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Background: A recent development in valgus-producing knee braces has been the adjustable “unloader” brace. The purpose of this study was to compare the effectiveness of off-the-shelf and custom-made patient-adjustable, valgus-producing knee unloader braces in relieving pain, reducing stiffness, and improving function and in reducing varus angulation and the peak adduction moments about the knee during gait and stair-stepping in patients with painful varus gonarthrosis of the knee. Methods: Ten adult patients served as their own controls for the measurement of baseline values and then wore each of the two braces, one after the other, for four to five weeks in a random order. Pain, stiffness, and function were assessed with the Western Ontario and McMaster Universities Osteoarthritis Index. Gait and stair-stepping were evaluated with a three-dimensional motion analysis system and multicomponent force platform. Full-length (hip, knee, and ankle) standing anteroposterior radiographs were used to determine alignment of the knee. Results: Both braces significantly reduced pain and stiffness (p < 0.05), with the custom brace reducing stiffness significantly more than the off-the-shelf brace (p = 0.030). The custom brace significantly improved function (p = 0.010) and reduced the peak knee adduction moments during gait (p = 0.033) and stair-stepping (p = 0.002) compared with baseline values and compared with the off-the-shelf brace (p = 0.029 and p = 0.027, respectively). The custom brace significantly reduced varus angulation of the knee by 1.5° compared with baseline (p = 0.001) and by 1.3° compared with the off-the-shelf brace (p = 0.009). The off-the-shelf brace did not significantly reduce the varus angle. Conclusions: We investigated only the short-term effects of custom and off-the-shelf patient-adjustable valgus-producing knee “unloader” braces and found that patients with varus gonarthrosis of the knee may benefit significantly with respect to pain relief and reduced stiffness from use of either brace. However, such patients may experience additional significant benefit in improved function and reduced stiffness, varus angulation, and medial compartment loading of the knee from use of the custom-made patient-adjustable brace. Level of Evidence: Therapeutic Level II. See Instructions to Authors for a complete description of levels of evidence.

Purpose Coronoid injuries are classified according to the size of the coronoid fracture. The purpose of this study was to provide a detailed anatomic description of the coronoid process, with specific focus on the coronoid height, the coronoid width, and the olecranon–coronoid angle. Methods Thirty-five cadaveric arms were dissected. All soft tissue was removed and the ulna was disarticulated from the humerus, radius, and the carpal bones. A 3-dimensional digitizing system was used to locate 19 anatomic landmarks on each specimen. By using the 3-dimensional coordinates of the landmarks, the coronoid heights, proximal ulnar widths, and olecranon–coronoid angles were determined. Results The coronoid height, with its base defined by the trough of the trochlear notch and the slope change of the distal coronoid process, measured 15 mm and was 42% of the ulnar height. The coronoid height, with its base defined by the transverse groove of the sigmoid notch at the guiding ridge and the distal insertion of the brachialis muscle, measured 15 mm and was 43% of the ulnar height. The olecranon–coronoid angle ranged between 33° and 38°. Conclusions For lateral radiographic classification of coronoid fractures, coronoid height is best defined by the trough of the trochlear notch and the slope change of the distal coronoid process. For anatomic studies, coronoid height is best defined by the transverse groove of the sigmoid notch at the guiding ridge and the distal insertion of the brachialis muscle. The olecranon–coronoid angle is best defined by the angle formed by the lines from the olecranon tip through the coronoid tip and through the slope change of the distal coronoid process. The coronoid anatomy measurements reported in this study may help to improve coronoid fracture classification.

A flatfoot deformity alters the contact characteristics of the ankle joint, shifting the location of articulation posterolaterally, increasing pressure, and decreasing the contact area within the ankle. These changes may explain the pattern of articular degeneration and subsequent angulation observed in a long-standing adult acquired flatfoot. Corrective orthoses and surgical reconstruction have been used to realign pes planovalgus feet, but the effects of these treatments on tibiotalar contact characteristics are unknown. We hypothesized that realignment of a flatfoot with either corrective orthosis or surgical reconstruction would restore the contact characteristics of the ankle to the intact state.The mean value of the contact area, contact pressure, peak contact pressure, and the relative locations of the global contact area and peak pressure within the ankle joint were determined from imprints created on pressure sensitive film for a series of cadaver lower limbs subjected to a weightbearing load in simulated midstance phase of gait. Each limb was loaded sequentially under four conditions: intact, flatfoot, flatfoot realigned with UCBL orthosis, and flatfoot realigned with a medial translational osteotomy of the calcaneus.The use of the UCBL orthosis and calcaneal osteotomy altered the contact characteristics of the ankle when compared with the flatfoot condition. Both interventions significantly decreased the mean global contact pressure from the flatfoot value, with the orthosis, demonstrating a significantly greater correction than the osteotomy. The orthosis also significantly reduced the peak contact pressure from the flatfoot value. Both interventions significantly corrected the lateral shift of the center of the peak contact pressure from the flatfoot value. The shift in the center of the global contact area approached significance when the orthosis was compared with the flatfoot.The changes observed in the magnitude and location of the mean and peak pressures indicate that the UCBL orthosis and calcaneal osteotomy altered hindfoot alignment to significantly influence tibiotalar contact characteristics. The results further suggest that the UCBL orthosis corrected ankle malalignment better than the calcaneal osteotomy in an adult acquired flatfoot. This study provides biomechanical data to support the clinical impression that realignment of the hindfoot corrects the pathologic tibiotalar contact characteristics associated with an adult acquired flatfoot. The results support the conclusion that the clinical management of a pes planovalgus foot with a UCBL orthosis or a medial translational osteotomy of the calcaneus may avert the onset of pantalar disease seen with late-stage posterior tibial tendon dysfunction.

Tripping over an obstacle is the most frequent cause of falls. We examined the effects of total knee arthroplasty on obstacle avoidance success rates in older adults. Obstacle avoidance success rates, body mass index, visual acuity, contrast sensitivity, depth perception, and single-leg stance duration were evaluated in 29 subjects who had bilateral total knee arthroplasties (age range, 72.6 +/- 5.4 years) and 27 age-matched healthy control subjects (age range, 70.6 +/- 5.5 years). The patients who had total knee arthroplasties had a lower obstacle avoidance success rate, lower single-leg stance duration, and greater body mass index than control subjects. Age, contrast sensitivity, and depth perception were not different between patients who had total knee arthroplasties and control subjects. Obstacle avoidance success rates decreased linearly as single-leg stance duration decreased in the control group and across all groups, but not in the group that had total knee arthroplasties. Linear relationships between obstacle avoidance success rates and body mass index existed for all subjects but not for the group that had total knee arthroplasties or the control group individually. Total knee arthroplasty reduces obstacle avoidance success rate, suggesting that persons who have total knee arthroplasties have an increased propensity to trip on an obstacle and fall. Increased body mass index and decreased single-leg stance duration in patients who have total knee arthroplasties are associated with a decreased obstacle avoidance success rate.

Seven cadaveric knees were used to investigate the effects of removal and reconstruction of the anterior cruciate ligament with a bone-patellar tendon-bone graft on contact characteristics of the patellofemoral joint during physiologic levels of quadriceps muscle loads at 30 degrees, 60 degrees, and 90 degrees of knee flexion. Loads were applied to the quadriceps tendon to equilibrate externally applied flexion moments equivalent to one-third of values for maximum isometric extension moments. Patellofemoral contact areas and pressures were measured using pressure-sensitive film. Excision of the anterior cruciate ligament resulted in significant decreases in the total patellofemoral contact area by as much as 94 mm2 (68%), the medial facet contact area by as much as 55 mm2 (93%), the combined average contact pressure by 0.7 MPa (21%), the medial facet average contact pressure by 2.3 MPa (70%), the combined peak contact pressure by 3.0 MPa (38%), and the medial facet peak contact pressure by 5.4 MPa (76%), all at 30 degrees of knee flexion. Excision of the anterior cruciate ligament also resulted in significant decreases in total, medial facet, and lateral facet patellofemoral contact areas at 60 degrees and 90 degrees of knee flexion. Intraarticular reconstruction returned these to levels not significantly different from those of the intact knee.

Changes in the tibiotalar contact characteristics were investigated using eight fresh frozen cadaver ankle specimens to further develop an established model of the acquired flatfoot deformity. The deformity was simulated by sectioning the tendons and ligaments of the ankle and foot that normally support the longitudinal arch. Axial loads of 1,350 N were applied to the foot in a neutral position in both the intact specimen and flatfoot model. The flatfoot condition resulted in significant lateral shifts of 5.28 mm in global contact area and 11.26 mm in the location of peak pressure, and in a small but significant posterior shift of 1.14 mm in global contact area. The flatfoot condition also resulted in a significant, 35%, reduction in contact area. Significant increases in mean pressure, 14%, and peak pressure, 13%, were also found, but were not in proportion to the relatively large decrease in contact area. This suggests a transfer of load off of the talar dome. Increased loading of the lateral facet and fibula are suspected. The lateral shift in the contact region created a local increase in mean contact pressure that may be responsible for long term degenerative changes in patients with this deformity.

Background . Elderly patients treated with antidepressants for depression are at high risk for injury due to falling. The primary purpose of this study was to determine the effects of amitriptyline, desipramine, and paroxetine on the gait of healthy elderly subjects during unobstructed and obstructed (i.e., stepping over obstacles) gait. Psychomotor and mood tests were also performed. Methods . A randomized, crossover, four-period, double-blind, placebo-controlled laboratory trial was performed. Twelve healthy elderly subjects (average age, 67 years; range, 65‐72 years) were tested. Subjects were assigned the three antidepressant drugs or a placebo in a random order. Single doses of amitriptyline 50 mg, desipramine 50 mg, paroxetine 20 mg, or placebo were given 4 hours prior to gait testing. Temporal-distance measures and kinematics of the lower trailing limb (i.e., limb going over obstacle last) were obtained. Results . Compared with placebo, amitriptyline significantly reduced gait velocity by as much as 8.0% ( p 5 .028), cadence by as much as 4.9% ( p 5 .012), angular velocity of hip flexion by as much as 10.0% ( p 5 .004), and angular velocity of knee flexion by as much as 8.3% ( p 5 .018) during the crossing strides when stepping over obstacles. Except for knee flexion angle, unobstructed gait was not affected. Amitriptyline affected integrative capacity of the central nervous system (CNS) and ability to concentrate as measured by psychomotor and mood tests. Conclusions . The results for amitriptyline suggest that the subjects slowed their obstacle crossing speeds as a result of reduced CNS integrative capacities. Neither paroxetine nor desipramine significantly affected gait, psychomotor function, or mood.

Twenty fresh frozen hand specimens from cadavers were studied. Physiologic levels of extrinsic muscle loads were applied to the extrinsic flexor tendons of the index finger to simulate tip pinch of the finger on a fixed plate. The acute effects of transection of the radial collateral ligament and accessory radial collateral ligament (radial collateral ligament complex) with and without transection of the dorsal capsule and volar plate on the position of the proximal phalanx with respect to the metacarpal bone of the index finger were investigated. The acute effects of reconstruction of the radial collateral ligament, for each of two different surgical techniques, on the position of the proximal phalanx also were investigated. The spatial positions of the metacarpal bone and proximal phalanx were measured with a six-degree-of-freedom digitizing system for flexion angles from 0 degrees to 90 degrees in increments of 15 degrees. Transection of the radial collateral ligament complex resulted in significant increases in ulnar deviation (adduction) of the proximal phalanx and in volar translation. Additional transection of the dorsal capsule and volar plate caused significant increases in ulnar deviation, pronation, volar translation, and ulnar shift. The first surgical technique, one traditionally used to reconstruct the metacarpophalangeal joint of the thumb, failed to return the three-dimensional position of the proximal phalanx on the metacarpal head of the index finger to normal. The second surgical technique, based on anatomy, returned the position of the proximal phalanx to levels not statistically different from normal for most flexion angles.

We present a posterior stabilized mobile-bearing prosthesis, TRAC PS, which has congruent contact from full extension to full flexion, allows for freedom of internal-external rotation, and has an automatic posterior shift in tibiofemoral contact on the tibia to maximize the quadriceps lever arm in flexion. TRAC PS has 2 radii of curvature in the sagittal plane, 1 for the distal femoral condyles and 1 for the posterior femoral condyles, as does the normal knee. The distal and posterior femoral condyles articulate congruently in the inner tracks or the outer tracks of the polyethylene bearing, respectively. Anterior or posterior sliding of the femoral condyles on the bearing or of the bearing on the tibial tray cannot occur, providing inherent anterior and posterior stability. Three-dimensional knee laxity testing was performed on 17 patients from 12 months to 25 months after total knee arthroplasty with the TRAC PS and on 18 healthy control subjects of similar ages. Normal ligament balancing and normal internal-external rotational laxity were achieved with the TRAC PS prosthesis. Anterior and posterior laxity in the patients with TRAC PC was significantly reduced compared with that of the control subjects.

We studied 7 younger and 5 older patients who had rotating-hinge total knee replacements, 10 patients who had semiconstrained total knee replacements, and 8 younger and 11 older healthy control subjects to determine the effects of the rotating-hinge device on gait and stair stepping. The younger patients with the rotating-hinge device had few significant differences from the younger control subjects during gait or stair stepping. The older patients with the rotating-hinge device had several significant differences from both the older control subjects and subjects with the semiconstrained device during gait and stair stepping. Nevertheless, the proportions of older patients with the 2 devices who were able to perform the step-on activity for the highest step were the same.

In the past, there has been a plausible hypothesis that anterior cruciate ligament graft placement at isometric sites, such that the tibial and femoral attachment sites remain equidistant from each other throughout knee range of motion, would increase the likelihood of a satisfactory outcome. For a given tibial placement we wanted to determine whether placing the graft on the average of the most isometric femoral line, a fixed distance from the outlet of the intercondylar notch, would return normal laxity to all knees. The three-dimensional kinematics of seven cadaveric knees were measured for angles from full extension to 90° of flexion at 15° increments. Physiologic levels of quadriceps muscle forces were applied to the intact knee, after transection of the anterior cruciate ligament, and after ligament reconstruction with a patellar tendon graft. On average, the reconstruction was found to return anterior-posterior translation, internal-external rotation, and varus-valgus rotation to levels not significantly different from those of the intact knee. However, the ranges of the translation and rotations were large. Placing the graft on the average most isometric femoral line did not restore knee laxity to normal in all knees. This supports the need to customize graft placement in each knee at the time of surgery.

Patellofemoral pain may be associated with anterior cruciate ligament deficiency or may occur after anterior cruciate ligament reconstruction. We investigated the effects of the removal and reconstruction of the anterior cruciate ligament on the kinematics of the tibiofemoral and patellofemoral joints during physiologic levels of quadriceps muscle loads in seven cadaveric knees. A bone-patellar tendon-bone graft was used for intraarticular reconstruction of the anterior cruciate ligament. The spatial positions of the tibiofemoral and patellofemoral joints were measured between 0 degrees and 90 degrees of knee flexion in 15 degrees increments with a six degree-of-freedom digitizing system. Excision of the anterior cruciate ligament resulted in statistically significant increases in anterior tibial translation between 0 degrees and 90 degrees and valgus tibial rotation between 30 degrees and 90 degrees; intraarticular reconstruction returned these to levels not significantly different from those of the intact knee. Excision of the anterior cruciate ligament resulted in significant increases in lateral patellar tilt, ranging from 6.3 degrees to 9.0 degrees between full extension and 90 degrees of knee flexion, and in lateral patellar shift, ranging from 2.9 mm at 15 degrees of knee flexion to 5.9 mm at 90 degrees; intraarticular reconstruction returned these to levels not significantly different from those of the intact knee. Neither removal nor reconstruction of the anterior cruciate ligament significantly affected tibial internal-external rotation, patellar flexion, patellar mediolateral rotation, patellar anteroposterior translation, or patellar proximodistal translation.

We modeled an intraarticular anterior cruciate ligament graft and investigated the effects of attachment orientation and twist of the graft on its isometry during quadriceps muscle loading. Physiologic levels of quadriceps muscle loads were applied to 15 intact cadaveric knees. We measured the changes in distance between points on the tibia and femur for knee flexion angles between 0 degree and 120 degrees using a three-dimensional digitizer. Selected points on the tibia and femur, representing graft attachment sites, allowed us to model the graft as a broad band. Distance was used to approximate graft fiber length. A 180 degrees twist in the graft significantly reduced the maximal range of changes in distance when the graft was attached in the anteroposterior direction. Range is defined as the difference between the largest and smallest changes in distance among the fibers of the graft for a given angle of flexion. This reduction enhanced isometry among the fibers of the graft. Enhanced isometry would be expected to enhance load sharing among these fibers, thereby increasing the overall strength of the graft. For a graft 10 mm wide and 4 mm thick, the dimensions of a typical patellar tendon graft, the best overall isometry was found when the breadth of the graft was attached to the tibia in the mediolateral direction, to the femur along the most isometric line, and with a 180 degrees twist in the graft.

We report the effects of femoral tunnel position and graft tensioning technique on posterior laxity of the posterior cruciate ligament-reconstructed knee. An isometric femoral tunnel site was located using a specially designed alignment jig. Additional femoral tunnel positions were located 5 mm proximal and distal to the isometric femoral tunnel. With the graft in the proximal femoral tunnel, graft tension decreased as the knee flexed; with the graft in the distal femoral tunnel, graft tension increased as the knee flexed. When the graft was placed in the isometric femoral tunnel, a nearly isometric graft tension was maintained between 0 degrees and 90 degrees of knee flexion. One technique tested was tensioning the graft at 90 degrees of knee flexion while applying an anterior drawer force of 156 N to the tibia. This technique restored statistically normal posterior stability to the posterior cruciate ligament-deficient knee between 0 degrees and 90 degrees for the distal femoral tunnel position, between 0 degrees and 75 degrees for the isometric tunnel position, and between 0 degrees and 45 degrees for the proximal tunnel position. When the graft was tensioned with the knee in full extension and without the application of an anterior drawer force, posterior translation of the reconstructed knee was significantly different from that of the intact knee between 15 degrees and 90 degrees for all femoral tunnel positions.

We investigated the changes in distance between Gerdy's tubercle on the tibia and points on the posterior two thirds of the lateral surface of the lateral femoral condyle and adjacent lateral femoral shaft in 15 cadav eric knees. A three-dimensional digitizer was used to quantify motion of the knee during flexion ranging from full extension to 120° of flexion. Four load states were applied: internal, external, and neutral rotation, and quadriceps muscles loads based on one third of values in the literature for maximal isometric quadriceps muscles moments. The femoral location most isometric to Gerdy's tubercle was found to be strongly influenced by the load state. A 1.0 cm wide iliotibial band tenodesis was mod elled by five straight lines arising from Gerdy's tu bercle and attaching to a simulated washer at the junction of the lateral femoral condyle and shaft. Using this model and the motion data obtained from the cadavers, we investigated the effects of quadri ceps muscles loading and external rotation of the knee on changes in the distances between these tibial and femoral attachments for each of the five lines. A 180° twist modelled into the tenodesis sig nificantly reduced the range of changes in distance (difference between the largest and smallest changes in distance among the lines for a given angle of flex ion) for both of these load states. Therefore, a 180° twist in the tenodesis can enhance isometry among the fibers of the tenodesis. This implies that a 180° twist can enhance load sharing among the fibers of the tenodesis and, therefore, enhance the overall strength of the tenodesis.

We assessed the function of the posterior malleolus, the anterior tibiofibular ligament, and the fibula with regard to posterior stability of the talus in ten ankles of cadavera. Posteriorly directed loads of as much as 200 newtons were applied. Two groups of ankles were tested; in the first group, three ankles in which the ligamentous and osseous structures were intact were tested after transection of the posterior capsule and after removal of 10, 20, 30, and 40 per cent of the articular surface of the distal end of the tibia from the posterolateral corner. In the second group, seven ankles were tested in the same sequence, but the anterior tibiofibular ligament and the fibula were transected before sectioning of the articular surface. Compared with the results for the intact ankle, the experiments on the first group demonstrated less than one millimeter of additional posterior translation of the talus after removal of as much as 40 per cent of the articular surface. In the second group, in which the anterior tibiofibular ligament and the fibula had been transected, significant posterior translation of the talus (more than three millimeters) occurred after removal of 30 per cent of the articular surface (p < 0.01). This represented a 160 per cent increase in translation compared with that in the intact ankle.

We studied six patients to determine the effects of unilateral marginal resection of the proximal part of the fibula on stability of the knee and on gait. At the time of the operation, the fibular collateral ligament and the tendon of the biceps femoris were reattached, but no attempt was made to stabilize the fibula otherwise. The patients were tested an average of sixty-one months after operation. Stability of the knee was measured with an instrumented system. Gait was evaluated with an optical electronic three-dimensional digitizing system and a multicomponent force-platform. The gait of six healthy control subjects of similar age was also studied, and the reproducibility of measurements of stability of the knee was investigated in four healthy adults. There were significant differences between the side on which an operation had been done and the contralateral side with regard to the extent of anterior translation and of total anterior-posterior translation of the tibia at both 20 and 90 degrees of flexion of the knee, and in total varus and valgus rotation of the knee (the number of degrees from a position of maximum varus to one of maximum valgus angulation) at 20 degrees of flexion. The measurements of gait and of motion of the knee were found to be normal when compared with those in the control subjects. In the ground-reaction measurements, there were some significant differences from normal in the medial-lateral plane, but they were clinically unimportant. Resection of the proximal part of the fibula can lead to instability of the knee.

The varus-valgus stability of 20 knees with unicompartmental osteoarthritis was studied in vivo at the time of total knee replacement. Intact osteoarthritic knees had an average of 11.0 degrees of varus-valgus motion. Removal of osteophytes from the osteoarthritic compartment significantly increased the motion to 13.1 degrees (P less than 0.05), while subsequent removal of osteophytes from the nonosteoarthritic compartment further increased motion to 14.7 degrees (P less than 0.025). In primarily unicompartmental osteoarthritis, marginal osteophytes appear to stabilize osteoarthritic knees, but can cause fixed deformity.

Strain in the anteromedial fibers of the anterior cruciate ligament [ACL(am)] was studied in six cadaver knees. ACL(am) strain was measured in five knees during the application of isometric quadriceps forces alone and simultaneously applied isometric quadriceps and hamstrings forces at 10 degrees increments from 0 degrees to 90 degrees of knee flexion. ACL(am) strain during muscle loading was measured with respect to the ACL(am) strain measured with the knee in its resting position (neutral or near neutral position). A sixth knee was used to investigate the reproducibility of the resting position and quadriceps-induced ACL(am) strains. The strains induced in the ACL(am) by the quadriceps were significantly greater than 0 at knee flexion angles from 0 to 40 degrees and not significantly different from 0 for 50 to 90 degrees. The ACL(am) strains induced by simultaneously applied hamstrings and quadriceps forces were not significantly different from 0 at any of the knee flexion angles tested. Simultaneously applied hamstrings and quadriceps forces significantly reduced ACL(am) strain at 10, 20, and 90 degrees of knee flexion compared to the ACL(am) strain induced by quadriceps forces alone. The hamstrings are potentially capable of both significantly reducing and negating quadriceps-induced ACL(am) strain at 10 and 20 degrees of knee flexion.

Purpose Osteoarthritis of the trapeziometacarpal (TMC) joint of the thumb affects as many as 25% of postmenopausal women and 5% of middle-aged men. This study investigated the relative contribution of the dorsoradial ligament (DRL) and the deep anterior oblique ligament (dAOL) to the stability of the TMC joint. This knowledge will improve our understanding of the pathomechanics of osteoarthritis at the base of the thumb and may help to design novel reconstructive surgical procedures. Methods Seventeen intact cadaver hands were dissected to reveal the DRL and dAOL. Either the DRL or dAOL was transected randomly, physiologic muscle loads were applied to simulate lateral key pinch or thumb opposition, or a 3-dimensional magnetic tracking system was used to record the position of the thumb metacarpal relative to the trapezium. The differences in the 3-dimensional positions between the control and transected states were determined. Results In lateral pinch, transection of the DRL resulted in a mean increased 3-dimensional translation of 1.3 mm, whereas transection of the dAOL resulted in a mean increased 3-dimensional translation of 0.6 mm. Statistically significant 2-dimensional findings in lateral pinch after transecting the DRL or dAOL included an increased palmar subluxation of 0.3 mm and 0.2 mm, an increased radial (1.0 mm) and ulnar (0.3 mm) translation, and an increased pronation of 4.1° and 2.4°, respectively. In thumb opposition, transection of the DRL resulted in a mean increased 3-dimensional translation of 1.0 mm, whereas transection of the dAOL resulted in a mean increased 3-dimensional translation of 0.5 mm. Conclusions In most degrees of freedom of metacarpal movement relative to the trapezium, the DRL is relatively more important than the dAOL in providing stability to the TMC joint.

The pain associated with knee osteoarthritis (OA) has been shown to lead to an increased propensity to trip on an obstacle. Pain-relieving intra-articular injections are widely utilized in the treatment of knee OA. This study examined the effects of pain-relieving intra-articular knee injections on the ability to avoid contacting a suddenly appearing obstacle in patients with knee OA. Obstacle avoidance success rates, pain, body mass index, visual acuity, contrast sensitivity, depth perception, and single-leg stance duration were evaluated in nine patients with painful osteoarthritis of the knee and 14 age-matched healthy control subjects. Obstacle avoidance success rates, pain, and single leg stance duration were tested a second time in the patients with knee OA after they received their injections, which contained a fast-acting local anesthetic to provide rapid pain relief. After receiving the pain-relieving knee injections, patients with knee OA had 48% less pain and were 31% more successful in avoiding stepping on the obstacle. However, after receiving the injection, the obstacle avoidance success rates remained 20% less than those of the healthy controls. The results of this study suggest that knee pain-relief can decrease the propensity of people with painful knee OA to trip and fall over an obstacle. However, pain-relief alone did not return the patients with knee OA in this study to a disease-free risk of tripping.

Tripping on an object is the most frequent cause of falls. We examined the effects of painful osteoarthritis of the knee on obstacle avoidance success rates in older adults. Obstacle avoidance success rates, pain, body mass index, visual acuity, contrast sensitivity, depth perception, and single-leg stance duration were evaluated in 17 patients with painful osteoarthritis of the knees (age range, 59.6 +/- 8.1 years) and 14 age-matched healthy control subjects (age range, 61.1 +/- 10.0 years). The patients with osteoarthritis of the knees had a 37% lower obstacle avoidance success rate, a 54% lower single-leg stance duration, and a 24% greater body mass index than the control subjects. Age, visual acuity, contrast sensitivity, and depth perception were not different between the two groups. Obstacle avoidance success rates and single-leg stance durations decreased linearly as pain increased in the patients with osteoarthritis of the knees. Obstacle avoidance success rates also decreased linearly as single-leg stance duration decreased in the patients with osteoarthritis of the knees. Osteoarthritis of the knees reduced obstacle avoidance success rates, supporting epidemiologic studies that have found osteoarthritis to be a risk factor for falls. This study showed that pain associated with osteoarthritis of the knees increased the propensity to trip on an obstacle (the greater the pain the greater the propensity to trip and fall) and underscores the importance of treating pain associated with osteoarthritis.

Osteoarthritic knee pain affects patient mobility. Relief of knee pain in osteoarthritis has been reported to increase loading of the knee during gait, but it is unknown whether such pain relief enhances knee loading during more demanding activities such as stair-stepping. The gait of 19 patients and stair-stepping of 14 patients with painful medial compartment osteoarthritis of the knee was assessed before and after pain-relieving intraarticular injection of the knee and compared with those of 21 healthy control subjects. There were significant increases in gait velocity, cadence, maximum external knee adduction moment (indicating increased loading in the medial compartment of the knee), and maximum external hip adduction and ankle abduction moments immediately after the injection. With the exception of velocity and ankle abduction moment, these variables were returned to levels that were not statistically different from those of the control subjects. However, no significant differences were found during stair-stepping in the external adduction-abduction moments about the knee, hip, or ankle after injection. Furthermore, the postinjection magnitudes of these variables during stair-stepping were significantly less than those of the controls. Therefore, although the relief of knee pain is sufficient to enhance gait function in osteoarthritis of the knee, it is insufficient to enhance stair-stepping function.

Purpose The intrinsic muscles and ulnar capsuloligamentous structures (UCLS), which consist of the ulnar collateral ligament (UCL), accessory UCL, dorsal capsule, and volar plate of the thumb metacarpophalangeal (MCP) joint are important for controlling the motion and stability of the MCP joint during pinch. The purpose of this cadaveric study was to determine the effects of the adductor pollicis (AdP) and abductor pollicis brevis (APB) on the 3-dimensional MCP joint laxity before transection of the UCLS and after reconstruction of the UCL and repair of the dorsal capsule. Methods Loads were applied to the flexor pollicis longus (FPL) alone, to the AdP and FPL in combination, and to the APB and FPL in combination in 11 cadavers. This was done in the intact joint after the UCLS were transected and after the UCL was reconstructed for flexion angles of 0°, 15°, 30°, and 45°. The spatial positions of the proximal phalanx and the metacarpal of the MCP joint were measured with a 6-degrees-of-freedom digitizing system. Results In the intact joint combined loading of the AdP and FPL did not affect the position of the proximal phalanx. Combined loading of the APB and FPL changed the position of the phalanx from an ulnar to a radial shift and from an ulnar to a radial deviation and it increased pronation. After transection of the UCLS combined loading of the FPL and AdP increased supination of the MCP joint and combined loading of the FPL and APB increased radial shift, radial deviation, and pronation of the joint. Reconstruction of the UCL restored normal laxity to the MCP joint. Conclusions The AdP failed to affect MCP joint motion. The ABP produced a radial shift and radial deviation of the MCP joint and increased pronation of the thumb. Transection of the UCLS increased joint laxity for each of the combined loadings and reconstruction of the UCL restored normal laxity to the MCP joint.

We investigated the effects of early compared with late (ie, in flexion) rollback on quadriceps efficiency during stair stepping. We studied 10 patients with the IB II (Zimmer, Warsaw, IN) total knee arthroplasty (TKA), designed to enforce rollback at 73 degrees of knee flexion; 9 patients with the Maxim PS (Biomet, Inc, Warsaw, IN) TKA, designed to enforce rollback between 20 degrees and 30 degrees of flexion; 8 patients with the TRAC PS (Biomet, Inc, Warsaw, IN) mobile bearing TKA, designed to enforce rollback at 8 degrees of flexion; and 21 healthy control subjects during stair stepping. We measured the external knee flexion moments, which must be largely balanced by quadriceps force acting over the quadriceps lever arm, as indicators of quadriceps efficiency. The peak external knee flexion moment generated by the IB II patients during stair stepping was 12.4% and occurred at 65 degrees of knee flexion. This moment was significantly less (P=.006) than the peak moment, 17.6%, generated by the healthy controls. Knee flexion for the IB II patients did not reach 73 degrees, and rollback was not enforced until after the peak moment (ie, maximum demands on the quadriceps) had been attained. The peak moments generated by the TRAC PS patients, 14.2%, and Maxim patients, 14.8%, were not significantly different from that of the controls. These results suggest that early as compared with late rollback returns more normal quadriceps efficiency during stair stepping.

The purpose of this study was to develop an analytical model to simulate a trip and fall during gait. The human body was modeled as a 12 degree-of-freedom linkage system. The kinematics of the lower extremity for one cycle of gait were obtained for a healthy subject using an optoelectronic three-dimensional data acquisition system. Inverse dynamics was used to compute the moments about the hip, knee and ankle joints of the lower extremity. These moments were then used as input actuators to the joints in to a forward dynamics model to simulate the swing phase of gait from toe-off to heel-strike. An optimization procedure to minimize errors associated with the computed experimental torque was applied to correct for mathematical instability. An experiment was performed to measure the three-dimensional foot--obstacle contact force for a healthy subject tripping on an obstacle during gait. The contact force was applied to the swing limb of the forward dynamics model for 0.09 s beginning at 0.04 s after toe-off. Tripping on an obstacle followed by a muscle-relaxed fall was simulated. The simulation results were visualized with animation software.

Injuries to the ulnar collateral ligament (UCL) of the metacarpophalangeal joint of the thumb are common and may result in functional instability of the joint. Eight cadaveric hands were studied. Physiologic levels of muscle loads were applied to the extrinsic flexor tendon of the thumb to simulate tip pinch of the thumb. We investigated the effects of transection of the UCL and accessory UCL (UCL complex) with and without transection of the dorsal capsule and volar plate and of reconstruction of the UCL, for 2 surgical techniques, on the position of the proximal phalanx with respect to the thumb metacarpal. The spatial positions of the metacarpal and proximal phalanx were measured with a 6 degrees of freedom digitizing system for flexion angles from 0 degrees to 60 degrees in 15 degrees increments. Transection of the UCL complex, dorsal capsule, and volar plate (ulnar capsuloligamentous structures) of the metacarpophalangeal joint did not affect radioulnar deviation or radioulnar shift, but did produce significant increases in supination by 8 degrees and volar translation by 2 mm at 45 degrees and 60 degrees compared with those found for the intact joint. The UCL was reconstructed with a tendon graft using the autogenous extensor digiti quinti. The first surgical technique, a traditional technique, and the second surgical technique, a technique based on anatomy, returned the position of the proximal phalanx on the metacarpal head to normal, with the exceptions of volar translation of the proximal phalanx at 60 degrees and trends toward abnormal supination of the proximal phalanx for flexion angels of 45 degrees and 60 degrees.

De elektromyografische activiteit van zes spieren van het bovenbeen werd door middel van bipolaire oppervlakte-elektroden geregistreerd tijdens actieve extensie van de knie bij zes gezonde mannen. De signaalamplitudes werden in overeenstemming gebracht met de amplitudes die waren geregistreerd

This study was performed to test the hypothesis that reducing the horizontal distance between the trailing foot (foot crossing the obstacle last) and obstacle, during stance just prior to stepping over the obstacle, would reduce flexion of the hip, knee, and ankle joints of the trailing limb when the toe is over the obstacle to reduce the vertical toe-obstacle clearance and increase the risk of tripping. Fourteen healthy young adults stepped over an obstacle of 51, 102, 153, and 204 mm height in a self-selected manner (i.e., toe-obstacle distance was not controlled) and for toe-obstacle distance targets of 10, 20, 30, and 40% of their step lengths measured during unobstructed gait. The reductions in toe-obstacle distance resulted in linear decreases in flexion of the hip, knee, and ankle when the toe was over the obstacle. Toe-obstacle clearance of the trailing limb decreased significantly as toe-obstacle distance decreased. The reductions in toe-obstacle distance led to contact of the trailing (but not the leading) foot with the obstacle, the closer the obstacle the greater the number of contacts. The reductions also resulted in linear decreases in swing time of the trailing limb from toe-off to when the toe was over the obstacle. The height of the hip was not affected by toe-obstacle distance. Angular velocity of knee flexion was found to increase linearly as toe-obstacle distance decreased and appears to be of primary importance in avoiding obstacle contact.

We tested the effect of intraarticular reconstructions of the anterior cruciate ligament alone and in combination with extraarticular reconstructions in 10 cadaveric knees. These knees had anterior cruciate ligament deficiency alone or in combination with anterolateral capsuloligamentous deficiencies. In the knees with combined injury, intraarticular reconstruction returned anterior stability to levels not significantly different from levels found for the knees deficient in the anterior cruciate ligament alone and treated with this procedure. After intraarticular reconstruction, rotational stability of the knee with combined injuries failed to return to the levels seen in the knee with isolated anterior cruciate ligament deficiencies that underwent the same treatment. When a tenodesis with either 0 N or 22 N of tension was added to the intraarticular reconstruction in the knee with combined injuries, we found that excessive internal rotation significantly decreased at all angles of flexion, except at full extension with 0 N of tension. In addition, the extraarticular reconstruction with 22 N of tension in the tenodesis overconstrained the knee in internal rotation between 30 degrees and 90 degrees of knee flexion. The tenodesis with 0 N of tension overconstrained the knee at only 60 degrees and 90 degrees of flexion. These results suggest extraarticular reconstruction as an adjunct to the intraarticular operation for the knee with anterior cruciate ligament and anterolateral structural injuries. The results also suggest that the surgeon can affect anterior and rotational laxity by adjusting the tension in the tenodesis.

The effect of reconstructing the posterior cruciate ligament on anteroposterior laxity of the knee was evaluated in 7 cadaveric knees. A bone-patellar tendon-bone graft was used. Femoral pilot holes were drilled to locate the most isometric sites for attachment of the graft to the femur using an isometer. A tension of 89 N was set in the graft using a tensiometer with the knee in 90 degree flexion while applying an anterior drawer force of 156 N to the tibia. Posterior displacement of the knee was measured in 15 degree increments from O degree to 90 degrees in the intact knee, in the knee with the posterior cruciate ligament transected, and after reconstruction of the posterior cruciate ligament in response to 100 N of posteriorly applied force. Graft tension was nearly constant between 0 degrees and 90 degrees flexion, indicating the grafts to be isometric. The reconstruction reduced posterior translation of the tibia in the posterior cruciate ligament excised knee at all angles of flexion; the differences were statistically significant. The reconstruction returned posterior translation to levels not significantly different from those of the intact knee between 0 degrees and 45 degrees flexion but not in the greater angles of flexion tested.

We compared the reproducibility of measurements made with the Genucom knee analysis system using two methods of restraint. The first method was that sug gested by the manufacturer and consisted of clamping the thigh to the examination chair with 70 N of vertical force and 110 N of mediolateral force and used a single elastic strap to secure the electrogoniometer cuff to the leg. In the second, or enhanced, method, the vertical and mediolateral clamping forces were each increased to 156 N, and an additional strap was used to secure the cuff to the leg. Tests performed were the anteroposte rior stress tests at 20° and 90° of knee flexion, and the varus-valgus stress test, the internal-external rotation stress test, and the medial and lateral pivot shift tests at 20°. Five normal subjects were installed and tested on 6 different days with the manufacturer's suggested se curing method and on 12 different days with the en hanced securing method. The enhanced method of re straint resulted in significantly reduced day-to-day variance for all tests performed except the varus-valgus stress test.

Patients have complained of pain after the use of the central one-third patellar tendon for reconstruction of the anterior cruciate ligament-deficient knee. This study investigated the effect on patellofemoral contact areas and pressures of harvesting the central 10 mm of the patellar tendon in five cadaveric knees. Isometric quad riceps forces were applied to produce approximately 30% of reported maximum voluntary extension mo ments at the knee. Using Fuji pressure-sensitive film, measurements were recorded for three states: the normal knee, after the graft removal, and after the tendon was closed. Contact areas and pressures were measured at 20°, 30°, 60°, and 80° of knee flexion in each specimen. Tests of the reproducibility of our meth ods were performed. Average patellofemoral contact areas for three states ranged from 1.6 cm2 at 20° of knee flexion to 3.0 cm2 at 60°. The average patellofemoral contact pressures ranged from 1.9 MPa at 20° of knee flexion to 3.0 MPa at 30°. At each flexion angle there were no significant differences in average patellar contact area or pressure for the three states ( P < 0.05). These results suggest that neither harvesting the central 10 mm of the patellar tendon, nor closing the gap, significantly alters patello femoral contact area or pressure.

The biomechanical effectiveness of an extraarticular ACL reconstruction, an intraarticular ACL reconstruc tion, and the combination of these on both anterior stability and internal rotational stability of the ACL de ficient knee was investigated in six cadaver knees. The extraarticular reconstruction consisted of the Müller anterolateral femorotibial ligament iliotibial band teno desis, and the intraarticular reconstruction used the middle third of the patellar tendon in the manner of Clancy. The extraarticular reconstruction was found to over- constrain internal tibial rotation of the ACL excised knee between 30° and 90° ( P < 0.05). While the isolated extraarticular reconstruction did not return normal an terior stability to the ACL deficient knee ( P < 0.05), it did significantly reduce the anterior laxity of the ACL deficient knee between 30° and 90° of knee flexion ( P < 0.05). For the combined reconstruction, the intraarticular procedure was performed and then only enough ten sion was applied to the extraarticular reconstruction to take up slack in the tenodesis without shifting the rotatory position of the tibia from that produced by the intraarticular procedure alone. Neither the intraarticular reconstruction nor the combined procedure resulted in any significant shifts from normal ( P < 0.05) in the rotatory position of the unloaded tibia; during loading neither resulted in rotational displacements significantly different from normal; and both of these procedures reduced the increased anterior laxity of the ACL defi cient knee to a level not statistically different from normal. Because the extraarticular reconstruction shared the load when performed with the intraarticular reconstruc tion as part of a combined procedure, we concluded that it would be useful as an adjunctive procedure in appropriate clinical situations.

Twenty-two patients with primary osteoarthritis (OA) of the knee were studied to determine the effects of OA on laxity of the knee joint. Laxity was measured with a Genucom Knee Analysis System. Ten knees had mild OA (> 50% preservation of joint space). Fifteen knees had moderate OA (some preservation of joint space, but < 50%). Eighteen knees had severe OA (no joint space). A group of 18 knees from 9 healthy (asymptomatic) subjects of ages similar to those of the OA patients were used as controls. Compared to control knees, severe OA knees had less total anteroposterior (AP) translation (12.2 versus 6.6 mm, p < 0.025) and less total tibial rotation (79 versus 59 degrees, p < 0.01). Compared to early OA knees, knees with severe OA had 57% less average total AP translation (15.2 versus 6.6 mm, p < 0.01), 31% less total varus/valgus rotation (15 degrees versus 10.4 degrees, p < 0.016), and 26% less total internal/external tibial rotation (80.1 degrees versus 59 degrees, p < 0.007). These data indicate that osteoarthritic knees tend to have less laxity than normal knees, probably because of a combination of contracture of the ligaments and pressure of osteophytes against ligaments and other capsular structures.

Patellofemoral joint pain is one of the most common ailments associated with visits to sports medicine clinics and can be disabling, although conservative clinical treatment has a reportedly very high success rate. Patellofemoral joint pain is often associated with improper tracking of the p

The biomechanical effectiveness of the Müller anterolateral femorotibial ligament (ALFTL) iliotibial band tenodesis on anterior stability and internal rotational stability of the ACL deficient knee was investigated in six cadaver knees. Anterior drawer and internal rotation of the tibia were measured at 15 degrees increments from 0 degrees to 90 degrees in response to 50 N of anteriorly applied tibial force and 3 Nm of internally applied internal torque, respectively, in the intact knee, the ACL excised knee, and following the ALFTL reconstruction. A strain gage was used to measure the resting graft tension and to measure strain in the graft during the load-displacement tests. The Müller ALFTL tenodesis failed to return normal anterior stability to the ACL deficient knee (P less than 0.05). The tenodesis did, however, reduce the anterior laxity of the ACL deficient knee from 30 degrees to 90 degrees of knee flexion (P less than 0.05). The tenodesis overconstrained internal tibial rotation of the ACL excised knee from 30 degrees to 90 degrees (P less than 0.05). Measurements of strain in the tenodesis supported the load-displacement findings that the tenodesis was most effective in constraining anterior drawer and internal tibial rotation from 30 degrees to 90 degrees of knee flexion.

The electromyographic activities of six muscles of the thigh were recorded, using bipolar surface electrodes, during active extension of the knee by six healthy men. The signal amplitudes were normalized to those recorded during isometric maximum voluntary contractions. Extension of the knee from 90 to 0 degrees (full extension) was performed at the rate of 10 degrees per second with the leg unimpeded and with weights of 1.8, 3.6, 5.4, or 7.2 kilograms attached to the ankle. The hamstrings were found to coactivate with the quadriceps during the terminal phase of extension. Coactivation of all three hamstrings was found to occur at joint angles of as much as 9 degrees, with the maximum at full extension of the knee and the strength of the signals ranging to as much as 20 per cent. The signals of all of the flexors and extensors increased with increasing loads on the ankle and, with the exception of the rectus femoris at 9 degrees of flexion, they also increased as the knee extended. The results of this study support the hypothesis that the hamstrings function synergistically with the anterior cruciate ligament to prevent the anterior tibial displacement that is produced by active contraction of the quadriceps in the terminal degrees of extension of the knee. This information is important for the physical conditioning of healthy individuals in preparation for athletic endeavors. Furthermore, if coactivation of the hamstrings with the quadriceps is mediated by sensors other than, or in addition to, those of the anterior cruciate ligament, then strengthening of the hamstrings appears to be an important adjunct to rehabilitation programs after repair or reconstruction of that ligament.