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Background: Ankle lateral ligament sprains are common injuries in sports, and some may result in persistent ankle pain and a feeling of instability without clinical evidence of instability. The anterior talofibular ligament (ATFL) has 2 distinct fascicles, and recent publications have suggested that injury isolated to the superior fascicle might be the cause of these chronic symptoms. This study aimed to identify the biomechanical properties conferred by the fascicles in stabilizing the ankle in order to understand potential clinical problems that may follow when the fascicles are injured. Purpose/Hypothesis: The aim of this study was to determine the contribution of superior and inferior fascicles of the ATFL in restraining anteroposterior tibiotalar resistance, internal external tibial rotation resistance, and inversion eversion talar rotation resistance. It was hypothesized that an isolated injury of the ATFL superior fascicle would have a measurable effect on ankle stability and that the superior and inferior fascicles would restrain different motions of the ankle. Study Design: Descriptive laboratory study. Methods: A robotic system with 6 degrees of freedom was used to test ankle instability in 10 cadavers. Serial sectioning following the most common injury pattern (from superior to inferior fascicles) was performed on the ATFL while the robot ensured reproducible movement through a physiological range of dorsiflexion and plantarflexion. Results: Sectioning of only the ATFL superior fascicle had a significant and measurable effect on ankle stability, resulting in increased internal rotation and anterior translation of the talus, especially in plantarflexion. Sectioning of the entire ATFL resulted in significantly decreased resistance in anterior translation, internal rotation, and inversion of the talus. Conclusion: Rupture of only the superior fascicle of the ATFL may lead to minor instability or microinstability of the ankle joint, without objective clinical findings of gross clinical laxity. Clinical Relevance: Some patients develop chronic symptoms after an ankle sprain without overt signs of instability. This may be explained by an isolated injury to the ATFL superior fascicle, and diagnosis may require careful clinical evaluation and magnetic resonance imaging examination looking at the individual fascicles. It is possible that such patients may benefit from lateral ligament repair despite having no gross clinical instability.

Background Patellofemoral pain is a prevalent and significant clinical problem that is often reported to persist even following evidence based intervention. It is clear therefore that there is much about this complex patient group that is not presently fully understood. This is particularly concerning given the reported links between patellofemoral pain in adolescence and the subsequent development of osteoarthritis and anxiety. Assessment Clinical assessment has historically focussed on biomechanical factors such as altered lower limb kinematics, muscle weakness and late muscle ‘onset or activation’ during activity. However when examined it is clear that study findings from patellofemoral populations are often inconsistent. Reasons for this are discussed and specifically the limitations around current ‘gold standard’ measurement methods, such as motion capture are outlined. A biomechanical approach is applied to demonstrate the importance of ensuring optimal patient alignment during rehabilitation, where optimal is defined as ensuring the most energy efficient muscle or muscles are used by the patient to perform a movement. This in turn ensures that the direction, magnitude and location of load applied to the skeleton during activity is optimal and therefore less likely to lead to injury. Treatment The role of alignment in patellofemoral pain and the importance of correcting this during rehabilitation is discussed, and examples provided. Validated, reliable, and reproducible methods of measuring skeletal geometry, muscle geometry, muscle force and direction, and kinematics of activity must be developed as a priority in order for us to further our understanding and improve outcomes in this complex clinical population.

The Kager fat pad is one of the largest soft tissue structures local to the ankle joint, yet it is poorly understood. It has been hypothesised to have a role in Achilles tendinopathy. This study aimed to investigate the pressure areas in the Kager fat pad adjacent to the Achilles tendon and to assess the anatomy and deformation of the Kager fat pad in cadavers. Twelve fresh frozen cadaveric ankles (mean age 44 years, range 38–51) were mounted in a customized testing rig, enabling plantar flexion and dorsiflexion of the ankle, with the Achilles tendon loaded. A needle tipped pressure sensor was inserted in two areas of the Kager fat pad under ultrasound guidance (retrocalcaneal bursa and at 3 cm proximal from Achilles insertion). Pressure readings were recorded at different flexion angles. Following testing, the specimens were dissected to expose the Kager fat pad and retrieve it for analysis. MRI images were also taken from three healthy volunteers and the Kager fat pad deformation examined. Mean pressures significantly increased in all specimens at terminal ankle plantar and dorsi flexion in both regions (p

Patients often have difficulty recovering knee extension strength post total knee arthroplasty (TKA), and that may reflect alteration of the mechanics including geometry and rollback kinematics, so the purpose of this work was to explore this by comparing the knee extension torque (KET) of the native knee, TKA and patellofemoral arthroplasty (PFA) in response to quadriceps tension. Eight fresh-frozen knees were mounted in a knee extension rig with quadriceps loading and tibial extension torque measurement. Each knee was subject to four conditions: native knee, PFA, cruciate-retaining (CR) and posterior-stabilized (PS) TKA. The KET was measured from 120° to 0° knee flexion. Data were analyzed using one-way ANOVA and post-hoc paired t-tests. The native KET was lowest in terminal extension and 70–100° flexion, and maximal at 20–30° flexion. PFA produced the greatest KET (p

Patellofemoral pain (PFP) is a highly prevalent condition, affecting up to 23% of the general and 28% of the adolescent population [1]. Recent evidence suggests that patellofemoral joint (PFJ) osteoarthritis is a sequelae of PFP [2, 3] challenging the traditional notion that adolescent anterior knee pain is a benign pathology. Furthermore, high levels of depression and anxiety are reported amongst patients suffering PFP [4]. It is therefore concerning that despite the implementation of evidence-based interventions including exercise therapy, the prognosis of this condition remains poor, with 40–56% of patients reporting ongoing symptoms 1–2 years following conservative treatment [5, 6]. It is estimated that over 50% of people with the condition will report symptoms continuing beyond 5 years following diagnosis [7]. In addition, those patients who complain of high base levels of pain and longer duration of symptoms are typically found to have the most unfavourable recovery [5]. These poor long-term outcomes highlight that despite PFP populations being widely investigated, at present the answers on how best to manage these patients are lacking. With this in mind, how then does the treating clinician go about designing a successful rehabilitation programme for these patients? This chapter reviews current evidence in this field and discusses biomechanical principles to help guide how this might be achieved. We note that growing evidence highlights the importance of also considering psychological factors affecting this population [4], and these are discussed in a separate chapter.

Ankle sprains are the most common sports injury. Gaining a better understanding of ankle mechanics will help improve current treatments, enabling a better quality of life for patients following surgery. In this paper, the development of a robotic system for ankle joint testing is presented. It is composed of an industrial robot, a universal force/torque sensor and bespoke holders allowing high repositioning of specimens. A specimen preparation protocol that uses optical tracking to register the ankle specimens is used. A registration technique is applied to define and calibrate the task related coordinate system needed to control the joint's degrees of freedom and to simulate standardised, clinical ankle laxity tests. Experiments were carried out at different flexion angles using the robotic platform. Optical tracking was used to record the resulting motion of the tibia for every simulated test. The measurements from the optical tracker and the robot were compared and used to validate the system. These findings showed that the optical tracking measurements validate those from the robot for ankle joint testing with interclass coefficients equal to 0.991, 0.996 and 0.999 for the anterior–posterior translations, internal–external and inversion–eversion rotations.

Introduction: Peroneal tendon injuries are a significant cause of lateral ankle symptoms in the active population. Accurate diagnosis and prompt treatment is important for minimizing the risk of long-term sequelae associated with chronic peroneal tendinopathy. Although several studies have been published on diagnostic strategies and treatment outcomes, there is no consensus on the optimal management of peroneal tendon pathologies. Purpose: The purpose of this ESSKA-AFAS consensus statement was to conduct an international and multidisciplinary agreed guideline on management of patients with peroneal tendon pathologies. Methods: Using the Nominal Group Technique, a panel comprised of sixteen specialists spanning nine countries was convened by the ESSKA-AFAS board. In preparation for the meeting, relevant questions were identified and supported by a systematic literature search. During the meeting, the panel members gave presentations on each question, and the evidence supporting each subject was then vetted by open discussion. Statements were thereafter adjusted on the basis of the discussion and voted upon to determine consensus using a 0–10 range Likert scale. Agreement was confirmed when a mean score of at least 7.5 was reached. Conclusion: This ESSKA-AFAS consensus statement on the optimal management of peroneal tendon pathologies is the result of international and multidisciplinary agreement combined with a systematic review of the literature. Level of evidence: V.

Background: Tibialis posterior (TP) tendon transfer is an effective treatment for foot drop. Currently, standard practice is to immobilize the ankle in a cast for 6 weeks nonweightbearing, risking postoperative stiffness. To assess whether early active dorsiflexion and protected weightbearing could be safe, the current study assessed tendon displacement under cyclic loading and load to failure, comparing the Pulvertaft weave (PW) to interference screw fixation (ISF) in a cadaveric foot model. Methods: Twenty-four cadaveric ankles had TP tendon transfer performed, 12 with the PW technique and 12 with ISF to the cuboid. The TP tendon was cycled 1000 times at 50 to 150 N and then loaded to failure in a materials testing machine. Tendon displacement at the insertion site was recorded every 100 cycles. An independent t test and 2-way analysis of variance were performed to compare techniques, with a significance level of P < .05. Results: Mean tendon displacement was similar in the PW group (2.9 ± 2.5 mm [mean ± SD]) compared with the ISF group (2.4 ± 1.1 mm), P = .35. One specimen in the ISF group failed early by tendon pullout. None of the PW group failed early, although displacement of 8.9 mm was observed in 1 specimen. Mean load to failure was 419.1 ± 82.6 N in the PW group in comparison to 499.4 ± 109.6 N in the ISF group, P = .06. Conclusion: For TP tendon transfer, ISF and PW techniques were comparable, with no differences in tendon displacement after cyclical loading or load to failure. Greater variability was observed in the PW group, suggesting it may be a less reliable technique. Clinical Relevance: The results indicate that early active dorsiflexion and protected weightbearing may be safe for clinical evaluation, with potential benefits for the patient compared with cast immobilization.

Background: The plantaris tendon (PT) has been thought to contribute to symptoms in a proportion of patients with Achilles midportion tendinopathy, with symptoms improving after PT excision. Hypothesis: There is compression and differential movement between the PT and Achilles tendon (AT) during ankle plantarflexion and dorsiflexion. Study Design: Descriptive laboratory study. Methods: Eighteen fresh-frozen cadaveric ankles (mean ± SD age: 35 ± 7 years, range = 27-48 years; men, n = 9) were mounted in a customized testing rig, where the tibia was fixed but the forefoot could be moved freely. A Steinmann pin was drilled through the calcaneus, enabling a valgus torque to be applied. The soleus, gastrocnemius, and plantaris muscles were loaded with 63 N with a weighted pulley system. The test area was 40 to 80 mm above the os calcis, corresponding to where the injury is observed clinically. Medially, the AT and PT were exposed, and a calibrated flexible pressure sensor was inserted between the tendons. Pressure readings were recorded with the ankle in full dorsiflexion, full plantarflexion, and plantargrade and repeated in these positions with a 5 N·m torque, simulating increased hindfoot valgus. The pressure sensor was removed and the PT and AT marked with ink at the same level, with the foot held in neutral rotation and plantargrade. Videos and photographs were taken to assess differential motion between the tendons. After testing, specimens were dissected to identify the PT insertion. One-way analysis of variance and paired t tests were performed to make comparisons. Results: The PT tendons with an insertion separate from the AT demonstrated greater differential motion through range (14 ± 4 mm) when compared with those directly adherent to the AT (2 ± 2 mm) ( P < .001). Mean pressure between the PT and AT rose in terminal plantarflexion for all specimens ( P < .001) and was more pronounced with hindfoot valgus ( P < .001). Conclusion: The PT inserting directly into the calcaneus resulted in significantly greater differential motion as compared with the AT. Tendon compression was elevated in terminal plantarflexion, suggesting that adapting rehabilitation tendon-loading programs to avoid this position may be beneficial. Clinical Relevance: The insertion pattern of the PT may be a factor in plantaris-related midportion Achilles tendinopathy. Terminal range plantarflexion and hindfoot valgus both increased AT and PT compression, suggesting that these should be avoided in this patient population.

Background: Anterolateral tenodeses are increasingly popular in combination with intra-articular anterior cruciate ligament reconstructions. Despite the perception of risk of overconstraint and lateral osteoarthritis, evidence is lacking regarding the effect of graft tensioning on knee kinematics and intra-articular compartmental joint pressures. Purpose: To investigate tibiofemoral joint contact pressures and kinematics related to an anterolateral lesion and the effectiveness of a MacIntosh tenodesis in restoring these when varying (1) graft tension and (2) tibial rotation during graft fixation. Study Design: Controlled laboratory study. Methods: Eight fresh-frozen cadaveric knees were tested in a customized rig with femur fixed and tibia free to move from 0° to 90° of flexion. The quadriceps and iliotibial band were loaded by means of a weighted pulley system. At 30° intervals of knee flexion, tibiofemoral contact pressures were measured with a Tekscan sensor and tibiofemoral kinematics were recorded by use of an optical tracking system. The knee was tested intact and then with an anterolateral soft tissue transection. MacIntosh tenodeses were then tested in a randomized order with 20 N or 80 N of graft tension, each with the tibia held in neutral intact alignment or free to rotate. Results: Tibial anterior translation and internal rotation were significantly increased and lateral contact pressures significantly reduced compared with the intact knee following anterolateral soft tissue cutting ( P < .05). Contact pressures were restored with fixed neutral tibial rotation combined with 20 N or 80 N of graft tension or by a free-hanging tibia with 20 N of graft tension (all P values > .5). Grafts tensioned with 80 N caused significant overconstraint both when the tibia was fixed and free hanging (all P values < .05). Increases in the lateral tibiofemoral contact pressures were also seen when the tibia was free hanging and 80 N was used for graft tension ( P < .05). Conclusion: Anterolateral soft tissue injury caused reduced lateral tibiofemoral contact pressures and altered tibiofemoral kinematics; these were restored with a MacIntosh procedure performed with 20 N of graft tension. If 80 N of graft tension was used, increased lateral contact pressures and overconstraint in internal rotation were seen. With the tibia free hanging, intact contact biomechanics were restored when 20 N of graft tension was applied, but 80 N of graft tension significantly increased lateral tibiofemoral pressures and overconstrained internal rotation. The kinematic and contact pressure effects were significantly correlated: Changes in tibial rotation caused by increased graft tension correlated with elevated lateral articular contact pressure. Clinical Relevance: Controlling tibial position appears important when tensioning anterolateral tenodeses. However, the identified changes were subtle and may not be clinically significant in a fully loaded knee.

Opinions are very prevalent in the field of orthopaedics. Indeed, a significant proportion of current clinical interventions are conducted on the basis of these opinions. However, all too often, these opinions lack robust scientific evidence that should arguably be in place to support their application. Surely, we should be better equipped by now to challenge such dogma. Sports medicine is an active research field with an abundance of publications in a rapidly growing number of journals. It is an attractive field that engages many young, talented researchers. Yet, despite this, opinions remain more common than science. One reason for this, and my primary worry for moving the profession forward, is the clear lack of robust, objective measurement techniques in sports medicine. I strongly believe that basic science holds the fundamental foundation that should enable us to advance the field and promote successful outcomes in patients but that the need for this is not widely appreciated.

The treatment of painful chronic tendinopathy is challenging. Multiple non-invasive and tendon-invasive methods are used. When traditional non-invasive treatments fail, the injections of platelet-rich plasma autologous blood or cortisone have become increasingly favored. However, there is little scientific evidence from human studies supporting injection treatment. As the last resort, intra- or peritendinous open or endoscopic surgery are employed even though these also show varying results. This ESSKA basic science committee current concepts review follows the first part on the biology, biomechanics and anatomy of tendinopathies, to provide a comprehensive overview of the latest treatment options for tendinopathy as reported in the literature.

Background Vastus Medialis Muscles (VMM) damage has been widely identified following patellar dislocation. Rehabilitation programmes have been suggested to strengthen the VMM and reduce clinical symptoms of pain and instability. This controlled laboratory study investigated the hypothesis that reduced Vastus Medialis Obliquus (VMO) and Vastus Medialis Longus (VML) muscle tension would alter patellar tracking, stability and PFJ contact pressures. Methods Nine fresh-frozen dissected cadaveric knees were mounted in a rig with the quadriceps and iliotibial band loaded to 205 N. An optical tracking system measured joint kinematics and pressure sensitive film between the patella and trochlea measured PFJ contact pressures. Measurements were repeated for three conditions: 1. With all quadriceps heads and iliotibial band (ITB) loaded; 2. as 1, but with the VMO muscle unloaded and 3. as 1, but with the VMO and VML unloaded. Measurements were also repeated for the three conditions with a 10 N lateral displacement force applied to the patella. Results Reduction of VMM tension resulted in significant increases in lateral patellar tilt (2.8°) and translation (4 mm), with elevated lateral and reduced medial joint contact pressures from 0.48 to 0.14 MPa, and reduced patellar stability (all p

Background:Tibial tubercle (TT) transfer and medial patellofemoral ligament (MPFL) reconstruction are used after patellar dislocations. However, there is no objective evidence to guide surgical decision making, such as the ability of MPFL reconstruction to restore normal behavior in the presence of a lateralized TT.Hypothesis:MPFL reconstruction will only restore joint contact mechanics and patellar kinematics for TT–trochlear groove (TG) distances up to an identifiable limit.Study Design:Controlled laboratory study.Methods:Eight fresh-frozen cadaveric knees (mean TT-TG distance, 10.4 mm) were placed on a testing rig. Individual quadriceps heads and the iliotibial band were loaded with 205 N in physiological directions using a weighted pulley system. Patellofemoral contact pressures and patellar tracking were measured at 0°, 10°, 20°, 30°, 60°, and 90° of flexion using pressure-sensitive film and an optical tracking system. The MPFL attachments were marked. TT osteotomy was performed, and a metal T-plate was fixed to the anterior tibia with holes at 5-mm intervals for TT fixation. The anatomic TT position was restored after plate insertion. The TT was lateralized in 5-mm intervals up to 15 mm, with pressure and tracking measurements recorded. The MPFL was transected and all measurements repeated before and after MPFL reconstruction using a double-stranded gracilis tendon graft. Data were analyzed using repeated-measures ANOVA, Bonferroni post hoc analysis, and paired t tests.Results:MPFL transection significantly elevated lateral patellar tilt and translation and reduced mean medial contact pressures during early knee flexion. These effects increased significantly with TT lateralization. MPFL reconstruction restored patellar translation and mean medial contact pressures to the intact state when the TT was in anatomic or 5-mm lateralized positions. However, these were not restored when the TT was lateralized by 10 mm or 15 mm. Patellar tilt was restored after 5-mm TT lateralization but not after 10-mm or 15-mm lateralization.Conclusion:Considering the mean TT-TG distance in this study (10.4 mm), findings suggest that in patients with TT-TG distances up to 15 mm, patellofemoral kinematics and contact mechanics can be restored with MPFL reconstruction. However, for TT-TG distances greater than 15 mm, more aggressive surgery such as TT transfer may be indicated.Clinical Relevance:This provides guidance to surgeons as to the threshold at which MPFL reconstruction may satisfactorily restore patellofemoral mechanics, beyond which more invasive surgery such as TT transfer may be indicated.

PURPOSE: There is a lack of objective evidence investigating how previous non-augmented ACL suture repair techniques and contemporary augmentation techniques in ACL suture repair restrain anterior tibial translation (ATT) across the arc of flexion, and after cyclic loading of the knee. The purpose of this work was to test the null hypotheses that there would be no statistically significant difference in ATT after non-, static- and dynamic-augmented ACL suture repair, and they will not restore ATT to normal values across the arc of flexion of the knee after cyclic loading. METHODS: Eleven human cadaveric knees were mounted in a test rig, and knee kinematics from 0° to 90° of flexion were recorded by use of an optical tracking system. Measurements were recorded without load and with 89-N tibial anterior force. The knees were tested in the following states: ACL-intact, ACL-deficient, non-augmented suture repair, static tape augmentation and dynamic augmentation after 10 and 300 loading cycles. RESULTS: Only static tape augmentation and dynamic augmentation restored ATT to values similar to the ACL-intact state directly postoperation, and maintained this after cyclic loading. However, contrary to dynamic augmentation, the ATT after static tape augmentation failed to remain statistically less than for the ACL-deficient state after cyclic loading. Moreover, after cyclic loading, ATT was significantly less with dynamic augmentation when compared to static tape augmentation. CONCLUSION: In contrast to non-augmented ACL suture repair and static tape augmentation, only dynamic augmentation resulted in restoration of ATT values similar to the ACL-intact knee and decreased ATT values when compared to the ACL-deficient knee immediately post-operation and also after cyclic loading, across the arc of flexion, thus allowing the null hypotheses to be rejected. This may assist healing of the ruptured ACL. Therefore, this study would support further clinical evaluation of dynamic augmentation of ACL repair.

Background:Lateral extra-articular soft tissue reconstructions in the knee may be used as a combined procedure in revision anterior cruciate ligament surgery as well as in primary treatment for patients who demonstrate excessive anterolateral rotatory instability. Only a few studies examining length change patterns and isometry in lateral extra-articular reconstructions have been published.Purpose:To determine a recommended femoral insertion area and graft path for lateral extra-articular reconstructions by measuring length change patterns through a range of knee flexion angles of several combinations of tibial and femoral insertion points on the lateral side of the knee.Study Design:Controlled laboratory study.Methods:Eight fresh-frozen cadaveric knees were freed of skin and subcutaneous fat. The knee was then mounted in a kinematics rig that loaded the quadriceps muscles and simulated open-chain knee flexion. The length changes of several combinations of tibiofemoral points were measured at knee flexion angles between 0° and 90° by use of linear variable displacement transducers. The changes in length relative to the 0° measurement were recorded.Results:The anterior fiber region of the iliotibial tract displayed a significantly different ( P < .001) length change pattern compared with the posterior fiber region. The reconstructions that had a femoral insertion site located proximal to the lateral epicondyle and with the grafts passed deep to the lateral collateral ligament displayed similar length change patterns to each other, with small length increases during knee extension. These reconstructions also showed a significantly lower total strain range compared with the reconstruction located anterior to the epicondyle ( P < .001).Conclusion:These findings show that the selection of graft attachment points and graft course affects length change pattern during knee flexion. A graft attached proximal to the lateral femoral epicondyle and running deep to the lateral collateral ligament will provide desirable graft behavior, such that it will not suffer excessive tightening or slackening during knee motion.Clinical Relevance:These results provide a surgical rationale for lateral extra-articular soft tissue reconstruction in terms of femoral graft fixation site and graft route.

Background: An incorrect femoral tunnel position or inappropriate graft tensioning during medial patellofemoral ligament (MPFL) reconstruction may cause altered patellofemoral joint kinematics and contact mechanics, potentially resulting in pain and joint degeneration. Hypothesis: Nonanatomic positioning of the tunnel or graft overtensioning during MPFL reconstruction will have an adverse effect on patellar tracking and patellofemoral joint contact mechanics. Study Design: Controlled laboratory study. Methods: Eight fresh-frozen cadaveric knees were placed on a customized testing rig, with the femur fixed and the tibia mobile through 90° of flexion. Individual heads of the quadriceps muscle and the iliotibial band were separated and loaded with 205 N in anatomic directions using a system of cables and weights. Patellofemoral contact pressures and patellar tracking were measured through the flexion range at 10° intervals using Tekscan pressure-sensitive film inserted between the patella and trochlea and an optical tracking system. The MPFL was transected and then reconstructed using a double-strand gracilis tendon graft. Pressures and kinematics were recorded for reconstructions with the graft positioned in anatomic, proximal, and distal tunnel positions. Measurements were then repeated with an anatomic tunnel and graft tension of 2 N, 10 N, and 30 N, fixed at 3 different flexion angles of 0°, 30°, and 60°. Statistical analysis was undertaken using repeated-measures analysis of variance, Bonferroni post hoc analysis, and paired t tests. Results: For a graft tensioned to 2 N, anatomically positioned MPFL reconstruction restored intact medial and lateral joint contact pressures and patellar tracking ( P > .05), but femoral tunnels positioned proximal or distal to the anatomic origin resulted in significant increases in peak and mean medial pressures and medial patellar tilt during knee flexion or extension, respectively ( P < .05). Grafts tensioned with 10 N or 30 N also caused significant increases in medial pressure and tilt. Graft fixation at 30° or 60° restored all measures to intact values ( P > .05), but fixation at 0° caused significant increases ( P < .05) in medial joint contact pressures compared with intact knees. Conclusion: Anatomically positioned reconstruction with 2-N tension fixed at 30° or 60° of knee flexion restored joint contact pressures and tracking. However, graft overtensioning or femoral tunnels positioned too proximal or distal caused significantly elevated medial joint contact pressures and increased medial patellar tilting. The importance of a correct femoral tunnel position and graft tensioning in restoring normal patellofemoral joint kinematics and articular cartilage contact stresses is therefore evident. Clinical Relevance: A malpositioned femoral tunnel or overtensioned graft during MPFL reconstruction resulted in increased medial contact pressures and patellar tilting. This may lead to adverse outcomes such as early degenerative joint changes or pain if occurring in a clinical population.

Medial patellofemoral ligament (MPFL) disruption may alter patellofemoral joint (PFJ) kinematics and contact mechanics, potentially causing pain and joint degeneration. In this controlled laboratory study, we investigated the hypothesis that MPFL transection would change patellar tracking and PFJ contact pressures and increase the distance between the attachment points of the MPFL. Eight fresh frozen dissected cadaveric knees were mounted in a rig with the quadriceps and ITB loaded to 205 N. An optical tracking system measured joint kinematics, and pressure sensitive film between the patella and trochlea measured PFJ contact pressures. Length patterns of the distance between the femoral and patellar attachments of the MPFL were measured using a suture led to a linear displacement transducer. Measurements were repeated with the MPFL intact and following MPFL transection. A significant increase in the distance between the patellar and femoral MPFL attachment points was noted following transection (p

Background:Anterolateral soft tissue structures of the knee have a role in controlling anterolateral rotational laxity, and they may be damaged at the time of anterior cruciate ligament (ACL) ruptures.Purpose:To compare the kinematic effects of anterolateral operative procedures in combination with intra-articular ACL reconstruction for combined ACL plus anterolateral–injured knees.Study Design:Controlled laboratory study.Methods:Twelve cadaveric knees were tested in a 6 degrees of freedom rig using an optical tracking system to record the kinematics through 0° to 90° of knee flexion with no load, anterior drawer, internal rotation, and combined loading. Testing was first performed in ACL-intact, ACL-deficient, and combined ACL plus anterolateral–injured (distal deep insertions of the iliotibial band and the anterolateral ligament [ALL] and capsule cut) states. Thereafter, ACL reconstruction was performed alone and in combination with the following: modified MacIntosh tenodesis, modified Lemaire tenodesis passed both superficial and deep to the lateral collateral ligament, and ALL reconstruction. Anterolateral grafts were fixed at 30° of knee flexion with both 20 and 40 N of tension. Statistical analysis used repeated-measures analyses of variance and paired t tests with Bonferroni adjustments.Results:ACL reconstruction alone failed to restore native knee kinematics in combined ACL plus anterolateral–injured knees ( P < .05 for all). All combined reconstructions with 20 N of tension, except for ALL reconstruction ( P = .002-.01), restored anterior translation. With 40 N of tension, the superficial Lemaire and MacIntosh procedures overconstrained the anterior laxity in deep flexion. Only the deep Lemaire and MacIntosh procedures—with 20 N of tension—restored rotational kinematics to the intact state ( P > .05 for all), while the ALL underconstrained and the superficial Lemaire overconstrained internal rotation. The same procedures with 40 N of tension led to similar findings.Conclusion:In a combined ACL plus anterolateral–injured knee, ACL reconstruction alone failed to restore intact knee kinematics. The addition of either the deep Lemaire or MacIntosh tenodesis tensioned with 20 N, however, restored native knee kinematics.Clinical Relevance:The current study indicates that unaddressed anterolateral injuries, in the presence of an ACL deficiency, result in abnormal knee kinematics that is not restored if only treated with intra-articular ACL reconstruction. Both the modified MacIntosh and modified deep Lemaire tenodeses (with 20 N of tension) restored native knee kinematics at time zero.

Background:There remains a lack of evidence regarding the optimal method when reconstructing the medial patellofemoral ligament (MPFL) and whether some graft constructs can be more forgiving to surgical errors, such as overtensioning or tunnel malpositioning, than others.Hypothesis:The null hypothesis was that there would not be a significant difference between reconstruction methods (eg, graft type and fixation) in the adverse biomechanical effects (eg, patellar maltracking or elevated articular contact pressure) resulting from surgical errors such as tunnel malpositioning or graft overtensioning.Study Design:Controlled laboratory study.Methods:Nine fresh-frozen cadaveric knees were placed on a customized testing rig, where the femur was fixed but the tibia could be moved freely from 0° to 90° of flexion. Individual quadriceps heads and the iliotibial tract were separated and loaded to 205 N of tension using a weighted pulley system. Patellofemoral contact pressures and patellar tracking were measured at 0°, 10°, 20°, 30°, 60°, and 90° of flexion using pressure-sensitive film inserted between the patella and trochlea, in conjunction with an optical tracking system. The MPFL was transected and then reconstructed in a randomized order using a (1) double-strand gracilis tendon, (2) quadriceps tendon, and (3) tensor fasciae latae allograft. Pressure maps and tracking measurements were recorded for each reconstruction method in 2 N and 10 N of tension and with the graft positioned in the anatomic, proximal, and distal femoral tunnel positions. Statistical analysis was undertaken using repeated-measures analyses of variance, Bonferroni post hoc analyses, and paired t tests.Results:Anatomically placed grafts during MPFL reconstruction tensioned to 2 N resulted in the restoration of intact medial joint contact pressures and patellar tracking for all 3 graft types investigated ( P > .050). However, femoral tunnels positioned proximal or distal to the anatomic origin resulted in significant increases in the mean medial joint contact pressure, medial patellar tilt, and medial patellar translation during knee flexion or extension, respectively ( P < .050), regardless of graft type, as did tensioning to 10 N.Conclusion:The importance of the surgical technique, specifically correct femoral tunnel positioning and graft tensioning, in restoring normal patellofemoral joint (PFJ) kinematics and articular cartilage contact stresses is evident, and the type of MPFL graft appeared less important.Clinical Relevance:The correct femoral tunnel position and graft tension for restoring normal PFJ kinematics and articular cartilage contact stresses appear to be more important than graft selection during MPFL reconstruction. These findings emphasize the importance of the surgical technique when undertaking this procedure.

Background: Pain in the anterior and lateral parts of the knee during exercise is a common clinical problem for which current management strategies are often unsuccessful. Purpose: To investigate the effect of an ultrasound-guided botulinum toxin (BT) injection into the tensor fasciae latae (TFL), followed by physical therapy, in patients classified with lateral patellofemoral overload syndrome (LPOS) who failed to respond to conventional treatment. Study Design: Case series; Level of evidence, 4. Methods: A total of 45 patients (mean ± SD age, 32.4 ± 8.6 years) who met the inclusion criteria of (1) activity-related anterolateral knee symptoms, (2) symptoms lasting longer than 3 months, (3) a pathological abnormality confirmed by magnetic resonance imaging, and (4) previous failed physical therapy received an ultrasound-guided injection of BT into the TFL followed by physical therapy. Patient-reported outcomes were collected at 5 intervals: before the injection; at 1, 4, and 12 weeks after the injection; and at a mean 5 years after the injection. In 42 patients, relative iliotibial band (ITB) length changes were assessed using the modified Ober test at the first 4 time points. A computational model was run to simulate the effect of TFL weakening on gluteus medius (GMed) activity. Statistical analysis was undertaken using 1-way analysis of variance and paired t tests with Bonferroni post hoc correction. Results: There was a significant improvement in Anterior Knee Pain Scale scores from before the injection (61 ± 15) to 1 (67 ± 15), 4 (70 ± 16), and 12 weeks (76 ± 16) after the injection and in 87% of patients (39/45 patients available for follow-up) at approximately 5 years (from 62.9 ± 15.4 to 87.0 ± 12.5) after the injection (all P < .010). A significant effect on the modified Ober test was identified as a result of the intervention, with an increase in leg drop found at 1 (3° ± 5°), 4 (4° ± 5°), and 12 (7° ± 6°) weeks after the injection compared with before the injection (all P < .010). Simulating a progressive reduction in TFL strength resulted in corresponding increases in GMed activity during gait. Conclusion: An injection of BT into the TFL, combined with physical therapy, resulted in a significant improvement of symptoms in patients with LPOS, which was maintained at 5-year follow-up. This may result from reduced lateral TFL/ITB tension or to an increase in GMed activity in response to inhibition of the TFL.

Background: Incompetence of the medial patellofemoral ligament (MPFL) is an integral factor in patellofemoral instability. Reconstruction of this structure is gaining increasing popularity. However, the natural behavior of the ligament is still not fully understood, and crucially, the correct landmark for femoral attachment of the MPFL at surgery is poorly defined. Purpose: To determine the length change pattern of the native MPFL, investigate the effect of nonanatomic femoral and differing patellar attachment sites on length changes, and recommend a reproducible femoral attachment site for undertaking anatomic MPFL reconstruction. Study Design: Descriptive laboratory study. Methods: Eight cadaveric knees were dissected of skin and subcutaneous fat and mounted in a kinematics rig with the quadriceps tensioned. The MPFL length change patterns were measured for combinations of patellar and femoral attachments using a suture and displacement transducer. Three attachments were along the superomedial border of the patella, and 5 femoral attachments were at the MPFL center and 5 mm proximal, distal, anterior, and posterior to this point. Reproducibility of attachment sites was validated radiographically. Results: The femoral attachment point, taking the anterior-posterior medial femoral condyle diameter to be 100%, was identified 40% from the posterior, 50% from the distal, and 60% from the anterior border of the medial femoral condyle. This point was most isometric, with a mean maximal length change to the central patellar attachment of 2.1 mm from 0° to 110° of knee flexion. The proximal femoral attachment resulted in up to 6.4 mm mean lengthening and the distal attachment up to 9.1 mm mean shortening through 0° to 110° of knee flexion, resulting in a significantly nonisometric graft ( P < .05). Conclusion: We report the anatomic femoral and patellar MPFL graft attachments, with confirmation of the reproducibility of their location and resulting kinematic behavior. Nonanatomic attachments caused significant loss of isometry. Clinical Relevance: The importance of an anatomically positioned MPFL reconstruction is highlighted, and an identifiable radiographic point for femoral tunnel position is suggested for use intraoperatively.

Peroneal tendon injuries are a significant cause of lateral ankle symptoms in the active population. Accurate diagnosis and prompt treatment is important for minimizing the risk of long-term sequelae associated with chronic peroneal tendinopathy. Although several studies have been published on diagnostic strategies and treatment outcomes, there is no consensus on the optimal management of peroneal tendon pathologies.The purpose of this ESSKA-AFAS consensus statement was to conduct an international and multidisciplinary agreed guideline on management of patients with peroneal tendon pathologies.Using the Nominal Group Technique, a panel comprised of sixteen specialists spanning nine countries was convened by the ESSKA-AFAS board. In preparation for the meeting, relevant questions were identified and supported by a systematic literature search. During the meeting, the panel members gave presentations on each question, and the evidence supporting each subject was then vetted by open discussion. Statements were thereafter adjusted on the basis of the discussion and voted upon to determine consensus using a 0-10 range Likert scale. Agreement was confirmed when a mean score of at least 7.5 was reached.This ESSKA-AFAS consensus statement on the optimal management of peroneal tendon pathologies is the result of international and multidisciplinary agreement combined with a systematic review of the literature.V.

Background:Injury to the posteromedial meniscocapsular junction has been identified after anterior cruciate ligament (ACL) rupture; however, there is a lack of objective evidence investigating how this affects knee kinematics or whether increased laxity can be restored by repair. Such injury is often overlooked at surgery, with possible compromise to results.Hypotheses:(1) Sectioning the posteromedial meniscocapsular junction in an ACL-deficient knee will result in increased anterior tibial translation and rotation. (2) Isolated ACL reconstruction in the presence of a posteromedial meniscocapsular junction lesion will not restore intact knee laxity. (3) Repair of the posteromedial capsule at the time of ACL reconstruction will reduce tibial translation and rotation to normal. (4) These changes will be clinically detectable.Study Design:Controlled laboratory study.Methods:Nine cadaveric knees were mounted in a test rig where knee kinematics were recorded from 0° to 100° of flexion by use of an optical tracking system. Measurements were recorded with the following loads: 90-N anterior-posterior tibial forces, 5-N·m internal-external tibial rotation torques, and combined 90-N anterior force and 5-N·m external rotation torque. Manual Rolimeter readings of anterior translation were taken at 30° and 90°. The knees were tested in the following conditions: intact, ACL deficient, ACL deficient and posteromedial meniscocapsular junction sectioned, ACL deficient and posteromedial meniscocapsular junction repaired, ACL patellar tendon reconstruction with posteromedial meniscocapsular junction repair, and ACL reconstructed and capsular lesion re-created. Statistical analysis used repeated-measures analysis of variance and post hoc paired t tests with Bonferroni correction.Results:Tibial anterior translation and external rotation were both significantly increased compared with the ACL-deficient knee after posterior meniscocapsular sectioning ( P < .05). These parameters were restored after ACL reconstruction and meniscocapsular lesion repair ( P > .05).Conclusion:Anterior and external rotational laxities were significantly increased after sectioning of the posteromedial meniscocapsular junction in an ACL-deficient knee. These were not restored after ACL reconstruction alone but were restored with ACL reconstruction combined with posterior meniscocapsular repair. Tibial anterior translation changes were clinically detectable by use of the Rolimeter.Clinical Relevance:This study suggests that unrepaired posteromedial meniscocapsular lesions will allow abnormal meniscal and tibiofemoral laxity to persist postoperatively, predisposing the knee to meniscal and articular damage.

Background:Tibial tuberosity (TT) transfer is a common procedure to treat patellofemoral instability in patients with elevated TT–trochlear groove (TG) distances. However, the effects of TT lateralization or medialization on patellar stability, kinematics, and contact mechanics remain unclear.Hypothesis:Progressive medialization and lateralization will have increasingly adverse effects on patellofemoral joint kinematics, contact mechanics, and stability.Study Design:Controlled laboratory study.Methods:Eight fresh-frozen cadaveric knees were placed on a testing rig, with a fixed femur and tibia mobile through 90° of flexion. Individual quadriceps heads and the iliotibial band were separated and loaded with 205 N in anatomic directions using a weighted pulley system. Patellofemoral contact pressures and patellar tracking were measured at 0°, 10°, 20°, 30°, 60°, and 90° of flexion using pressure-sensitive film behind the patella and an optical tracking system. The intact knee was measured with and without a 10-N patellar lateral displacement load, and recordings were repeated after TT transfer of 5, 10, and 15 mm medially and laterally. Statistical analysis used repeated-measures analysis of variance, Bonferroni post hoc analysis, and Pearson correlations.Results:Tibial tuberosity lateralization significantly elevated lateral joint contact pressures, increased lateral patellar tracking, and reduced patellar stability ( P < .048). There was a significant correlation between mean lateral contact pressure and the TT position ( r = 0.810, P < .001) at 10°. Tibial tuberosity medialization reduced lateral contact pressures ( P < .002) and did not elevate peak medial contact pressures ( P > .11).Conclusion:Progressive TT lateralization elevated lateral contact pressures, increased lateral patellar tracking, and reduced patellar stability. Medial contact pressure and tracking did alter with progressive TT medialization, but the changes were smaller.Clinical Relevance:Lateral patellofemoral joint contact pressures increased with progressive lateralization of the TT; medialization of the TT reduced these effects, restoring patellar stability, and did not cause excessive peak pressures. These data provide a rationale for medial TT transfer surgery in patients with elevated TT-TG distances.

The medial patellofemoral complex, consisting of the medial patellofemoral ligament (MPFL) and the medial patellotibial ligament, is the main passive stabiliser of the patellofemoral joint. Since it has been shown that rupture of the MPFL is the main pathological consequence of patellar dislocation and biomechanical studies have demonstrated that the MPFL is the main restraint against lateral patellar displacement, reconstruction of the MPFL has become a widespread technique for restoration of patellofemoral stability.

Medial patellofemoral ligament (MPFL) disruption may alter patellofemoral joint (PFJ) kinematics and contact mechanics, potentially causing pain and joint degeneration. In this controlled laboratory study, we investigated the hypothesis that MPFL transection would change patellar tracking and PFJ contact pressures and increase the distance between the attachment points of the MPFL. Eight fresh frozen dissected cadaveric knees were mounted in a rig with the quadriceps and ITB loaded to 205 N. An optical tracking system measured joint kinematics, and pressure sensitive film between the patella and trochlea measured PFJ contact pressures. Length patterns of the distance between the femoral and patellar attachments of the MPFL were measured using a suture led to a linear displacement transducer. Measurements were repeated with the MPFL intact and following MPFL transection. A significant increase in the distance between the patellar and femoral MPFL attachment points was noted following transection (p0.05). MPFL transection resulted in significantly increased lateral translation and lateral tilt of the patella in early flexion (p0.05). Peak and mean medial PFJ contact pressures were significantly reduced and peak lateral contact pressures significantly elevated in early knee flexion following MPFL transection (p0.05). MPFL transection resulted in significant alterations to PFJ tracking and contact pressures, which may affect articular cartilage health.