous injuries by magnetic resonance imaging (MRI) in 24 patients with an acute radial head fracture (Mason type II and III) without documented dislocation or tenderness at the distal radioulnar joint. Elbow radiographs (anteroposterior and lateral views) were obtained on all patients as well as magnetic resonance images in the sagittal, coronal, axial, axial oblique, and coronal oblique planes with the injured elbow in a splint. The incidence of associated injuries revealed by MRI was medial collateral ligament not intact in 13 of 24 (54.16%), lateral ulnar collateral ligament not intact in 18 of 24 (80.1%), both collateral ligaments not intact in 12 of 24 (50%), capitellar osteochondral defects in 7 of 24 (29.1%), capitellar bone bruises in 23 of 24 (95.83%), and loose bodies in 22 of 24 (91.67%). A high level of suspicion should be used when one is treating displaced or comminuted radial head fractures, because concurrent osteochondral injuries and/or ligamentous injuries may be present.

Adult↗
PubMed2006

3T MR imaging of the musculoskeletal system (Part II): clinical applications.

The gain in SNR that is afforded by 3T MR imaging systems has tremendous clinical applications in the musculoskeletal system. The potential for demonstrating and enhancing the visibility of normal osseous, tendinous, cartilaginous, and ligamentous structures is exciting. Furthermore, harnessing this added signal to increase spatial resolution may improve our diagnostic abilities in various joints dramatically. Radiologists have enjoyed great success in assessing joint disease with current MR imaging field strengths; however, many intrinsic joint structures remain poorly evaluated, which leads to a golden opportunity for 3T MR imaging. The articular cartilage of the knee, the glenoid labrum of the shoulder, the intrinsic ligaments and TFC of the wrist, the collateral ligaments of the elbow, the labrum and articular cartilage of the hip, and the collateral ligaments of the ankle have been evaluated suboptimally on 1 .5T systems using routine nonarthrographic MR images. Because of the enhanced SNR, the higher spatial resolution, and the greater CNR of intrinsic joint structures at higher field strengths, 3T MR imaging has the potential to improve diagnostic abilities in the musculoskeletal system vastly, which translates into better patient care and management. The author's 2 years of clinical experience with musculoskeletal MR imaging on 3T systems has met and exceeded his expectations, and has bolstered the confidence of his orthopedic surgeons in his diagnoses. As coil technology advances and as the use of parallel imaging becomes more available in the extremities, the author expects to see even more dramatic improvements in image quality.

Humans↗
PubMedDate not supplied

MR assessment of posttraumatic flexion contracture of the elbow.

Preoperative assessment of posttraumatic flexion contracture of the elbow includes plain radiographs and tomograms, which are difficult to obtain in the coronal plane due to the contracture. We conducted this study to determine the usefulness of MR imaging in the work-up of these patients. Twelve patients with flexion contracture of the elbow were studied. In addition to standard spin-echo sequences, a sagittally acquired spoiled gradient-recalled echo 3D data set of the flexed elbow was obtained and reformatted coronally using a curved plane of reconstruction. The MR findings were compared to the plain films, tomograms and surgical results. MRI allowed identification of loose bodies that were sometimes poorly visualized, or not seen, on plain films, and demonstrated degenerative changes equally as well as tomograms. MR showed soft tissue abnormalities including capsular and collateral ligament thickening. Curvilinear reconstructions were helpful in the assessment of collateral ligaments in patients with severe contractures. We conclude that MR is useful in the evaluation of elbow flexion contractures, particularly in assessing soft tissue causes.

Adult↗
PubMed1998

Vascular volume determination of articular tissues in normal and anterior cruciate ligament-deficient rabbit knees.

The vasculature of diarthroidal joints has been well documented; however, the volume of vessels supplying different articular tissues is unknown. Angiogenesis, the formation of new vessels from preexisting ones, is difficult to quantify in joints due to the unavailability of a suitable technique. Although angiogenesis is known to occur in rheumatoid arthritis, the development of new vessels following joint injury has not been ascertained. A vascular casting technique was developed using carmine red dye to measure the vascular volume of the medial collateral ligament (MCL), lateral collateral ligament (LCL), menisci, medial capsule, and infrapatellar fat pad of the rabbit knee joint. Vascular volume determinations were repeated at 4 weeks in a group of anterior cruciate ligament (ACL)-transected animals and in a sham-operated control group. The volume of vessels supplying the MCL was estimated to be 0.22 +/- 0.07 microliter (mean +/- S.E.M.), the LCL volume was 0.25 +/- 0.05 microliter, the medial meniscus volume was 0.19 +/- 0.03 microliter, the lateral meniscus volume was 0.40 +/- 0.08 microliter, the medial capsule volume was 0.14 +/- 0.05 microliter, and the infrapatellar fat pad volume was 1.90 +/- 0.62 microliters. Following ACL transection, angiogenesis was found to occur in the MCL only. All other tissue vascularities were not significantly different from sham-operated controls. A quantifiable method for measuring vascular volume of knee joint tissues has been described. Joint instability stimulates angiogenesis in the ipsilateral MCL; however, the absence of angiogenic activity in other articular tissues might help explain the lack of posttraumatic healing associated with these joints.

Animals↗
PubMed1995

The effect of variable relative insertion orientation of human knee bone-ligament-bone complexes on the tensile stiffness.

In order to evaluate the contribution of the knee ligaments to restrain joint motions, knowledge about their structural properties is required. Due to the variable relative insertion orientation of the ligaments during knee motion, however, different fiber bundles are recruited, each with their specific mechanical properties. Hence, the structural properties vary as a function of knee motion. For this reason, a relationship between the structural tensile properties and the relative insertion orientation is required in order to define the role of the ligaments in knee mechanics. In the present study, this relationship is determined by performing a series of tensile tests in which the relative orientations of the insertion sites of human knee bone-ligament-bone preparations were varied systematically. The experimentally obtained stiffness was significantly affected by the relative orientation of the insertion sites, but more profoundly for the anterior and posterior cruciate ligaments (ACL and PCL) as compared to the medial and lateral collateral ligaments (MCL and LCL). The average decreases in stiffness per 5 degrees tilt of the insertion sites were estimated at -11.6 +/- 3.5 N mm-1 (ACL), -20.9 +/- 2.7 N mm-1 (PCL), -2.6 +/- 0.9 N mm-1 (MCL) and -3.7 +/- 0.3 N mm-1 (LCL). For the PCL and the MCL these changes in stiffness with tilt were rather insensitive to the side of the femoral insertion site which was lifted. The ACL and the LCL, conversely, displayed significant differences in stiffness changes between the different tilt directions.(ABSTRACT TRUNCATED AT 250 WORDS)

Aged↗
PubMed2005

[Soft tissue management in knees with varus deformity. Computer-assisted sequential medial ligament release].

BACKGROUND: Knees with severe varus deformities and contractures of the medial and lateral collateral ligaments and the posterior capsule require special soft tissue management to gain a stable knee over the full range of movement. The introduction of navigation systems into knee surgery has now made precise measurement of the leg axis and gap size possible. METHODS: Ten knee joints received a computer-assisted total knee replacement (Ci navigation system DePuy) I-Orthopaedics, Munich). The change of the leg axis and the size of the mediolateral gaps were measured and documented when performing a standardized medial ligament release sequence. RESULTS: We found a significant effect after each release step regarding the change of the leg axis as well as the gap width (p<0.001). The highest effect was seen for the 6-cm capsule release in extension and the release of the medial collateral ligament in 90 degrees flexion. CONCLUSION: Implementation of computer-assisted navigation facilitates visualization and quantification of the effect of the sequential medial soft tissue release in total knee arthroplasty.

Arthroplasty, Replacement, Knee↗
PubMed1996

Characterization of the mechanical behavior of human knee ligaments: a numerical-experimental approach.

During knee-joint motions, the fiber bundles of the knee ligaments are nonuniformly loaded in a recruitment pattern, which depends on successive relative orientations of the insertion sites. These fiber bundles vary with respect to length, orientation and mechanical properties. As a result, the stiffness characteristics of the ligaments as a whole are variable during knee-joint motion. The purpose of the present study is to characterize this variable mechanical behavior. It is hypothesized that for this purpose it is essential to consider the ligaments mechanically as multi-bundle structures in which the variability in fiber bundle characteristics is accounted for, rather than as one-dimensional structures. To verify this hypothesis, bone-ligament-bone preparations of the ligaments were subjected to series of unidirectional subfailure tensile tests in which the relative insertion orientations were varied. For each individual test specimen, this series of tensile tests was simulated with a mathematical ligament model. Geometrically, this model consists of multiple line elements, of which the insertions and orientations are anatomically based. In a mathematical optimization process, the unknown stiffness and recruitment parameters of the line elements are identified by fitting the variable stiffness characteristics of the model to those of the test series. Thus, lumped parameters are obtained which describe the mechanical behavior of the ligament as a function of the relative insertion orientation. This method of identification was applied to all four knee ligaments. In all cases, a satisfactory fit between experimental results and computer simulation was obtained, although the residual errors were lower for the cruciate ligaments (1.0-2.4%) than for the collateral ligaments (3.7-8.1%). It was found that models with three or less line elements were very sensitive to geometrical parameters, whereas models with more than 7 line elements suffered from mathematical redundancy. Between 4 and 7 line elements little difference was found. It is concluded that the present ligament models can realistically simulate the variable tensile behavior of human knee ligaments. Hereby the hypothesis is verified that it is essential to consider the ligaments of the knee as multi-bundle structures in order to characterize fully their mechanical behavior.

Aged↗
PubMedDate not supplied

Avulsion fracture of the tibial eminence associated with severe medial ligamentous injury in an adolescent. A case report and literature review.

In the presence of open physes, tibial eminence fractures are usually isolated injuries. However, adults sustaining a fracture of the tibial eminence are more likely to have other associated injuries, most commonly a tear of the medial collateral ligament. A case of an adolescent with a tibial eminence fracture and a complete tear of the medial collateral ligament is reported. Review of the literature revealed two similar cases in adolescents. If medial instability is demonstrated on valgus stress of the knee in an adolescent with tibial eminence fracture, we believe stress roentgenograms of the knee should be obtained to distinguish between physeal injury and collateral ligament tear.

Adolescent↗
PubMed2002

A finite element model of the human knee joint for the study of tibio-femoral contact.

As a step towards developing a finite element model of the knee that can be used to study how the variables associated with a meniscal replacement affect tibio-femoral contact, the goals of this study were 1) to develop a geometrically accurate three-dimensional solid model of the knee joint with special attention given to the menisci and articular cartilage, 2) to determine to what extent bony deformations affect contact behavior, and 3) to determine whether constraining rotations other than flexion/extension affects the contact behavior of the joint during compressive loading. The model included both the cortical and trabecular bone of the femur and tibia, articular cartilage of the femoral condyles and tibial plateau, both the medial and lateral menisci with their horn attachments, the transverse ligament, the anterior cruciate ligament, and the medial collateral ligament. The solid models for the menisci and articular cartilage were created from surface scans provided by a noncontacting, laser-based, three-dimensional coordinate digitizing system with an root mean squared error (RMSE) of less than 8 microns. Solid models of both the tibia and femur were created from CT images, except for the most proximal surface of the tibia and most distal surface of the femur which were created with the three-dimensional coordinate digitizing system. The constitutive relation of the menisci treated the tissue as transversely isotropic and linearly elastic. Under the application of an 800 N compressive load at 0 degrees of flexion, six contact variables in each compartment (ie., medial and lateral) were computed including maximum pressure, mean pressure, contact area, total contact force, and coordinates of the center of pressure. Convergence of the finite element solution was studied using three mesh sizes ranging from an average element size of 5 mm by 5 mm to 1 mm by 1 mm. The solution was considered converged for an average element size of 2 mm by 2 mm. Using this mesh size, finite element solutions for rigid versus deformable bones indicated that none of the contact variables changed by more than 2% when the femur and tibia were treated as rigid. However, differences in contact variables as large as 19% occurred when rotations other than flexion/extension were constrained. The largest difference was in the maximum pressure. Among the principal conclusions of the study are that accurate finite element solutions of tibio-femoral contact behavior can be obtained by treating the bones as rigid. However, unrealistic constraints on rotations other than flexion/extension can result in relatively large errors in contact variables.

Adult↗
PubMedDate not supplied

Anatomic and biomechanical study of the lateral collateral and popliteofibular ligaments.

The position of the fibula around the proximal tibia varies in different people; it was therefore hypothesized that this variation would affect the orientation of the lateral collateral ligament and the popliteofibular ligament complex. This hypothesis was studied in 10 cadaveric knees by measuring the orientation and length changes in these structures as the knee was flexed. The data were correlated with tibiofibular joint position. The strength of the ligaments was also tested. There were significant correlations between fibular head position and ligament orientation with the knee extended. The lateral collateral ligament slackened significantly with knee flexion, whereas the popliteofibular ligament complex did not. The structures became significantly steeper in the sagittal plane as the knee was flexed. The lateral collateral ligament passed through vertical at 70 degrees of knee flexion and was thus poorly oriented to withstand tibial external rotation. The lateral collateral and popliteofibular ligaments had tensile strengths of 309 and 186 N, respectively. The popliteofibular ligament is dominant when the knee is flexed, because of the slackening of the lateral collateral ligament, and so it should always be reconstructed. The anatomic variation causes some knees to have better ligament orientations to withstand posterolateral tibial displacements and, conversely, other knees may be inherently more difficult to stabilize by reconstruction.

Aged↗
PubMedDate not supplied

Knee injury in skiing. A multifaceted approach.

During the past four ski seasons, all 1,141 ski injuries which occurred in a large northern Vermont ski area were evaluated prospectively. Of these injuries, 21.6% involved knee ligaments and 18.6% involved sprains of the medial collateral ligament. Females sustained a disproportionately high incidence of Grade I medial collateral sprains, but suffered the more severe sprains at a rate similar to that of males. Individuals who were smaller, younger, less experienced, and less skilled sustained a higher incidence of Grade I injuries. Skiers suffering complete tears of the medial collateral ligament were no smaller, younger, or less skilled or experienced than our control population. Medial collateral sprains are produced primarily by external rotation and valgus forces. Two-mode release bindings are insensitive to several loading configurations which could produce knee sprains. Bindings which allow release in roll, shear, and twist at the heel, as well as twist at the toe and forward lean, appear to be necessary to protect the knee.

Athletic Injuries↗
PubMed2001

Ulnar deviation after volar subluxation of the proximal interphalangeal joint.

A rare case of irreducible and progressive ulnar deviation after volar subluxation of the proximal interphalangeal joint is presented. An immobilized proximal interphalangeal joint with remaining volar subluxation after improper reduction showed ulnar deviation at 3 weeks after injury. During surgery, the radial collateral ligament was found to be ruptured at its origin, with formation of concomitant scar tissues. There were no apparent lesions at the central slip, lateral band, and volar plate. Interposition of the ruptured ligament and infiltration of the surrounding scar tissues into the proximal interphalangeal joint were identified. Surgical incision of the capsule along the dorsal margin of the radial collateral ligament readily produced successful reduction. The irreducible and progressive ulnar deviation of the proximal interphalangeal joint seemed to result from gradual infiltration of the scar tissues, subsequent to remaining volar subluxation because of interposition of the ruptured collateral ligament.

Adult↗
PubMed1987

Traumatic horizontal deviation of the second toe: mechanism of deformity, diagnosis, and treatment.

Two patients with a deviated overlapping second toe due to rupture of the dorsal lateral metatarsophalangeal (MTP) collateral ligament and the lateral interosseous tendon were diagnosed, analyzed, and treated. Athletic activities were responsible for the tendon-ligament ruptures and the ensuing medial deviation of the second toe. Pain occurred in the second MTP joint, and a dorsal corn formed over the proximal interphalangeal joint (PIP). Reconstructive procedures included lengthening of the interosseous-lumbrical tendons and the collateral ligament on the medial side of the joint; a dorsal capsule incision; repair of the lateral collateral ligament and interosseous tendon; transfer of the flexor digitorum longus to the extensor digitorum longus; and shortening of the proximal phalanx in one patient. These soft tissue reconstructive procedures and realignment joint congruity are essential to relieve pain and prevent traumatic arthrosis. The treatment completed on the two patients resulted in relief of pain, satisfactory function, and alignment of the digits involved.

Adult↗
PubMedDate not supplied

Pathomechanics of posterior sag of the tibia in posterior cruciate deficient knees. An experimental study.

This study was an investigation of the pathomechanics of posterior sag of the tibia in knees with posterior knee instability caused by PCL deficiency. By using fresh cadaver knees, the authors hoped to define the relationship of the posterior joint capsule and the medial and lateral collateral ligaments (MCL, LCL) with posterior knee instability in the PCL deficient knee. Thirty newtons of posterior stress were applied to the knees to simulate postoperative conditions. Roentgenographic methods were then used to evaluate posterior sag and change in the distance between the origin and insertion of the PCL. Strain gauges were used to measure the actual strain of the PCL and the collateral ligaments. The PCL, the posterior capsule, and the medial and lateral collateral ligaments were sequentially divided and the above measurements were then repeated in the same way, using 30 N of applied posterior stress. When only the PCL was cut, posterior sag and medial rotation of the tibia occurred with increasing severity as flexion increased. No sagging or rotation of the tibia was observed at full extension in the knees that had isolated PCL "injury". When the posterior capsule was sectioned, no significant changes were noted in the severity of the sag or the rotation. When the MCL or LCL was divided in a PCL deficient knee, greater sag occurred with flexion and a significant sag was observed even at full extension. The MCL "injury" was associated with increased medial rotation, whereas LCL "injuries" were associated with lateral rotation of the tibia.(ABSTRACT TRUNCATED AT 250 WORDS)

Aged↗