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Purpose: To compare suture tape-augmented MPFL repair with allograft MPFL reconstruction using patellofemoral contact pressure and joint kinematics to assess the risk of patellofemoral over-constrainment at point zero.Methods: A total of ten fresh frozen cadaveric knee specimens were tested in four different conditions of the MPFL: (1) native, (2) cut, (3) reconstructed with tendon graft, and (4) augmented with suture tape. The patellofemoral mean pressure (MP), peak pressure (PP) and contact area (CA) were measured independently for the medial and lateral compartments using pressure-sensitive films. Patellar tilt (PT) and shift (PS) were measured using an optical 3D motion tracking system. Measurements were recorded at 0°, 10°, 20°, 30°, 60° and 90° of flexion. Both the tendon graft and the internal brace were preloaded with 2 N, 5 N, and 10 N.Results: There was no significant differences found between surgical methods for medial MP, medial PP, medial CA, lateral MP and PS at any preload or flexion angle. Significant differences were seen for lateral PP at 20° knee flexion and 10 N preload (suture tape vs. reconstruction: 1045.9 ± 168.7 kPa vs. 1003.0 ± 151.9 kPa; p = 0.016), for lateral CA at 10° knee flexion and 10 N preload (101.4 ± 39.5 mm2 vs. 108.7 ± 36.6 mm2; p = 0.040), for PT at 10° knee flexion and 2 N preload (- 1.9 ± 2.5° vs. - 2.5 ± 2.3°; p = 0.033) and for PT at 0° knee flexion and 10 N preload (- 0.8 ± 2.5° vs. - 1.8 ± 3.1°; p = 0.040). A preload of 2 N on the suture tape was the closest in restoring the native joint kinematics.Conclusions: Suture tape augmentation of the MPFL resulted in similar primary contact pressures and joint kinematics in comparison with MPFL reconstruction using a tendon graft. A pretension of 2 N was found to restore the knee joint closest to normal patellofemoral kinematics. [ABSTRACT FROM AUTHOR]

Purpose: The acromioclavicular ligament complex (ACLC) is the primary stabilizer against horizontal translation with the superior ACLC providing the main contribution. The purpose of this study was to evaluate the specific regional contributions in the superior half of ACLC, where the surgeon can easily access and repair or reconstruct, for posterior translational and rotational stability.Methods: The superior half of ACLC was divided into three regions; Region A (0°-60°): an anterior 1/3 region of the superior half of ACLC, Region B (60°-120°): a superior 1/3 region of the superior half of ACLC, and Region C (120°-180°): a posterior 1/3 region of the superior half of ACLC. Fifteen fresh-frozen cadaveric shoulders were used. Biomechanical testing was performed to evaluate the resistance force against passive posterior translation (10 mm) and the resistance torque against passive posterior rotation (20°) during the following the four conditions. (1) Stability was tested on all specimens in their intact condition (n = 15). (2) The ACLC was dissected and stability was tested (n = 15). (3) Specimens were randomly divided into three groups by regions of suturing. Stability was tested after suturing Region A, Region B, or Region C (n = 5 per group). (4) Stability was tested after suturing additional regions: Region A + B (0°-120°), Region B + C (60°-180°), or Region A + C (0°-60°, 120°-180°, n = 5 per group).Results: The translational force increased after suturing Region A when compared with dissected ACLC (P = 0.025). The force after suturing Region A + B was significantly higher compared to the dissected ACLC (P < 0.001). The rotational torque increased after suturing Region A or Region B compared with dissected ACLC (P = 0.020, P = 0.045, respectively). The torque after suturing the Region A + C was significantly higher compared to the dissected ACLC (P < 0.001).Conclusion: The combined Region A + B contributed more to posterior translational stability than Region B + C or Region A + C. In contrast, combined Region A + C contributed more to posterior rotational stability than Region A + B or Region B + C. Based on these findings, surgical techniques restoring the entire superior ACLC are recommended to address both posterior translational and rotational stability of the AC joint. [ABSTRACT FROM AUTHOR]

Purpose: Numerous surgical techniques and fixation methods have been described in medial patellofemoral ligament (MPFL) reconstruction such as choice of graft, graft fixation method of patella/femur and initial tension. We describe short term clinical results of MPFL reconstruction by using soft suture anchor and adjustable cortical fixation system. Methods: Twenty-four patients who underwent isolated MPFL reconstruction by using soft suture anchor and adjustable cortical fixation system were included in this study. All patients were followed up for at least 2 years, and pre-operative and 2 years post-operative Kujala score, IKDC score and Knee Injury and Osteoarthritis Outcome Score were used to assess clinical outcome. Radiographic evaluation included the Q angle, congruence angle and patellar tilt angle. Pre- and post-operative changes were evaluated by Mann--Whitney U test. Results: There were no complications including re-dislocation, patella fracture, infection, and joint contracture. The apprehension test was positive in 4.2% post-operatively. A statistically significant improvement in clinical scores and radiographic evaluation were evident after surgery. Conclusions: Isolated MPFL Reconstruction using soft suture anchor and adjustable cortical fixation system led good restoration of patellar stability and significant improvement of knee function in short-term results. This surgical technique can reduce complications such as patella fractures, and can be done safely. Clinical relevance: This technique may be a treatment option with little associated complications in the treatment for patellar instability. Level of Evidence: Case series, Level IV. [ABSTRACT FROM AUTHOR]

Background: The ligamentum teres (IT) continues to be a structure of debate and interest. Previously thought of as a vestigial structure, an awareness of LT pathology and its potential importance has increased with the expansion of hip arthroscopy. Purpose: To provide a comprehensive literature synthesis on the LT and provide clinicians with the most current research regarding the LT and its anatomical features, functional relevance, prevalence of injury, risk factors for injury, clinical presentation, and treatment for pathology. Methods: A systematic literature search was conducted using Medline/PuhMed, CINAHL/EBSCO, and Cochrane/Wiley databases/ plat forms using the following search terms: ligament, ligament teres, hip, femur, femoral head, round ligament. Results: This search yielded 1284 articles of which 44 met the inclusion/exclusion criteria and contributed to this manuscript. Information on the LT was summarized into the following areas: anatomy, function, injury prevalence, risk factors, mechanism of injury, duration of symptoms, clinical presentation (symptoms, range of motion, functional limitations, special testing), imaging, and treatment. Conclusions: The results of this review supported the following: 1) the LT has a function in restraining hip rotation range of motion; 2) the prevalence of LT pathology in any given population may be largely dependent on the severity of bony deformity (either femoroacetabular impinge me nt(FAI) or dyplasia) and activity level; 3) older age and ace-tabular bony deformity (either FAI or dyplasia) are risk factors for generalized LT pathology; 4) unique signs and symptoms are difficult to identify because LT pathology rarely occurs in isolation and is likely the end-stage consequence of other hip pathology; 5) the presence of LT pathology may negatively affect an individual's ability to function; and 6) surgical debridement is recommend for pain relief of partial LT tears with reconstruction possible for complete LT tears when complaints of instability are noted. Level of Evidence: 3 [ABSTRACT FROM AUTHOR]

Purpose: This study aims to investigate the clinical effect and complications of a novel technique named bridge crane for the treatment of the severe thoracic ossification of the ligamentum flavum (TOLF) with myelopathy.Method: A patient diagnosed as TOLF (T9-T11) was treated with the bridge crane technique and the outcomes were reported. The main surgical procedures include installation of pedicle screws, rods and transverse connectors; preparation of stay prolene sutures passing through the laminae-OLF complex (LOC); en bloc isolation of the LOC; tightening of the sutures to achieve posterior suspension of the LOC; and fixation of the LOC to the transverse connectors. The modified Japanese Orthopaedic Association (mJOA) scale was studied. The pre- and postoperative radiological parameters and surgical complications were also investigated.Results: Postoperative CT and MRI showed a sufficient decompression of spinal cord by the technique of bridge crane. The ratio of spinal canal encroachment improved significantly. At the final follow-up assessment, no specific complications were identified. Imaging information suggested that the bone graft was fused and the "bridge" was in good position. The mJOA score was 9 with a recovery rate of 75% at the final follow-up.Conclusions: The technique of bridge crane is feasible and may be relatively safe and effective for the treatment of severe TOLF with myelopathy. However, further studies with large-scale cases and control groups are required to reveal the generalizability and safety of the bridge crane technique in the future. These slides can be retrieved under Electronic Supplementary Material. [ABSTRACT FROM AUTHOR]

Purpose: Ossification of the ligamentum flavum (OLF) is a possible cause of thoracic myelopathy. We report two rare cases with recurrent thoracic myelopathy caused by OLF markedly re-extended at the same intervertebral level after the primary surgery.Methods: Both patients had thoracic myelopathy caused by OLF and underwent decompressive laminectomy and resection of the OLF in the primary surgery. However, the neurological conditions gradually deteriorated following recovery after the primary surgery due to the recurrent OLF at the same intervertebral level.Results: These patients were successfully treated by revision surgery via resection of the recurrent OLF and posterior spinal fusion with instrumentation. Two years after the second surgery, the neurological disturbance was resolved satisfactorily, and re-growth of the resected ossified lesion was not observed.Conclusions: The recurrence of OLF following resection of the ossified lesions is exceedingly rare but should be noted in patients treated surgically for thoracic myelopathy due to OLF. [ABSTRACT FROM AUTHOR]

Purpose: To introduce a new surgical approach to the multilevel ossification of the ligamentum flavum (OLF) aided by three-dimensional (3D) printing technology.Methods: A multilevel OLF patient (male, 66 years) was scanned using computed tomography (CT). His saved DICOM format data were inputted to the Mimics14.0 3D reconstruction software (Materialise, Belgium). The resulting 3D model was used to observe the anatomical features of the multilevel OLF area and to design the surgical approach. At the base of the spinous process, two channels were created using an osteotomy bilaterally to create a "V" shape to remove the bone ligamentous complex (BLC). The decompressive laminoplasty using mini-plate fixation was simulated with the computer. The physical model was manufactured using 3D printing technology. The patient was subsequently treated using the designed surgery.Result: The operation was completed successfully without any complications. The operative time was 90 min, and blood loss was 200 ml. One month after the operation, neurologic function was recovered well, and the JOA score was improved from 6 preoperatively to 10. Postoperative CT scanning showed that the OLF was totally removed, and the replanted BLC had not subsided.Conclusion: 3D printing technology is an effective, reliable, and minimally invasive method to design operations. The technique can be an option for multilevel OLF surgical treatment. This can provide sufficient decompression with minimum damage to the spine and other intact anatomical structures. [ABSTRACT FROM AUTHOR]

Purpose: Recurrent patellar dislocation is currently treated with anatomical reconstruction of the medial patellofemoral ligament (MPFL), and favourable postoperative outcomes have been reported. However, it is uncertain if healthy MPFL function is restored by anatomical reconstruction. The hypothesis in this study was that stabilization of the patella following MPFL reconstruction would be improved compared with that before surgery, but that function of the grafted tendon would differ from that of a healthy MPFL. The objective was to analyse the length change patterns of the MPFL before surgery and the grafted tendon after surgery in patients with recurrent patellar dislocation treated with anatomical MPFL reconstruction.Methods: The subjects were 12 patients (13 knees) in whom recurrent patellar dislocation was treated with anatomical MPFL reconstruction. The length change patterns of the MPFL and reconstructed ligament were analysed at extension and flexion of the knee joint using open MRI.Results: The postoperative grafted tendon length was significantly shorter than that of the preoperative MPFL at knee extension, and significantly longer at 90° and 120° of knee flexion. The postoperative length of the grafted tendon only changed slightly from 0° to 30° of knee flexion, and then significantly decreased at flexion of 30° or more. The morphology of the grafted tendon was linear until 60° knee flexion, but became convex toward the extraarticular side at flexion of 90° or more.Conclusion: The grafted tendon length at knee extension was shorter than that of the preoperative MPFL, but there was no significant difference at 30° flexion. These findings suggest that the effect of damping of the patella with a grafted tendon after MPFL reconstruction may differ from that in a healthy knee. In addition, the morphology at 60° knee flexion was improved to linear after surgery, suggesting that ligament morphology at this flexion was normalized by MPFL reconstruction.Level Of Evidence: III. [ABSTRACT FROM AUTHOR]

Purpose: Medial patellofemoral ligament reconstruction (MPFL-R) is the standard surgical intervention for patella instability. However, limited knowledge exists concerning the causes for failure, and outcome after revision MPFL-R. The purpose of this study is to evaluate the causes of primary MPFL-R failure and clinical outcomes after revision MPFL-R.Methods: Twenty-three patients (6 males and 17 females) with failed primary MPFL-R underwent isolated revision MPFL-R or combined revision MPFL-R with tibial tuberosity osteotomy (TTO). The mean age was 23 (SD 8.6). Prior to surgery, dysplasia of the patellofemoral joint, sulcus angle, Insall-Salvati index, cartilage lesions, tibial tuberosity trochlear groove (TTTG) distance, and tunnel placement were evaluated by magnetic resonance imaging (MRI). Their scores on the Kujala Anterior Knee Pain Scale and pain scores were assessed prior to surgery, 1 year post-operatively and at final follow-up. The mean follow-up time was 44 months (median range 39). The radiographic characteristics and clinical outcomes were compared with a 224 primary MPFL-R patient cohort (240 knees).Results: Non-anatomical fixation of the graft at the medial femoral condyle after primary MPFL-R was seen in 67% of revision patients with anterior/proximal misplacement in most cases. Severe trochlear dysplasia Dejour types C and D were seen in 36% of the patients compared to 30% of primary MPFL-R patients (NS). The mean Kujala Anterior Knee Pain Scale score at final follow-up was 61.7 (SD 18.8) compared to 80.3 (SD 18) in primary MPFL-R patients (P < 0.01). The mean pain score at rest was 2.3 (SD 2.5) for revision MPFL-R patients compared to 1.7 (SD 2.5) in primary MPFL-R patients (NS) and their mean pain score during activity was 5.0 (SD 3.2) compared to 1.3 (SD 2.2) in primary MPFL patients (P < 0.001).Conclusion: Although revision MPFL-R establishes acceptable patellar stability, the subjective outcomes after revision MPFL-R do not improve significantly, and are poorer than after primary MPFL-R. Non-anatomical graft position can be an important cause of MPFL-R failure. The clinical relevance of this study is that it shows that it may be difficult to improve self-reported outcomes in revision MPFL-R patients.Level Of Evidence: III. [ABSTRACT FROM AUTHOR]

Purpose: The aim of the present study is to present the outcome of a cohort of adolescent patients with trochlear dysplasia and elevated tibial tuberosity trochlear groove (TTTG) distance suffering from recurrent patellar dislocation. Treatment consisted of medial patellofemoral ligament (MPFL) reconstruction and a modified Grammont procedure.Methods: MRI examinations were obtained pre- and postoperatively. Trochlear dysplasia was classified according to Déjour, and TTTG was measured on MRI. The Tegner Activity Scale and the Kujala Knee Score were assessed preoperatively and at follow-up. The Kujala Knee score and the IKDC 2000 knee score were documented at follow-up (median 50, range 20-61 months; SD 16.6).Results: Seven knees of six patients (median age 16.5 years, range 14-17 years) with trochlear dysplasia and elevated TTTG distance (median 17 mm, range 16.1-21.9 mm; SD 2.8) were treated. Trochlear dysplasia was classified as Déjour type A in 1, type B in 5, and type C in 1 knee. The Kujala Knee Score significantly increased from values of 55 (range 17-88; SD 25.9) to 94 (range 73-100; SD 9.1) at follow-up (p = 0.028). TAS improved from preoperative 2 (range 0-7; SD 2.5) to 5 (range 4-9; SD 1.8) at follow-up (p = 0.034). Median IKDC 2000 Knee Score at follow-up was 89 (range 61-100, SD 13.4). No re-dislocations were encountered.Conclusion: In selected adolescents with recurrent patellofemoral instability, MPFL reconstruction in combination with a modified Grammont technique yields excellent functional outcome and could, therefore, help to avoid major procedures, such as osteotomies.Level Of Evidence: Therapeutic, Level IV. [ABSTRACT FROM AUTHOR]

Background: Spinous processes and posterior ligaments, such as inter- and supraspinous ligaments are often sacrificed either deliberately to harvest osseous material for final spondylodesis e.g. in deformity corrective surgery or accidentally after posterior spinal instrumentation. This biomechanical study evaluates the potential destabilizing effect of a progressive dissection of the posterior ligaments (PL) after instrumented spinal fusion as a potential risk factor for proximal junctional kyphosis (PJK).Methods: Twelve calf lumbar spines were instrumented from L3 to L6 (L3 = upper instrumented vertebra, UIV) and randomly assigned to one of the two study groups (dissection vs. control group). The specimens in the dissection group underwent progressive PL dissection, followed by cyclic flexion motion (250 cycles, moment: + 2.5 to + 20.0 Nm) to simulate physical activity and range of motion (ROM) testing of each segment with pure moments of ±15.0 Nm after each dissection step. The segmental ROM in flexion and extension was measured. The control group underwent the same loading and ROM testing protocol, but without PL dissection.Results: In the treatment group, the normalized mean ROM at L2-L3 (direct adjacent segment of interest, UIV/UIV + 1, PJK-level) increased to 104.7%, 107.3%, and 119.4% after dissection of the PL L4-L6, L3-L6, and L2-L6, respectively. In the control group the mean ROM increased only to 103.2%, 106.7%, and 108.7%. The ROM difference at L2-L3 with regard to the last dissection of the PL was statistically significant (P = 0.017) and a PL dissection in the instrumented segments showed a positive trend towards an increased ROM at UIV/UIV + 1.Conclusions: A dissection of the PL at UIV/UIV + 1 leads to a significant increase in ROM at this level which can be considered to be a risk factor for PJK and should be definitely avoided during surgery. However, a dissection of the posterior ligaments within the instrumented segments while preserving the ligaments at UIV/UIV + 1 leads to a slight but not significant increase in ROM in the adjacent cranial segment UIV/UIV + 1 in the used experimental setup. Using this experimental setup we could not confirm our initial hypothesis that the posterior ligaments within a long posterior instrumentation should be preserved. [ABSTRACT FROM AUTHOR]

Background: Although smoking is known to be harmful to the musculoskeletal system, no studies have investigated its effects on the outcomes of ankle ligament surgery. We determined the effects of smoking on the clinical and radiological outcomes of lateral ankle ligament reconstruction using tendon allografts according to smoking status.Methods: From among 105 patients with chronic ankle instability who were treated with anatomical reconstruction of the anterior talofibular ligament and the calcaneofibular ligament using semitendinosus tendon allografts and bio-tenodesis screws, 70 ankles, from 23 smokers and 47 non-smokers, were analyzed. Visual analog scale (VAS) pain scores, American Orthopedic Foot and Ankle Society ankle-hindfoot scores, Karlsson scores and complications were routinely determined at each follow-up visit. Anterior translation and the talar tilt angle on radiographic stress views were also assessed.Results: The mean follow-up period was 21.8 months (12-68 months). No significant differences were observed between the two groups with respect to age, gender, body mass index, or the duration of preoperative symptoms. The mean preoperative pain VAS scores were 5.8 and 5.3 among non-smokers and smokers, respectively. Postoperatively, the mean pain VAS score improved to 1.4 in both groups (p < 0.001). Clinical and radiographic measures did not show significant changes according to the presence of smoking after surgery. However, two wound complications, 1 delayed healing and 1 superficial necrosis, occurred in non-smokers, whereas five, 2 delayed healing, 2 superficial infections and 1 superficial necrosis in smokers (p = 0.035).Conclusion: The radiographic outcomes of smokers were comparable to those of non-smokers in the short term, whereas wound complications were more common in the smoker group. [ABSTRACT FROM AUTHOR]

Background: Ossification of the posterior longitudinal ligament or the ligamentum flavum parallels endochondral ossification. Cell differentiation at the ossification front is known to be important during this process, although the factors regulating its initiation and progression are still unclear. The purpose of this study was to identify factors important for the regulation of chondrocyte/osteoblast differentiation during spinal ossification.Methods: Ligamentum flavum tissue was isolated from 25 patients who underwent decompressive surgery for cervical ossification of the posterior longitudinal ligament. Tissue sections were used for in vitro culture to obtain primary cells through migration methods. To identify microRNAs associated with ossification of the posterior longitudinal ligament, cultured cells were prepared from the ligamentous tissue (n = 4; continuous type) or from control ligamentous samples harvested from patients with cervical spondylosis without spinal ossification, and analyzed using a microRNA array. The ligamentous sections were also examined by immunohistochemistry for the expression of candidate microRNA target genes.Results: The microRNA array identified 177 factors; 12 of which were expressed at significantly different levels in patients with ossification of the posterior longitudinal ligament compared to those in control patients. The hsa-miR-487b-3p was down-regulated in patients with ossification of the posterior longitudinal ligament, which met the false discovery rate of <0.05. This microRNA was predicted to regulate the expression of genes involved in Wnt signaling. Furthermore, immunohistochemistry of Wnt signaling proteins, including Wnt 3a, LRP5/6, and beta-catenin, revealed positive expression in mesenchymal cells and/or premature chondrocytes at the ossification front.Conclusion: Our results suggested that down-regulation of miR-487b-3p plays an important role in the initiation of Wnt signaling during the ossification process. Wnt signaling may regulate both chondrocyte and osteoblast differentiation and the specification of endochondral ossification in the pathogenesis of ossification of the posterior longitudinal ligament or the ligamentum flavum. [ABSTRACT FROM AUTHOR]

The anterolateral ligament (ALL) of the knee has gained attention recently for its potential role in rotational stability of the knee, especially in association with anterior cruciate ligament (ACL) injuries. Anatomic studies have characterized the ALL as it runs in an anteroinferior and oblique direction from the lateral distal femur to the anterolateral proximal tibia, although the prevalence and variance of this ligament are not well understood. Magnetic resonance imaging and ultrasound have identified the ligament and linked it with the classically described Segond fracture. While the ALL likely plays a role in rotational stability of the knee, further studies investigating the significance of ALL injuries and the role of ALL reconstruction in combination with ACL reconstruction are warranted. [ABSTRACT FROM AUTHOR]

Purpose: Medial patellofemoral ligament (MPFL) reconstruction offers good clinical results with a very low rate of instability recurrence. However, its in vivo effect on patellar tracking is not clearly known. The aim of this study is to investigate the effects of MPFL reconstruction on patellar tracking using dynamic 320-detector-row CT.Methods: Ten patients with patellofemoral instability referred to isolated MPFL reconstruction surgery were selected and subjected to dynamic CT before and ≥6 months after surgery. Patellar tilt angles and shift distance were analysed using computer software specifically designed for this purpose. Kujala and Tegner scores were applied, and the radiation of the CTs was recorded. Two protocols for imaging acquisition were compared: a tube potential of 80 kV and 50 mA versus a tube potential of 120 kV and 100 mA, both with a slice thickness of 0.5 mm and an acquisition duration of 10 s.Results: There were no changes in patellar tracking after MPFL reconstruction. There was no instability relapse. Clinical scores improved from a mean of 51.9 (±15.6)-74.2 (±20.9) on the Kujala scale (p = 0.011) and from a median of 2 (range 0-4) to 4 (range 1-6) on the Tegner scale (p = 0.017). The imaging protocols produced a dose-length product (DLP) of 254 versus 1617 mGycm and a radiation effective estimated dose of 0.2 versus 1.3 mSv, respectively. Both protocols allowed the analysis of the studied parameters without loss of precision.Conclusions: Reconstruction of the MPFL produced no improvement in patellar tilt or shift in the population studied. The low-radiation protocol was equally effective in measuring changes in patellar tracking and is recommended. Although the procedure successfully stabilized the patella, knee surgeons should not expect patellar shift and tilt correction when performing isolated patellofemoral ligament reconstruction in patients with recurrent patellar instability.Level Of Evidence: IV. [ABSTRACT FROM AUTHOR]

Purpose: Medial patellofemoral ligament (MPFL) reconstruction for recurrent patellar instability has gained popularity, and anatomical and biomechanical studies have recently altered our operative techniques. The aim of this study was to report the clinical outcome of this new anatomical MPFL reconstructive technique and investigate whether correlating factors could be identified.Methods: Between 2009 and 2012, a total of 31 consecutive patients underwent MPFL reconstruction using an autologous gracilis graft and anatomical tunnel placement. Pre- and post-operative data were collected as a part of routine clinical practice. The preoperative assessment included a rotational profile CT scan of the lower extremity according to the Lyon protocol with TT-TG distance measurement. Outcomes were evaluated with the Kujala and Norwich patella instability (NPI) scores preoperatively and at follow-up (1.5-5.1 years).Results: A significant improvement in both the Kujala (p < 0.001) and NPI (p = 0.012) scores was recorded. A medium and large negative correlations were found between TT-TG distance and Kujala score improvement (ρ = -0.48, p = 0.020) and NPI score improvement (ρ = -0.83, p = 0.042), respectively. Multiple regression analysis identified TT-TG distance, Beighton score and BMI as factors explaining the variance of Kujala score improvement.Conclusion: Anatomical MPFL reconstruction with the gracilis autograft for patellar instability resulted in good outcome. This underlines the importance of anatomical tunnel placement in MPFL reconstruction. With a precise preoperative work-up, factors can be identified that may guide selecting the optimal operative strategy and improve counselling of the patient.Level Of Evidence: Case series, Level IV. [ABSTRACT FROM AUTHOR]

Purpose: How much force is needed to pre-tension the ligaments during total knee arthroplasty? The goal of this study was to determine this force for extension and flexion, and for both compartments, and to identify predicting patient-related factors.Methods: Eighty patients [55 females, mean age 71 (SD 9.7)] were recruited and had a navigated cruciate-retaining total knee arthroplasty. Distraction of the medial and lateral compartments of the extension and flexion gap (90°) with an instrumented bi-compartmental double-spring tensioner took place after finishing the bone cuts. Applied forces and resulting gap distances were recorded by the navigation system, resulting in a force-elongation curve. Lines were fitted with the intersection defined as the stiffness transition point. The slopes (N/mm) represented the stiffness of the ligamentous complex. Linear multiple regression analysis was performed to identify predicting factors.Results: The amount of force at the stiffness transition point was on average 52.3 (CI95 50.7-53.9), 54.5 (CI95 52.7-56.3), 48.3 (CI95 46.2-50.2), and 59.3 (CI95 57.0-61.6) N for the medial and lateral extension and flexion gap, respectively, and varied considerably between patients. The force at the stiffness transition point was significantly different between extension and flexion and both compartments (P < 0.05). Stiffness of the ligaments statistically significantly helped to predict the amount of force at the stiffness transition point, as well as body mass index, gender, and varus-valgus alignment.Conclusion: The amount of force at the stiffness transition point varies between 48 and 59 N, depending on flexion/extension and compartment. Patient-related factors influence the stiffness transition point and can help predict the stiffness transition point. When forces higher than 60 N are used for gap distraction, the ligamentous sleeve of the knee might be over-tensioned.Level Of Evidence: Prognostic study, Level I-high-quality prospective cohort study with >80 % follow-up, and all patients enrolled at same time point in disease. [ABSTRACT FROM AUTHOR]

Purpose: In MPFL reconstruction, anatomical graft positioning is required to restore physiological joint biomechanics and patellofemoral stability. Considerable rates of non-anatomical femoral tunnel placement exist. The purpose of this study was to analyse whether intraoperative fluoroscopic control is applicable to reduce variability of femoral tunnel positioning.Methods: Femoral tunnel positions of 116 consecutive MPFL reconstructions applying intraoperative fluoroscopic images were analysed. Tunnel positions were determined by two independent observers according to Schöttle's radiographic measurement method. Mean positions, standard deviations and ranges were calculated to determine the variability of the tunnel positions. Interclass correlation coefficient (ICC) was calculated.Results: The mean anterior/posterior distances from the anatomical insertion of the MPFL to the centre of the femoral tunnel were 2.34 mm (range 0.0-5.9 mm) and 1.7 mm (range 0.1-7.3 mm, SD 1.3) for proximal/distal deviations; 95.7 % (111/116) of femoral tunnel positions were found to be within the anatomical insertion area defined by Schöttle. Interobserver tunnel position measurements were highly reliable (ICC: depth 0.979; height 0.979).Conclusion: The study demonstrates that intraoperative fluoroscopic control is a feasible and effective method that enables to create reproducible and precise anatomical femoral tunnel positions in MPFL reconstruction. Accordingly, the routine use of intraoperative fluoroscopy can be recommended. Furthermore, the results indicate Schöttle's method as a reliable method for intraoperative control and postoperative analysis of femoral tunnel positioning.Level Of Evidence: IV. [ABSTRACT FROM AUTHOR]

Introduction: The aim of this retrospective study was to analyse clinical and radiological outcome after medial patellofemoral ligament reconstruction (MPFLR) and tibial tuberosity medialisation (TTM) in patients with recurrent patellar instability.Materials and Methods: Thirty-five patients were included between 2008 and 2012. According to defined criteria such as tibial tuberosity-trochlear groove (TTTG) distance, hyperpression on the lateral patella facet and lateral retropatellar cartilage damage either MPFLR (group A) or TTM (group B) was performed: 18 patients underwent TTM, the other 17 patients underwent MPFLR. At a mean of 25.4 ± 9.7 (group A) and 35.2 ± 17.6 months (group B) patients were clinically and radiologically reviewed. Validated knee scores such as Kujala, Lysholm and Tegner score were evaluated.Results: In both groups one patient reported of a non-traumatic patellar redislocation. Patients who underwent MPFLR (group A) had less pain postoperatively during activity according to the Visual Analogue Scale (group A: 2.0 ± 2.1 points, group B: 3.9 ± 2.3 points). Retropatellar cartilage damage increased in group B from grade 1 (range: 1-3) preoperatively to grade 2 (range 1-3) postoperatively (p > 0.05). All other clinically evaluated items, as well as the applied knee scoring systems, indicated no significant difference (p > 0.05) and displayed good to excellent results.Conclusions: MPFLR and TTM leed to good clinical results despite its own indications. For this reason-in selected cases-TTM may still be a suitable procedure for surgical treatment of patellar instability. However, patients treated by TTM (group B) revealed an increased retropatellar cartilage damage as well as significantly more pain during activity. [ABSTRACT FROM AUTHOR]

Purpose: Medial patellofemoral ligament (MPFL) reconstruction has become a common form of treatment for recurrent patellar dislocation. This study was performed using open-MRI to compare the length change pattern of MPFL in patients with a history of patellar dislocation to that in healthy subjects.Methods: The subjects comprised 10 knees of 8 males and 13 knees of 12 females with a history of one or more patellar dislocations. The length of the MPFL was measured using open-MRI in both the leg-extended position and knee-flexed positions to analyse the length change pattern.Results: The average MPFL lengths were 58.6 ± 6.5 mm and 52.0 ± 4.6 mm for males and females in the extended knee position, respectively. The length change pattern of the MPFL showed slight variation up to a flexion angle of 30° and a clear decrease above 30°. This pattern differed from that of normal MPFL. In terms of morphology, the fibre bundle of the damaged MPFL followed a convex course towards the side of the patellofemoral joint surface at a knee flexion angle of 60°, whereas that of the normal MPFL followed a straight course.Conclusion: The in vivo damaged MPFL length change pattern was specific and differed distinctly from that of normal MPFL. The results of the present study suggested that MPFL fibres with a history of patellar dislocation lack sufficient tension at knee flexion angles of 0°-60°. However, further studies are needed to obtain a better understanding of cases with a patellar dislocation or postsurgical cases of MPFL reconstruction.Level Of Evidence: III. [ABSTRACT FROM AUTHOR]

Purpose: This study's purpose was to investigate how an ideal anatomic femoral attachment affects the dynamic length change pattern of a virtual medial patellofemoral ligament (MPFL) from an extended to a highly flexed knee position; to determine the relative length and length change pattern of a surgically reconstructed MPFL; and to correlate femoral attachment positioning, length change pattern, and relative graft length with the clinical outcome.Methods: Twenty-four knees with isolated nonanatomic MPFL reconstruction were analysed by three-dimensional computed tomography at 0°, 30°, 60°, 90°, and 120° of knee flexion. The lengths of the MPFL graft and a virtual anatomic MPFL were measured. The pattern of length change was considered isometric if the length distance changed <5 mm through the entire dynamic range of motion.Results: Knee flexion significantly affected the path lengths between the femoral and patellar attachments. The length of the anatomic virtual MPFL decreased significantly from 60° to 120°. Its maximal length was 56.4 ± 6.8 mm at 30°. It was isometric between 0° and 60°. The length of the nonanatomic MPFL with a satisfactory clinical result decreased during flexion from 0° to 120°. Its maximal length was 51.6 ± 4.6 mm at 0° of knee flexion. The lengths measured at 0° and 30° were isometric and statistically greater than the lengths measured at higher flexion degrees. The failed nonanatomic MPFL reconstructions were isometric throughout the dynamic range, being significantly shorter (27.1 ± 13.3 %) than anatomic ligaments.Conclusion: The femoral attachment point significantly influences the relative length and the dynamic length change of the grafts during knee flexion-extension and graft isometry. Moreover, it influences the long-term outcome of the MPFL reconstructive surgery. A nonanatomic femoral fixation point should not be considered the cause of persistent pain and instability after MPFL reconstruction in all cases.Level Of Evidence: III. [ABSTRACT FROM AUTHOR]

Appropriate placement of the acetabular cup is an important determinant of implant stability and longevity. Malposition of acetabular cups negatively influences prosthesis survival and leads to an increased dislocation rate. The objective of the study was to determine the role of 3-dimensional templating in obtaining accurate acetabular component placement in total hip arthroplasty. In this computed tomography-based study, the authors identified 93 patients who underwent primary total hip arthroplasty with computer-assisted navigation. Using 3-dimensional planning, the authors templated the acetabular component at an inclination of 40° and anteversion of 20°. To classify acetabular cup coverage by bone, the acetabulum was used as a clock face with the center of the transverse acetabular ligament (TAL) as 6-o'clock. Analyses revealed that 72% of cups were uncovered between 9- to 1-o'clock for right hips. On the left side, 88% of cups were uncovered between 11- to 3-o'clock. Across all hips, 74% of cups had a 1-o'clock position at the most lateral aspect. Further analysis revealed that 46% of acetabular cups had a teardrop at the same level of the most inferior aspect of the cup, whereas only 37% of cups had a teardrop above the inferior aspect of the cup. Finally, the acetabular component was aligned with the TAL in 76% of hips, retroverted to the TAL in 16%, and anteverted to the TAL in 8%. The current study demonstrates a useful gross intraoperative reference tool to standardize cup position without the need for additional equipment and reliance on anatomical landmarks. [Orthopedics. 2017; 40(4):e708-e713.]. [ABSTRACT FROM AUTHOR]

Purpose: To date, there is a paucity of literature on syndesmotic reconstruction techniques that restore both anatomic stability and physiologic syndesmotic biomechanics. In this cadaveric study, (1) a novel syndesmotic reconstruction surgical technique using autogenous peroneus brevis tendon was described and (2) the biomechanical properties of the reconstruction was investigated.Methods: Ten fresh-frozen lower extremities were used in this study. Reconstruction of the anterior and posterior, as well as the interosseous tibiofibular ligaments was performed with a halved peroneus brevis tendon. Biomechanics were assessed using foot external rotation torque and ankle dorsiflexion axial loading tests, which were performed in (a) intact, (b) cut, (c) anatomically reconstructed syndesmotic ligaments, and (d) 3.5 mm tricortical syndesmotic screw fixation. Medial-lateral and anterior-posterior displacements of the distal fibula were recorded during foot external rotation and fibular axial displacement was recorded during ankle axial loading.Results: The fibula was displaced posteriorly and proximally with respect to the tibia in all specimens during external rotation and axial loading tests, respectively. Significant differences (p < 0.05) were found in distal fibular displacements between anatomically reconstructed ligaments and screw fixation. Tricortical syndesmotic screw fixation resulted in 59% of posterior fibular displacement when compared to intact ligaments. No significant differences (n.s.) in distal fibular displacement were demonstrated between intact ligaments and anatomically reconstructed ligaments.Conclusion: Anatomical reconstruction of the distal tibiofibular ligaments with the peroneus brevis tendon provides stability and recreates the biomechanical properties of an intact syndesmosis. This new surgical technique may be a viable alternative for the treatment of syndesmotic injuries.Level Of Evidence: V. [ABSTRACT FROM AUTHOR]

Incisura fibularis (IF) is an important landmark in assessing syndesmotic stability radiologically postinjury. The purpose of this review was to explore the anatomy and morphometrics of this widely used anatomical landmark and to further the understanding of the same. A systematic review was conducted online using PubMed and Google Scholar, per PRISMA guidelines. Predefined eligibility criteria were applied, and the data thus compiled were analyzed. Wide variability in morphometrics and, thus, anatomy of IF were observed in the present review, which was influenced by gender. There was no side-to-side variability seen in this study. The study stresses the need to consider the anatomical and gender-based variability while assessing syndesmotic stability and further supports the recommendation of side-to-side comparison.Levels Of Evidence: Anatomical, Level V. [ABSTRACT FROM AUTHOR]

Purpose: The biomechanical behaviour of the knee following multiple-ligament reconstruction (MLKR) may play a role in the pathogenesis of post-traumatic osteoarthritis. The aim of this study was to compare three-dimensional knee kinematics and gait characteristics of MLKR patients to healthy controls during level walking.Methods: Three-dimensional optoelectronic motion capture during overground walking was performed on 16 patients with MLKR and a group of healthy controls matched individually to each patient for age, gender, height and weight. Three-dimensional knee angles were extracted from the weight acceptance and propulsion sub-phases of gait. Statistical analysis was performed using group-aggregated data, as well as for each patient-control pair using a single-case approach.Results: Although group analysis detected few differences, single-case analysis revealed significant differences for a proportion of patients for all dependent variables during weight acceptance and propulsion sub-phases of stance. These kinematic differences occurred in the context of reduced gait velocity, step length and cadence, as well as increased time spent in double support.Conclusion: Patients with MLKR display abnormalities in knee kinematics during gait at an average of 4.5 years after surgery. The pattern of kinematic abnormalities appears individual specific and may not be related to differences in spatiotemporal gait characteristics. The current findings describe detailed functional outcomes of MLKR reconstruction at average medium-term follow-up that provide improved prognostic information for clinicians to counsel patients with these types of injuries. [ABSTRACT FROM AUTHOR]

Purpose: To quantify the influence of ALL lesions on static and dynamic laxity in ACL-deficient knee.Methods: The study was performed in 10 fresh-frozen knees. The joints were analysed in the following conditions: intact, ACL resection and ACL + ALL resection. Testing parameters were defined as: anterior displacement at 30° and 90° of flexion (AP30, AP90) applying a manual-maximum load; internal rotation at 30° and 90° of flexion (INT30, INT90) applying a 5 N m torque and internal rotation and acceleration during manual pivot-shift (PS) test. Kinematics was acquired by a navigation system; a testing rig and a torquemeter were used to control the limb position and the applied torque. Paired Student's t test was conducted to assess statistical difference, and significance was set at P < 0.05.Results: The ALL resection determined a significant increase in terms of internal rotation (INT30 P = 0.02, INT90 P = 0.03), while AP30 (P n.s) and AP90 (P n.s) were not affected. ALL resection produced a significant increase in terms of acceleration during PS test (P < 0.01), but no significant change in PS internal rotation was observed.Conclusion: The ALL plays a significant role in controlling static internal rotation and acceleration during PS test. On the other hand, ALL resection did not produce any significant change in terms of anterior displacement. A trend was seen for the internal rotation during the pivot-shift test to increase after ALL resection was higher when compared to the intact and isolated ACL lesion states; however, the differences were not significant. The results highlight the clinical relevance of this structure that should be assessed before an ACL reconstruction in order to avoid residual laxity. [ABSTRACT FROM AUTHOR]

Purpose: To quantify the influence of Single-Bundle with Lateral Plasty and Double-Bundle reconstruction on static and dynamic laxity in combined ACL- and ALL-deficient knees.Methods: The study included 10 fresh-frozen human knees. The joints were analyzed in the following conditions: ACL + ALL resection, Single-Bundle with Lateral Plasty (SBLP) reconstruction, Double-Bundle (DB) reconstruction. Testing parameters were: anterior displacement at 30° and 90° of flexion (AP30, AP90) applying a manual maximum load; internal rotation at 30° and 90° of flexion (INT30, INT90) applying a 5 Nm torque and acceleration and internal rotation Pivot-Shift (PS) test. Kinematics was acquired by a navigation system. Paired Student's t test was conducted to assess statistical difference (P < 0.05).Results: At both 30° and 90° of knee flexion, both SBLP and DB surgical techniques showed a significant reduction (P < 0.01) of anterior-posterior tibial displacement compared to the resection of ACL + ALL. At 30° on knee flexion it is the SBLP that allows the greatest reduction of internal rotational laxity when compared to DB reconstruction. Concerning the PS test, only SBPL procedure had a significant laxity decrease considering the acceleration reached by the joint when compared with the ACL + ALL state (P < 0.01).Conclusion: Clinical relevance of this study is that the internal rotation and PS test were more efficiently controlled by the SBLP technique than by the DB one at both 30° and 90° of flexion in case of ACL + ALL lesions. [ABSTRACT FROM AUTHOR]

Background: Scapholunate dissociation is the most common form of carpal instability. However, there is no gold standard for operative treatment. In this prospective observational study on 54 patients, a modified minimally invasive dynamic extensor carpi radialis longus tenodesis is described, which is characterized by a smaller approach and application of a cannulated screw and washer for tendon fixation.Methods: Quick-Disabilities of Arm, Shoulder and Hand (DASH)-questionnaire results, post-operative satisfaction, range of motion and grip strength are analyzed.Results: A median Quick-DASH of 54.6 was observed pre-operatively which significantly improved to a median of 28.4 after the procedure (p < 0.001). Median follow-up was 24 months. Of 46 completely followed-up patients, 31 patients (67.4%) reported that they were satisfied with the outcome. Thirty-seven patients (80.4%) would recommend the procedure to a friend. Thirty-five patients (76.1%) reported some kind of complaint in the operated hand during follow-up. There was no association of severity of symptoms and co-morbidities with the outcome. Neither palmar flexion, nor dorsal extension was significantly different between the operated and non-operated wrist. The operated wrists were observed to have less grip strength than non-operated wrists.Conclusions: The presented method seems to be as successful as other techniques described in literature. It is less invasive, thus more patient friendly without harming feasibility of future salvage options. However, post-operative complaint rate was quite high. [ABSTRACT FROM AUTHOR]

Blackground: In the last couple of years dynamic fixation for syndesmosis injuries, using a suture-button technique, raised more interest due to its advantages over the static fixation. In the current systematic review suture-button fixation is compared to the traditionally applied static fixation in unstable ankle fractures accompanied with distal tibiofibular syndesmosis injury, including the functional outcome, post-operative complications, reoperation rate, recurrent diastasis and financial aspects.Methods: A computerized literature search using PubMed/MEDLINE and EMBASE was conducted in search of suitable articles between January 2006 and February 2016. A total of 4 suture-button studies, 5 suture-button vs. static fixation studies and 1 study discussing the financial aspects were identified.Results: The AOFAS of 104 patients treated with the suture-button device was 91.08 points with an average study-follow up of 24.85 months. The AOFAS of 106 patients treated with a static fixation device was 87.95 with an average follow-up of 24.78 months. Removal of the suture-button device was reported in 10.5% of 229 patients and removal of the screws in 38.5%.Conclusions: Dynamic fixation demonstrated to be a viable alternative to the static fixation device, with lower reoperation rates and less complications. They can accurately stabilize the ruptured syndesmosis without device breakage or loss of reduction.Level Of Evidence: 1A economic/decision. [ABSTRACT FROM AUTHOR]

Background: There has been a trend to reconstruct the coracoclavicular (CC) ligaments anatomically for management of acromioclavicular (AC) joint dislocations.Purpose: The aim of this study was to determine the location and orientation of the CC ligaments for anatomic reconstruction of the AC joint.Methods: The subjects were a total of 40 shoulders from 20 Chinese cadavers. Two K-wires were drilled through the insertion center of the conoid and trapezoid ligaments respectively. The distance from the center of the CC ligaments to the bone landmarks of the clavicle and the oblique angle of the two K-wires was measured respectively.Results: The distance from the center of the trapezoid ligament to the lateral end and the anterior border of the clavicle was 21.7 ± 1.1 mm and 6.4 ± 0.5 mm, respectively. The valgus angle and retroversion angle of the trapezoid ligament was 39.3°±0.9° and 6.0°±0.6°, respectively. The distance from the center of the conoid ligament to the lateral end and the posterior border of the clavicle was 36.6 ± 0.9 mm and 5.5 ± 0.4 mm, respectively. The valgus angle and retroversion angle of the conoid ligament was 6.6°±0.7° and 11.0°±0.9°, respectively.Conclusions: These findings are important for the anatomic reconstruction of the AC joint dislocations, by predicting the location and orientation of the conoid and trapezoid ligaments accurately. [ABSTRACT FROM AUTHOR]

Objective. Structures such as ligamentum flavum, annulus, and lamina play an important role in the segmental function. We proposed the surgical technique for achieving the sufficient preservation of segmental structures, in spite of sufficient removal of pathologic disc in the L5-S1 using the ligamentum flavum splitting and sealing technique. Methods. We retrospectively analyzed 80 cases that underwent percutaneous endoscopic lumbar discectomy for L5-S1 herniated nucleus pulposus, using the ligamentum flavum splitting and sealing technique between January 2011 and June 2013. Outcomes were assessed using VAS (leg, back), MacNab’s criteria, and the immediate postoperative MRI for all patients. Structural preservation was classified as complete, sufficient, and incomplete. Results. The surgical results are as follows: 65 cases were complete, 15 cases were sufficient, and 0 cases were incomplete. The VAS was decreased at the last follow-up (leg: from 7.91±0.73 to 1.15±0.62; back: from 5.15±0.71 to 1.19±0.75). A favorable outcome (excellent or good outcome by MacNab’s criteria) was achieved in 77 patients (96.25%). During the follow-up period, 2 cases (2.5%) of recurrence have occurred. Conclusion. According to the result, we could obtain the favorable clinical and radiological outcomes while simultaneously removing pathologic discs using the ligamentum flavum splitting and annular fissure sealing technique. [ABSTRACT FROM AUTHOR]

Purpose: Recurrent patellar dislocation is defined as a dislocation occurring more than once. There is no consensus as to the choice of operative technique for recurrent dislocation in adolescents. Recently, great importance has been attributed to MPFL reconstruction. The aim of this study is to evaluate the value of MPFL reconstruction (group A) in adolescents by comparing MPFL reconstruction with combined soft tissue proximal and distal alignment (group B).Methods: MPFL reconstruction by means of Avikainen's technique was performed on 32 knees. Another 33 knees were subject to the techniques combining retinacular plasty, vastus medialis advancement, and Roux-Goldthwait procedure. The results were assed clinically (Lyscholm scale and the Kujala Anterior Knee Pain Scale) and using X-rays (axial and lateral knee view). Isokinetic assessment of the quadriceps and hamstring was performed.Results: No statistically significant differences between the two groups were observed regarding the Lyscholm and Kujala scales, the presence of redislocation (9.3 % for group A versus 12.1 % for group B), apprehension test, abnormal patellofemoral angle, abnormal Caton index (p > 0.05). A statistically significant difference between the groups was observed regarding the rate of pain complaints, the incidence of an abnormal congruence angle, patellar medialization and deficits in the peak torque of the hamstring between the two angular velocities (p < 0.05).Conclusions: The redislocation rates risk is similar in both groups. However, a lower incidence of pain complaints in the group of patients with MPFL reconstruction favours the use of MPFL reconstruction as the first choice technique.Level Of Evidence: III. [ABSTRACT FROM AUTHOR]

Purpose: There are various types of intertrochanteric fractures that are unstable pertrochanteric fractures of the hip. The aim of this study was to develop a systematic and comprehensive classification of intertrochanteric fractures.Materials and Methods: This study enrolled 74 patients with intertrochanteric fractures treated by us between 2012 and 2015. The fractures were classified using 3D-CT images taken immediately after the fractures occurred based on the course of the lateral fracture line (LFL) that extends through the lateral femoral cortex distal to the vastus ridge of the greater trochanter in the intertrochanteric area. Furthermore, the presence or absence of additional typical fractures was also studied. Then, 4 orthopedic specialists examined the 3D-CT images of 20 patients randomly selected from the 74 patients to evaluate both the inter-rater and intra-rater agreement levels.Results: Intertrochanteric fractures were classified into three types according to the LFL patterns. Type I (41.9%), the Lateral Wall Pattern, has a LFL that extends towards the lateral fiber bundle attachment area of the iliofemoral ligament. Type II (24.3%), the Transverse Pattern, has a LFL that extends towards the medial bundle attachment area. Type III (33.8%), the Reverse Oblique Pattern, has a LFL that extends between the lateral and medial fiber bundle area of the iliofemoral ligament. Each type showed characteristic displacement and was associated with various combinations of typical fractures (fracture across the intertrochanteric line, posteromedial fragment, including the lesser trochanter, posterolateral fragment posterior to the femoral greater trochanter, and banana-shaped big fragment, including both the greater trochanter and the lesser trochanter). The mean κ values for the interobserver and intraobserver agreement levels were 0.77 (0.70-0.85) and 0.76 (0.70-0.85), respectively, which were considered substantial agreement levels.Conclusion: We believe our new classification is a useful communication tool for medical professionals in the diagnosis of fractures. [ABSTRACT FROM AUTHOR]

Background: The medial patellofemoral ligament varies in attachment of its fibers to the patella and vastus intermedius tendon. Our aim was to identify and describe its anatomic midpoint. To account for the variability of the attachment site, we refer to it as the medial patellofemoral complex.Methods: Using AutoCAD software, we identified the midpoint of the medial patellofemoral complex attachment on photographs of 31 cadaveric knee dissections. The midpoint was referenced relative to the superior articular surface of the patella (P1) and was described in terms of the percentage of the patellar articular length distal to this point. A second point, at the junction of the medial border of the vastus intermedius tendon with the superior articular border of the patella, was identified (P2). The distances of the midpoint to P1 and P2 were calculated and were compared using paired t tests.Results: Twenty-five images had appropriate quality and landmarks for digital analysis. The midpoint of the medial patellofemoral complex was located a mean (and standard deviation) of 2.3% ± 15.8% of the patellar articular length distal to the superior pole and was at or proximal to P1 in 12 knees. In all knees, the midpoint was at or proximal to P2. After exclusion of 2 knees with vastus intermedius tendon attachments only, the medial patellofemoral complex midpoint was closer to P2 (5.3% ± 8.6% of the patellar articular length) than to P1 (9.3% ± 8.5% of the patellar articular length) (p = 0.06).Conclusions: The midpoint of the medial patellofemoral complex was 2.3% of the articular length distal to the superior pole of the patella. Additionally, we describe an anatomic landmark at the junction of the medial border of the vastus intermedius tendon and the articular border of the patella that approximates the midpoint of this complex.Clinical Relevance: Our study shows that the anatomic midpoint of the attachment of the medial patellofemoral complex is proximal to the junction of the medial vastus intermedius tendon and the articular border of the patella, suggesting that graft placement may be more anatomic on the vastus intermedius tendon rather than on the patella. [ABSTRACT FROM AUTHOR]

Purpose: Ossification of the ligamentum flavum (OLF) is a common cause of progressive thoracic myelopathy in East Asia. Good surgical results are expected for patients who already show myelopathy. Surgical decompression using a posterior approach is commonly used to treat OLF. This study investigated the use of microendoscopic posterior decompression for the treatment of thoracic OLF.Methods: Microendoscopic posterior decompression was performed on 9 patients with myelopathy. Patients had a mean age of 59.8 years and single-level involvement, mostly at the T10-11 and T11-12 vertebrae. Computed tomography and magnetic resonance imaging were used to classify the OLF. A tubular retractor and endoscopic system were used for microendoscopic posterior decompression. Midline and unilateral paramedian approaches were performed in 2 and 7 patients, respectively. Intraoperative motor evoked potentials (MEPs) of 7 patients were monitored. Pre- and postoperative neurological status was evaluated using the modified Japanese Orthopaedic Association (mJOA) score.Results: Thoracic OLF for all patients were classed as bilateral type with a round morphology. Improvement of MEPs at least one muscle area was recorded in all patients following posterior decompression. A dural tear in one patient was the only observed complication. The mean recovery rate was 44.9 %, as calculated from mJOA scores at a mean follow-up period of 20 months.Conclusions: Microendoscopic posterior decompression combined with MEP monitoring can be used to treat patients with thoracic OLF. The optimal surgical indication is OLF at a single vertebral level and of a unilateral or bilateral nature, without comma and tram track signs, and a round morphology. [ABSTRACT FROM AUTHOR]

Background: Anatomic posterolateral knee reconstruction is a surgical procedure that reconstructs the lateral collateral ligament (LCL), the popliteus tendon, and the popliteofibular ligament (PFL). Until recently, diverse techniques have been reported for this reconstruction; however, the gold standard is still a matter of debate. Hypothesis: Clinical outcomes and stability with tibiofibular-based PFL reconstruction would be better than those with femorofibular-based PFL reconstruction. Study Design: Cohort study; Level of evidence, 3. Methods: The records of 10 patients who underwent anatomic posterolateral knee reconstruction between January 2011 and December 2012 (LCL, popliteus tendon, tibiofibular-based PFL reconstruction [group A]) with a minimum follow-up of 24 months were retrospectively reviewed. Ten patients who underwent anatomic posterolateral knee reconstruction (LCL, popliteus tendon, femorofibular-based PFL reconstruction [group B]) using a split Achilles tendon allograft were recruited into a matched control group. All patients in both groups had an associate posterior cruciate ligament (PCL) injury, and 8 in each group underwent concomitant PCL reconstruction. Clinical outcomes were evaluated with International Knee Documentation Committee (IKDC) subjective, Lysholm, and Tegner activity scale scores. Knee stability was assessed with the dial test for the evaluation of external rotation as well as varus and posterior instability by stress radiography. Results: The mean (±SD) follow-up period was 29.5 ± 3.8 months in group A and 60.4 ± 33.8 months in group B. There were no clinically significant between-group differences in IKDC subjective scores (group A: 83.8 ± 5.4, group B: 82.7 ± 6.5; P = .853), Lysholm scores (group A: 83.4 ± 5.1, group B: 84.1 ± 7.3; P = .853), or Tegner activity scale scores (group A: 4.8 ± 1.4, group B: 4.2 ± 0.9; P = .436) at the final follow-up. In addition, there was no difference in side-to-side measurements on varus stress radiography (group A: 0.9 ± 0.7 mm, group B: 1.3 ± 1.2 mm; P = .481) or posterior stress radiography (group A: 5.3 ± 1.9 mm, group B: 5.4 ± 2.2 mm; P = .971) at the final follow-up. Although the external rotation grade of the tibia was not significantly different between groups preoperatively (P = .709), it was smaller in group A at the final follow-up (P = .044). Conclusion: There were no significant differences in clinical outcomes or varus stability between the 2 techniques of PFL reconstruction in patients with posterolateral corner injuries who underwent anatomic posterolateral knee reconstruction. However, the external rotation grade of the tibia was smaller in the group that underwent tibiofibular-based PFL reconstruction. [ABSTRACT FROM AUTHOR]

Purpose: Reconstruction of the anterior talofibular ligament may be indicated in cases of residual instability after conservative treatment. Often, a bone tunnel is used for fixation in the talar bone. The purpose of this study is to evaluate possible routes for drilling the talar tunnel.Methods: Virtual tunnels were generated in a 3D bone model, oriented towards the following external landmarks: the talar neck, the most anterior point of the medial malleolus (MM), the most distal point of the MM, the most medial point of the MM, and the most posterior point of the MM. The parameters analysed for tunnels with lengths of 20, 25, and 30 mm were the maximum distance inside the bone and the distance from the tunnel to the bone surface. A minimal safe distance (MSD) was calculated for a tunnel with a diameter of 5 mm.Results: The shortest measured distance before arriving outside the talar bone was 16.7 mm. The longest distances were obtained in the tunnels oriented towards the talar neck (mean value of 36.6, SD 2.8) and towards the most posterior point of the MM (mean value of 35.8, SD 0.3). Only one tunnel, measuring 20 mm in depth and oriented towards the most posterior point of the MM, revealed no individual values below the MSD.Conclusion: External landmarks are useful for drilling a talar tunnel during reconstruction of the anterior talofibular ligament. Only one tunnel, oriented towards the most posterior point of the MM, measuring 5 mm in diameter and with a maximum depth of 20 mm, was safe in all individuals. Surgeons should be aware of these limits when treating patients with ankle instability. [ABSTRACT FROM AUTHOR]

The anterolateral ligament of the knee (ALL) has caused a lot of rumors in orthopaedics these days. The structure that was first described by Segond back in 1879 has experienced a long history of anatomic descriptions and speculations until its rediscovery by Claes in 2013. Its biomechanical properties and function have been examined recently, but are not yet fully understood. While the structure seems to act as a limiter of internal rotation and lateral meniscal extrusion its possible proprioceptive effect remains questionable. Its contribution to the pivot shift phenomenon has been uncovered in parts, therefore it has been recognized that a concomitant anterolateral stabilization together with ACL reconstruction may aid in prevention of postoperative instability after severe ligamentous knee damages. However, there are a lot of different methods to perform this procedure and the clinical outcome has yet to be examined. This concise review will give an overview on the present literature to outline the long history of the ALL under its different names, its anatomic variances and topography as well as on histologic examinations, imaging modalities, arthroscopic aspects and methods for a possible anterolateral stabilization of the knee joint. [ABSTRACT FROM AUTHOR]

Background Context: In contrast to the majority of outcome data, many consider C1 fractures to be benign injuries and so have advocated for conservative management, except in the case of concomitant transverse atlantal ligament (TAL) injury where C1-C2 or occiput-C2 fusions are recommended. Purpose: Our goal was to evaluate a series of unstable C1 fractures treated with C1 open reduction and internal fixation (ORIF) to assess clinical and radiographic outcomes by determining the success of reduction and pain relief. Study Design/setting: This is a retrospective cohort review. Patient Sample: The sample includes adult patients with unstable C1 fractures treated with open reduction and primary internal fixation. Outcome Measures: Primary outcome measures included visual analog pain scale (VAS), radiographic reduction (lateral mass displacement), maintenance of reduction, C1-C2 instability, and complications. Methods: A retrospective review of all patients with C1 fractures between September 2002 and September 2013 identified 12 consecutive patients from a level I trauma center who were treated with primary internal fixation without fusion. Electronic medical records and preoperative and postoperative radiographs were reviewed. The surgical technique consisted of a posterior cervical approach to the C1 arch and open reduction using bilateral C1 lateral mass screws connected transversely with a rod. Pre- and postoperative computed tomography scans were used to assess reduction. Long-term follow-up flexion and extension radiographs were used to assess C1-C2 stability. The authors did not receive relevant funding in relation to this research. Results: Twelve patients underwent C1 ORIF, with a mean age of 43 (9 males and 3 females) and a mean follow-up of 17 months. Transverse atlantal ligament was found to be disrupted with type I or type II injury in 11 of the 12 patients: 5 type I and 6 type II. Preoperative lateral mass displacement averaged 7.1 mm, with postoperative displacement after reduction averaging 2.4 mm (p-value <.001). The VAS score averaged 0.7 at latest follow-up. No patients went on to develop C1-C2 instability on final flexion-extension films. No patients had a complication that resulted in neurologic deficit or vascular injury associated with the procedure. No patients were found to have late sequelae of malunion or loss of reduction. Two surgically related complications occurred, namely one patient with errant screw requiring return to the operating room (OR) and one with arthrosis of the occipital-C1 joint. Conclusions: Although a small series, early evidence suggests that patients with unstable C1 ring fractures can be successfully managed with primary ORIF. Open reduction and internal fixation results in a stable construct that maintains reduction, results in excellent pain control, and does not lead to C1-C2 instability. In our series, we have not observed the presence of TAL injury to adversely affect outcomes, and thus do not believe it is a contraindication to ORIF. Comparative studies comparing internal fixation with non-operative, C1-C2, or occiput-C2 fusions would yield more insight into optimal treatment options for these fractures. [ABSTRACT FROM AUTHOR]

Background: Multiple-ligament injured knee (MLIK) is a rare but severe injury. Although the principles of MLIK management have progressed over the past 40 years, there is a paucity of high-quality evidence upon which to base the management of MLIK. Treatment strategies for MLIK are challenging for most orthopedic surgeons, and the optimal treatment remains controversial, especially with regard to repair vs. reconstruction of the ligaments. The aim of the present study was to observe clinical outcomes of single-stage in situ suture repair of knee dislocation with multiple-ligament injury using nonabsorbable suture material.Methods: Consecutive patients with MLIK between 2002 and 2010 were included, for a total of 25 patients with knee dislocation. 17 patients (18 knees) with closed knee dislocation with a mean follow-up of 4.8 ± 1.3 years were retrospective analyzed. All patients were treated surgically with single-stage in situ suture repair for all injured ligaments and followed a standardized postoperative rehabilitation protocol. The VAS score, satisfactory score, total SF-36 score, Lysholm score, Tegner score, the Meyers functional rating and the ranges of motion and knee stability were used to evaluate outcomes.Results: At final follow-up, mean visual analog scale score was 2.4 ± 0.9, patient satisfaction score was 8.0 ± 1.1, 36-item Short-Form Health Survey total score was 85.5 ± 10.4, and mean Lysholm score was 87.5 ± 7.7. There were significant differences between mean preinjury and postoperative Tegner activity scores (5.6 ± 1.4 and 3.4 ± 1.7, respectively; P < 0.01) and in mean range of motion between the injured and contralateral knees (112.5 ± 8.4° and 129.6 ± 10.3°, respectively; P < 0.01). At final follow-up, no patient demonstrated obvious ligamentous laxity, and only one patient was unable to return to work. Three patients had knee joint stiffness, two had wound problems (infection or fat liquefaction), and two had heterotopic bone formation.Conclusions: Single-stage in situ suture repair of injured ligaments confers advantages of reliable fixation and early exercise. It could be considered as an alternate and effective option in the dislocation knee with multiple-ligament injury. [ABSTRACT FROM AUTHOR]

Background: Studies have reported methods for radiographically delineating medial patellofemoral ligament (MPFL) femoral tunnel position on a true lateral knee radiograph. However, obtaining a true lateral fluoroscopic radiograph intraoperatively can be challenging, rendering radiographic methods for tunnel positioning potentially inaccurate. Purpose: To quantify the magnitude of MPFL femoral tunnel malposition that occurs on true lateral and aberrant lateral knee radiographs when using a previously reported radiographic technique for MPFL femoral tunnel localization. Study Design: Descriptive laboratory study. Methods: Ten fresh-frozen cadaveric knees were dissected to expose the MPFL femoral insertion and surrounding medial knee anatomy. True lateral and aberrant lateral knee radiographs at 2.5°, 5°, and 10° off-axis were obtained with a standard mini C-arm in 4 orientations: anterior to posterior, posterior to anterior, caudal, and cephalad. A previously reported radiographic method for MPFL femoral localization was performed on all radiographs and compared in reference to the anatomic MPFL attachment center. Results: The radiographic point, as previously described, was a mean distance of 4.1 mm from the anatomic MPFL attachment on a true lateral knee radiograph. The distance between the anatomic MPFL attachment center and the radiographic point significantly increased on aberrant lateral knee radiographs with as little as 5° of rotational error in 3 of 4 orientations of rotation when a standard mini C-arm was used. This corresponded to a malposition of 7.5, 9.2, and 8.1 mm on 5°-aberrant radiographs in the anterior-posterior, posterior-anterior, and cephalad orientations, respectively (P < .005). In the same 3 orientations of rotation, MPFL tunnel malposition on the femur exceeded 5 mm on 2.5° aberrant radiographs. Conclusion: The commonly utilized radiographic point, as previously described for MPFL femoral tunnel placement, results in inaccurate tunnel localization on a true lateral radiograph, and this inaccuracy is perpetuated with aberrant radiography. Aberrant lateral knee imaging of as little as 5° off-axis from true lateral has a significant effect on placement of a commonly used radiographic point relative to the anatomic MPFL femoral attachment center and results in nonanatomic MPFL tunnel placement. Clinical Relevance: This study demonstrates that radiographic localization of the MPFL femoral tunnel results in inaccurate tunnel placement on a true lateral radiograph, particularly when there is deviation from a true lateral fluoroscopic image, which can be difficult to obtain intraoperatively. Assessing anatomy directly intraoperatively, rather than relying solely on radiographs, may help avoid MPFL tunnel malposition. [ABSTRACT FROM AUTHOR]

This review article describes the potential range of image-guided interventional procedures performed following foot and ankle ligament and/or tendon repair. Diagnosis of the cause of recurrent or persistent pain/symptoms in this postoperative group is challenging and requires a coordinated clinical and radiologic assessment. This directs appropriate treatment including image-guided intervention that may be used both as a diagnostic tool and a therapeutic option. There is a paucity of high-quality studies on the role of image-guided intervention in the foot and ankle after ligament/tendon repair. Many of the procedures used in this group are extrapolated from other areas of the body or the preoperative scenario. We review the role of imaging to identify the cause of postsurgical symptoms and to direct appropriate image-guided intervention. The available injectables and their roles are discussed. Specific surgical procedures are described including lateral ligament repair, Achilles repair, posterior tibialis tendon surgery, and peroneal tendon surgery. [ABSTRACT FROM AUTHOR]

Gait pattern alterations were previously reported in association with objective patellar instability (OPI). Gait pattern comparison between a series of patients having undergone medial patellofemoral ligament (MPFL) reconstruction and a sample of control subjects. Thirty patients at 6 months postoperatively after MPFL reconstruction and thirty control subjects were enrolled in the study for a clinical and biomechanical assessment including gait analysis at three selected walking rates using the GAITRite(®) system. The mean raw IKDC score was 73 (± 19), and the mean Kujala knee function was 84 (± 17.5). The study of gait did not demonstrate any significant difference between the two groups at a normal and fast walking rate. At a 10 km/h running speed, the single-support phase was significantly shortened by a mean 2.33% (p < 0.05), the swing phase by a mean 2.64% (p < 0.05) and the double-support phase by a mean 3.49% (p < 0.05) on the operated side. MPFL reconstruction reported good midterm functional and clinical results in the management of OPI. At 6 months postoperatively, the patient gait pattern was similar to that observed in healthy subjects at a normal and fast walking speed. However, our study revealed persistent gait abnormalities at a 10 km/h running speed. These gait alterations seemed to be related to the ligament reconstruction in itself due to the higher strain applied on the reconstructed MPFL during running cycle (10 km/h). Level of evidence IV. [ABSTRACT FROM AUTHOR]

Background: Hallux valgus (HV) is occasionally associated with chronic dislocation of the lesser metatarsophalangeal (MTP) joints. We have developed a novel surgical procedure to treat dislocation of the lesser MTP joints. This study aimed to describe our procedure and investigate the outcomes of surgical intervention in the treatment of HV with dislocation of the lesser MTP joints.Methods: Twenty-three patients (27 feet, average age: 63.6 years, average follow-up: 49.5 months; a minimum follow-up of 24 months) underwent surgical intervention for HV and dislocation of the lesser MTP joints. Twenty-three feet had dislocation (10 feet) or subluxation (13 feet) of the second MTP joint, whereas 4 feet had dislocation of the second and third MTP joints. The surgical procedure included a distal soft-tissue procedure combined with proximal osteotomy for correction of the HV, and reconstruction of the collateral ligaments (CL) following open reduction with complete release of the capsule and the CL at the metatarsal head for dislocation of the lesser MTP joints. Outcomes were assessed using the Japanese Society for Surgery of the Foot (JSSF) scale and radiological examinations.Results: The JSSF score improved significantly from an average of 49.7 points preoperatively to 93.1 points postoperatively. The average HV angle and intermetatarsal angle decreased significantly from 44.6° and 18.1° preoperatively to 7.9° and 6.0° postoperatively, respectively. The average extension and flexion of the second MTP joint was 53.1° and 13.8° at the most recent follow-up, respectively. Postoperatively, no feet had dislocation of the second or third MTP joint, three had subluxation of the second MTP joint, and one had subluxation of the third MTP joint. Osteoarthritis of the lesser MTP joint had developed in two feet (7.4 %) at the time of the most recent follow-up.Conclusion: Our surgical procedure achieved significant correction of HV, a low rate of postoperative re-dislocation of the lesser MTP joints, and significant improvement of pain and function for symptomatic moderate-to-severe HV with dislocation of the lesser MTP joints.Level Of Evidence: Level IV, retrospective case series. [ABSTRACT FROM AUTHOR]

Background: Within the past 20 years, knee ligament injuries have been increasingly reported in the literature to be treated with anatomic reconstructions over soft tissue advancements or sling-type procedures to recreate the native anatomy and restore knee function. Historically, early clinician scientists published on the qualitative anatomy of the knee, which provided a foundation for the initial knee biomechanical studies in the nineteenth and twentieth centuries. Similarly, the work of early sports medicine orthopaedic clinician scientists in the late twentieth century formed the basis for the quantitative anatomic and functional robotic biomechanical studies found currently in the sports medicine orthopaedic literature. The development of an anatomic reconstruction first requires an appreciation of the quantitative anatomy and function of each major stabilizing component of the knee.Purpose: This paper provides an overview of the initial qualitative anatomic studies from which the initial knee ligament surgeries were based and expands to recent detailed quantitative studies of the major knee ligaments and the renewed recent focus on anatomic surgical reconstructions.Conclusions: Anatomic repairs and reconstructions of the anterior cruciate ligament, posterior cruciate ligament, medial collateral ligament and posterolateral corner attempt to restore knee function by rebuilding or restoring the native anatomy. The basis of anatomic reconstruction techniques is a detailed understanding of quantitative knee anatomy. Additionally, an appreciation of the function of each component is necessary to ensure surgical success.Level Of Evidence: V. [ABSTRACT FROM AUTHOR]

This paper describes anteromedial rotatory laxity of the knee joint. Combined instability of the superficial MCL and the structures of the posteromedial corner is the pathological background anteromedial rotatory laxity. Anteromedial rotatory instability is clinically characterized by anteromedial tibial plateau subluxation anterior to the corresponding femoral condyle. The anatomical and biomechanical background for anteromedial laxity is presented and related to the clinical evaluation, and treatment decision strategies are mentioned. A review of the clinical studies that address surgical treatment of anteromedial rotatory instability including surgical techniques and clinical outcomes is presented. Level of evidence V. [ABSTRACT FROM AUTHOR]

Purpose: The posterolateral corner (PLC) of the knee is anatomically complex with similarly complex MR imaging findings in acutely injured knees. The purpose of this study was to define the MRI pattern of injury in cases of PLC disruption requiring surgery because of clinical instability.Methods: The knee MRIs of 22 patients who underwent surgical repair and/or reconstruction of PLC injury were retrospectively reviewed. The fibular collateral ligament (FCL), popliteus tendon (PT), biceps femoris (BF), popliteofibular ligament (PFL), arcuate ligament (AL), and fabellofibular ligament (FFL) were evaluated and graded as follows: complete tear, high-grade partial tear, low-grade partial tear, and normal.Results: In the 22 cases of PLC injury that necessitated surgery, a constellation of findings involving the larger structures of the PLC was identified. Of the FCL, PT, and BF (considered larger structures), at least two were abnormal in all 22 injury cases. Of the PFL, AL, and FFL (considered smaller structures), the PFL appeared abnormal in 19 cases, yet neither the AL nor FFL were confidently characterized in the injury group.Conclusion: The larger structures of the PLC are easily evaluated using standard MRI techniques. This study identified a predictable pattern of imaging findings involving these more easily assessed structures in those patients who were felt to be clinically unstable and underwent surgical reconstruction, as at least two were abnormal in all 22 cases. The smaller structures of the PLC are difficult to assess with MRI; however, direct visualization of their involvement on MRI is not necessary to report a clinically unstable PLC injury. Emphasis of this simplified but critical analysis of the FCL, BF and PT on MRI scans reviewed by radiologists and orthopaedic surgeons may help to prevent delayed diagnosis of unstable PLC injuries.Level Of Evidence: III. [ABSTRACT FROM AUTHOR]

Background: Little is known about the long-term results of surgical correction of hallux valgus deformity, in particular, the recurrence rate and factors leading to recurrence. Methods: Of one hundred and eight patients (115 feet) who underwent a Scarf osteotomy, ninety-three patients (ninety-three feet) were examined at an average duration of follow-up of 124 months. Clinical examination before surgery and at the time of final follow-up included an evaluation of range of motion, pain as measured with a visual analog scale, and American Orthopaedic Foot & Ankle Society (AOFAS) scores. The Foot and Ankle Outcome Score (FAOS) was also assessed postoperatively. Radiographic data were evaluated preoperatively, at six weeks postoperatively, and at the time of final follow-up. Additional radiographic data were available for seventy-nine patients of the same patient cohort at an average of twenty-seven months postoperatively. Results: The median overall AOFAS score improved from 57 points preoperatively to 95 points at the time of final follow-up. All radiographic measurements (hallux valgus angle [HVA], intermetatarsal angle [IMA], distal metatarsal articular angle [DMAA], and sesamoid bone position) showed significant (p < 0.05) improvement at the time of final follow-up compared with preoperatively. The rate of recurrence (an HVA of ?20°) at the time of final follow-up was 30%. We were unable to determine if recurrence resulted in functional impairment or consequences for quality of life. Conclusions: The recurrence rate after ten years was 30%, and a higher final HVA resulted in higher pain levels. The limitations imposed by nonvalidated outcome measures precluded conclusions about the influence of HVA on function or quality of life. [ABSTRACT FROM AUTHOR]

Background. Posterior cruciate ligament (PCL) injuries are not rare in acute knee injuries, and several recent anatomical studies of the PCL and reconstructive surgical techniques have generated improved patient results. Now, we have evaluated PCL reconstructions performed by either the single-bundle or double-bundle technique in a patient group followed up retrospectively for more than 10 years. Methods. PCL reconstructions were conducted using the single-bundle (27 cases) or double-bundle (13 cases) method from 1999 to 2002. The mean age at surgery was 34 years in the single-bundle group and 32 years in the double-bundle group. The mean follow-up period was 12.5 years. Patients were evaluated by Lysholm scoring, the gravity sag view, and knee arthrometry. Results. The Lysholm score after surgery was 89.1±5.6 points for the single-bundle group and 91.9±4.5 points for the double-bundle group. There was no significant difference between the methods in the side-to-side differences by gravity sag view or knee arthrometer evaluation, although several cases in both groups showed a side-to-side difference exceeding 5 mm by the latter evaluation method. Conclusions. We found no significant difference between single- and double-bundle PCL reconstructions during more than 10 years of follow-up. [ABSTRACT FROM AUTHOR]

Objective: Our aim was to analyse whether MRI is useful in the follow-up of reconstruction of the ulnar collateral ligament (UCL) of the metacarpophalangeal joint of the thumb, to describe normal postoperative findings, and to evaluate different MR sequences.Material and Methods: Our study material consists of 10 patients who, because of a chronic rupture of the ulnar collateral ligament of the thumb, had been operatively treated using a free tendon graft. The patients were, in addition to the clinical examination and radiographs, also imaged using MRI both pre- and postoperatively. The postoperative MRI controls, undertaken at 2, 12 and 24 months were analysed without knowledge of the clinical or radiographic findings.Results: The reconstructed UCL was well visualised on MRI. One graft rupture was diagnosed on MRI and was later operatively confirmed. No increase in osteoarthritis of the metacarpophalangeal (MP) joint of the thumb was seen during the follow-up. The single most informative MR sequence was T2TSE in the coronal plane.Conclusion: Magnetic resonance imaging may provide a clinically valuable means of assessing graft integrity in patients with suspected postoperative graft failure after UCL reconstruction, although we do not consider MRI necessary in the routine follow-up of patients with an uneventful recovery. [ABSTRACT FROM AUTHOR]