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La rodilla es una articulación sinovial compleja y entre los distintos diagnósticos de enfermedad articular, las lesiones del ligamento cruzado craneal (LCrC) son la causa más frecuente de claudicación de las extremidades pélvicas y osteoartritis de la articulación de la rodilla en perros. La ruptura del LCC (RLCrC), generalmente cursa con signos clínicos como cojera de aparición aguda o gradual, dolor articular, rigidez, marcha inestable, temblores musculares del muslo afectado y signo de cajón positivo en la articulación. Existen diferentes técnicas propuestas para la estabilización de la rodilla clasificadas como técnicas intra-capsulares, extra-capsulares y modificadoras de la biomecánica. De acuerdo a la baja disponibilidad de recursos económicos de propietarios de mascotas, disponibilidad de materiales protésicos y bajo flujo de casos en nuestra zona de influencia, crearon la necesidad de desarrollar una alternativa quirúrgica viable, eficaz y eficiente. Este reporte presenta el tratamiento quirúrgico para la RLCrC bilateral en perro mestizo de ocho años de edad, con una técnica quirúrgica modificada titulada por los autores como sutura fabelo-tibial con tunelación del plato con la que se consiguió la estabilidad de las rodillas afectadas por RLCrC. Titulo Resumen Palabras clave Summary Keywords Introducción Presentación del paciente Anamnesis Hallazgos al examen clínico Diagnóstico diferencial Exámenes laboratoriales Técnica quirúrgica: descripción Discusión Conclusión Bibliografía 25. Hunter T, Downing R. cranial-cruciate-ligament-repair-extracapsular-repair-and-tightrope-procedure [Internet]. VCA Animal Hospital. [cited 2022 Oct 10]. Available from: https://vcahospitals.com/know-your-pet/cranial-cruciate-ligament-repair-extracapsular-repair-and-tightrope-procedure Especialización Especialista en Medicina y Cirugía en Animales de Compañía Artículo

One reported complication of the arthroscopic modified Brostrom operation is pain caused by the suture anchoring knot. We hypothesized that a knotless technique could reduce such pain. Therefore, in this study we evaluated the clinical and radiological outcomes after knotless all-inside arthroscopic modified Brostrom operation for lateral ankle instability. From July 2017 to November 2017, 28 patients were treated. Clinical and radiological features were evaluated preoperatively and 3, 6, and 12 months postoperatively using the American Orthopaedic Foot & Ankle Society ankle-hindfoot scale score, visual analogue scale score for pain, anterior talar drawer test, and talar tilt angle. The mean age of the 28 patients (14 men, 14 women) was 41.71 ± 17.19 years. Three (10.7%) complications, but no knot-associated pain, occurred. The clinical and radiological outcomes were significantly improved 12 months postoperatively compared with preoperative outcomes (all p < .05). Knotless all-inside arthroscopic modified Brostrom operation for lateral ankle instability avoided knot-associated pain and improved not only patient satisfaction but also clinical and radiological outcomes.

PurposeAlthough complete tear of the knee posterolateral corner (PLC) commonly occurs in combination with other knee ligamentous injuries, the incidence of isolated PLC injury was reported only 28% and overlooked in many cases. Nevertheless, an isolated PLC injury does not only provoke posterolateral instability, but also may be associated to hypermobile lateral meniscus. This study aims at showing the characteristics of isolated PLC injuries and to alert potential overlooked cases by describing their arthroscopic findings and clinical characteristics.MethodsSeventy-one patients with a clinically proven isolated PLC injury who underwent knee arthroscopy were included in this study. Pre-operative symptoms and clinical signs at examination were recorded: Pain at the posterolateral aspect, feelings of instability, catching, locking; and for clinical signs: McMurray test, varus stress test in extension and at 30° of flexion, posterolateral drawer test at 30° and 80°, dial test at 30° and 80° of flexion. In terms of arthroscopic findings, systematic meniscal stability was performed to evaluate the presence of hypermobile lateral meniscus, “lateral drive through test” was also recorded in all cases.ResultsPositive Lateral Drive through test was found in 69 patients (95.8%). Hypermobile lateral meniscus was seen in all patients.ConclusionsHyper mobile lateral meniscus was concomitant with all isolated PLC injuries in our case series. As the typical arthroscopic characteristic, lateral drive through test positive were seen in 95.8%. In order to prevent overlooking this concomitant pathology, meticulous arthroscopic observation is crucial.Level of evidenceLevel IV.

The posteromedial and posterolateral corner structures contribute significantly to knee stability. The posterior oblique ligament is a primary restraint to internal rotation and a secondary restraint to valgus. The superficial fibres of the medial collateral ligament are the primary valgus restraint and also provide secondary internal and external rotation stability. The deep fibres of the medial collateral provide additional restraint to internal and external rotation as well as valgus. The posteromedial capsule provides a secondary restraint to valgus and posterior translation. The lateral (fibular) collateral ligament is the primary varus stabiliser. The popliteus tendon complex is a primary restraint to external rotation. The popliteofibular ligament is a secondary restraint to external rotation and varus. Many physical examination manoeuvres have been described to assess these structures. Manoeuvres assessing the posterolateral structures include the varus stress test, dial test, the posterolateral drawer, the external rotation recurvatum test, heel height test and the reverse pivot shift. Examination manoeuvres that assess the posteromedial structures include the valgus stress test, dial test, anterolateral drawer test and anteromedial drawer test. Proper application of physical examination manoeuvres in conjunction with other diagnostic modalities will allow providers to develop appropriate treatment plans.

Objective The aim of the study was to determine the changes in biomechanical characteristics following tibial plateau levelling osteotomy (TPLO) using simulated manual tests. Study Design Twenty-one stifles from healthy Beagle dogs that had undergone TPLO or had not (control) were first tested in the intact form, and then the cranial cruciate ligament (CrCL) was transected in each to provide four test situations: control-intact, control-CrCL-transected, TPLO-intact and TPLO-CrCL-transected. The stifles were then analysed using a robotic joint biomechanical testing system. The craniocaudal drawer, axial rotation and proximal compression tests were applied. Results The craniocaudal displacement during the drawer test was not significantly different between the control-intact and TPLO-intact. However, the displacement was significantly greater in the TPLO-CrCL-transected than in the control-intact. In the axial rotation test, the internal–external (IE) rotation was significantly greater in the TPLO-intact than in the control-intact. Similarly, the IE rotation was significantly greater in the TPLO-CrCL-transected than in the control-CrCL-transected. In the proximal compression test, craniocaudal displacement was not significantly different among the control-intact, TPLO-intact and TPLO-CrCL-transected. Conclusion These findings suggest that TPLO influences the tension of the collateral ligaments and might generate laxity of the tibiofemoral joint. Instability after the osteotomy might be associated with the progression of osteoarthritis.

Context:Lesser metatarsophalangeal (MTP) instability is a common condition that can become debilitating and require surgery.Evidence Acquisition:An extensive literature review was performed through MEDLINE and Google Scholar for publications relating to the etiology, diagnosis, and treatment of lesser MTP instability using the keywords metatarsophalangeal instability, athlete, forefoot pain, and metatarsalgia from database inception to 2019.Study Design:Clinical review.Level of Evidence:Level 4.Results:Lesser MTP instability is a common condition, especially in the active and aging populations. It is frequently misdiagnosed, causing delays in treatment that allow for progressive pain and deformity, which prevents an active lifestyle. Fortunately, MTP instability can be diagnosed easily with the drawer test. Magnetic resonance imaging is helpful when still in doubt. Conservative treatment entails joint immobilization and gradual return to play with taping and offloading metatarsal pads.Conclusion:Lesser MTP instability is a common diagnosis. Its early detection and conservative treatment can help the patient regain their previous level of activity and avoid surgery.

The mobility of the first tarsometatarsal (TMT1) is said to be correlated to the severity of hallux valgus determined using both clinical and radiographic criteria. The sagittal mobility of the TMT1 joint can be evaluated objectively using a new ultrasound test, which quantifies it in the form of a unitless value (ratio of two measurements). The objective of this study was to describe the relationship between TMT1 mobility on an ultrasound test and hallux valgus severity. Hypothesis TMT1 joint mobility increases with hallux valgus severity. Forty-nine feet were included that were being treated for isolated hallux valgus and had no evidence of TMT1 hypermobility based on the dorsal drawer test. For each foot, the presence and intensity of load transfer (LT), the intermetatarsal angle (IMA), and the hallux valgus angle (HVA) were determined. Lastly, TMT1 mobility was evaluated with the ultrasound test. Clinically, no LT was present in 20 feet; it was present only under M2 in 20 feet and reached at least M3 in the other nine feet. The mean IMA on radiographs was 14.6° and the mean HVA was 34.5°. The value of the ultrasound test was significantly different between the three groups of clinical hallux valgus severity: 1.17 with no LT, 1.31 with isolated M2 LT, and 1.72 when LT was at least at M3. Furthermore, this value was correlated with the IMA but not the HVA. This study revealed a relationship between increased TMT1 mobility and hallux valgus severity based on clinical (LT) and radiographic (IMA) criteria. Thus, our working hypothesis is confirmed. However, there was no correlation between TMT1 mobility and HVA suggesting that this angle is less relevant for determining the severity of the condition. This is consistent with the classical pathophysiological concept of metatarsus primus varus where the hallux valgus originates in a metatarsus varus in the tarsometatarsal area. The severity of hallux valgus is correlated with increased mobility of the TMT1 joint, which appears to have a causal role in this condition.

Background: This study presents the clinical results from 22 children who underwent minimally invasive arthroscopically assisted screw fixation for the treatment of intercondylar eminence fractures.Methods: We retrospectively analyzed the clinical data of 22 children (aged 7.5 to 13.5 years) with type III tibial intercondylar eminence fractures who were treated in our department from March 2007 to September 2019. According to the type of operation, the patients were divided into two groups: group A (n = 12) received arthroscopically assisted cannulated screw fixation, and group B (n = 10) received open reduction and cannulated screw internal fixation. Radiography scans, Lysholm scores, International Knee Documentation Committee (IKDC) 2,000 subjective scores, Tegner scores, range of motion (ROM) of the knee, the anterior drawer test (ADT), the Lachman test, and the pivot-shift test were used to evaluate the clinical efficacy.Results: All 22 children were evaluated over a 12 to 58 month follow-up period (mean: 27.5 months). At the final exam, group A was significantly superior to group B in Lysholm scores (93.33 ± 3.55 vs. 86.20 ± 4.52), IKDC scores (92.06 ± 3.55 vs. 86.07 ± 5.81), and Tegner scores (7.75 ± 0.87 vs. 6.40 ± 0.52) and presented shorter operative times (25.42 ± 3.97 vs. 35.00 ± 5.27). The differences were statistically significant (P < 0.05). All the incisions healed primarily. No complications, such as fracture fragment displacement, delayed epiphyseal growth, or knee joint dysfunction, were observed. The drawer test, Lachman test, and pivot-shift test were negative for all patients.Conclusions: Arthroscopically assisted cannulated screw fixation is effective and safe for the treatment of tibial intercondylar eminence fractures, providing excellent stability and quick recovery of joint function.

Introduction In total knee replacement surgery, medio-lateral knee balancing is recognized as the key to achieving satisfactory functional results. But it may not be enough to stabilize the flexion gap using deep-dished implants. We achieved flexion gap balance by oversizing the femoral component, thus increasing the posterior condylar offset (PCO). The purpose of this study was to describe the applicability of this technique and to test whether it produced adverse effects on medium-term outcomes. We hypothesized that it would not compromise the results if used properly. We therefore asked: (1) at how many cases of flexion gap balance would require oversizing the femoral component; (2) if femoral components oversizing would modify the mid-term results as per forgotten joint score (FJS) scores and whether flexion gain would be comparable to patients in whom it was not increased. Materials and methods Ninety-four patients (120 knees) were operated between September 2009 and 2011 (age 68 ± 9 years) using the cementless Hyperflex version of the Natural Knees (Zimmer, Warsaw, IN, USA). Postero stabilization was achieved using deep-dished inserts. The Gender configuration has provided narrow inserts to better adapt the female anatomy. A special navigation system measured the displacement of the lateral and medial femoro-tibial contact points with infra-millimetric precision. Adopting a tibial cut first, gap-balancing technique with anterior referencing, the decision to oversize the femoral component relied on the 90° flexion drawer test, which showed more than 6 mm sagittal laxity before the femoral bone cuts. Eighty-one (105 knees) patients were reviewed with average 63 ± 27-month follow-up. Results Femoral components were augmented by 1 size in 60 cases and by 2 sizes in 7 cases. At final review, knees with an oversized femoral component (60) achieved the same results as those implanted with a non-oversized femoral component (n = 45) in terms of mean flexion gain (−5° ± 34 versus −4° ± 23, p = 0.78), mean FJS (63 ± 26 versus 61 ± 23; p = 0.56). Conclusion Balancing the Flexion gap by oversizing the femoral component did not compromise flexion range and functional results. Level of evidence IV, Retrospective cohort study.

Category: Ankle; Trauma Introduction/Purpose: Assessment of mortise stability is paramount in determining appropriate management of ankle fractures. While instability is readily apparent in bimalleolar or trimalleolar ankle fractures, determination of instability in the apparent isolated Weber B fibula fracture often requires further investigations such as stress radiography. While several authors have previously demonstrated poor predictive value of physical examination findings such as tenderness, ecchymosis and swelling with instability, no previous investigation has examined the ability of a translational test to determine deltoid ligament injury. The goal of this study is to test the validity of a novel clinical test, the lateral drawer test, in determining mortise instability in a cohort of patients with Weber B fibula fractures. Methods: Patients presenting with isolated fibula fractures were prospectively identified by an orthopaedic nurse practitioner or resident. Three views of the ankle as well as gravity stress views (GSV) were obtained. Prior to examining radiographs, two foot & ankle fellowship-trained orthopaedic surgeons (JYK, CPM) performed and graded the lateral drawer test. (Grade 0: no instability/symmetric to contralateral ankle, Grade I: translation < 5mm, Grade II: translation >= 5mm) While the surgeons were made aware of the presence of a Weber B fibula fracture, radiographs were not visualized prior to conducting the drawer test. Medial clear space (MCS) was measured. VAS pain scores were obtained before and after testing. The results of the lateral drawer test results were compared with radiographic measurements of MCS. Results: The study has thus far prospectively enrolled 14 consecutive patients with Weber B ankle fractures. Six (43%) patients demonstrated radiographic instability with widening of the medial clear space >= 5 mm on GSV. When correlated with MCS measurement, the lateral drawer test demonstrated a sensitivity of 83.3%, specificity of 100%, positive predictive value (PPV) of 100% and negative predictive value (NPV) of 88.9% for determining instability. There was a strong correlation between the lateral drawer test grade and amount of MCS widening (⍴=0.82, p=0.0003). Patients tolerated the lateral drawer test well with an average increase of 1.6 on the VAS pain scale after testing. Conclusion: The lateral drawer test demonstrates high sensitivity, specificity, PPV and NPV for detecting instability in patients presenting with Weber B fibula fractures. While further validation is required in a larger cohort of patients, the lateral drawer test may offer an adjunct tool via physical examination to predict mortise stability.

In the present study, we developed a finite element model of the human ACL taking into account the anatomical insertion zones of the ligament, a knee passive 3D kinematics and a realistic constitutive law. This study was performed in three steps. The first step was to determine the three dimensional kinematics of the knee during a passive flexion. The second step was to quantify the mechanical properties of the human ACL. Identification process allowed to determine an elastic potential which describes the non linear elastic behavior of the ligament. This potential formulation was suitable for large strain situations. Finally the third step was to incorporate the measured kinematics, the ligament insertion zones and the identified elastic law into a three dimensional finite element model. Different situations were then tested. Stress within the ligament was calculated for knee flexion till 70° under neutral, internal and external flexion. Anterior tibial drawer tests at 20° of flexion were also performed with the knee in neutral, internal and external rotation. As illustration, for the anterior tibial drawer tests, the hydrostatic stress field was almost comparable for the knee in neutral and external position. It was found that the hydrostatic and von Mises stresses during an anterior tibial drawer test were more important when the knee was in internal rotation.

Objective To investigate the occasion, method and effectiveness of the diplopic correction after the orbital fracture repair in Chinese patients with orbital fracture. Methods This was a retrospective observational study of 64 patients with remanent diplopia after the reconstructions of orbital fracture were studied between January 2014 and June 2017. The different cause, operational occasions, and surgical techniques analyzed. All patients were followed for 6 months after the surgeries. Results After treatment, 64 patients with III degree diplopia were all performed the operations on extraocular muscles. Different operation was selected to different patients according to the examinational results of the extraocular muscles and passive drawer test, including rectos retropulsion, suspension, excise, Jensen's connection, and fixation to periorbital membrane. During the surgery, 25 patients had no diplopia in mainly functional visual fields, while 15 patients still had III degree diplopia. After 6 months, 27 patients had no diplopia in mainly functional visual fields, while 13 patients still had II degree diplopia. Among these 13 patients with III degree diplopia, 7 patients had no the diplopia of primary position of eye, and 6 patients had the diplopia of primary position. These 6 patients were suggested to wear the triangular prisms for improvement of the diplopia. Conclusion The operations should be selected according to the examining results about eye movements and diplopia before and during the surgeries. Reasonable operations could correct diplopia and improve the eye movements effectually.

Anterior cruciate ligament (ACL) of the knee is often injured particularly in sports and other strenuous activities. Approaches for replacement of the ligament surround controversies due to complexities and varied outcome. In the present study, mechanical behavior of the ligament is analyzed during knee motion considering changing geometric arrangements of the ligament fibers and their material properties during both unloaded and loaded states. An analytical model with sagittal plane representation of the knee was employed. The two cruciate ligaments were modeled as bundles of fibers that were nonlinearly elastic. Flexion motion in the unloaded state was guided by selected fibers. Effects of external loads were then superimposed to simulate activity. In a simulated Drawer test with 130 N external force applied during 0–120° flexion, the ACL stretched increasingly in early to mid-flexion. From mid to high flexion range, the stretching effect decreased continuously. Further, anterior bundle of fibers in the ligament resisted the external load at each flexion angle. The posterior bundle of fibers contributed to resistance in low and high flexion only. The model calculations compared reasonably with in vitro experimental measurements on human knees that are available in the literature. In conclusion, the analysis indicates that surgical replacement of the ACL requires careful attention to ligament insertion positions on bones. Also, rehabilitation of ACL-injured or replaced knee requires carefully designed exercises to be safe and effective. Future work will also focus on parametric analysis.

Background: Cranial cruciate ligament (CCL) rupture is the most common orthopedic pathology in dog and in men. In human, optical computer-assisted technique is considered as a repeatable and reliable method for the biomechanical assessment of joint kinematics and laxity in case of CCL surgery.Aim: To evaluate the repeatability and reliability afforded by clinical tests in terms of laxity measured by means of a computer-assisted tracking system in two canine CCL conditions: CCL-Intact, CCL-Deficient. Methods: Fourteen fresh frozen canine stifles were passively subjected to Internal/External (IE) rotation at 120° of flexion and Cranial drawer test (CC). To quantify the repeatability and the reliability, intra-class correlation coefficient (ICC) and the mean percent error were evaluated (Δ r %).Results: The study showed a very good intra-class correlation, before and after CCL resection for kinematics tests. It was found a minimum ICC = 0.73 during the IE rotation in CCL-Intact and a maximum value of ICC = 0.97 for the CC displacement in CC-Deficient. IE rotation with CCL-Intact is the condition with the greatest Δ r % = 14%, while the lowest Δ r % = 6% was obtained for CC displacement in CCL-Deficient.Conclusion: The presented work underlined the possibility of using a computer-assisted method also for biomechanical studies concerning stifle kinematics and laxity. Keywords: Computer-assisted technique, Cranial cruciate ligament, Dog, Stifle joint.

Made available in DSpace on 2018-11-26T17:55:19Z (GMT). No. of bitstreams: 0 Previous issue date: 2018-08-01. Added 1 bitstream(s) on 2019-10-09T18:27:48Z : No. of bitstreams: 1 S0102-86502018000800684.pdf: 273247 bytes, checksum: c35f0431cc733052bd05867dee72d75e (MD5) Purpose: To evaluate clinically dogs that underwent tibial tuberosity advancement (TTA) six months previously. Methods: Dogs of various breeds, gender, weight, and age that had CCL rupture and underwent TTA for treatment were included in this study. Parapatellar arthrotomy was performed in all patients to assess the joint for a ruptured ligament and meniscal injury before the TTA. The appropriate cage for the TTA was chosen with planning surgery. The surgical procedure was performed according to the literature, using a modified Maquet technique. Six months after surgery, lameness during walking; muscular atrophy; crepitation, cranial drawer and tibial compression tests and quality of life based on owner's evaluation were assessed. Results: Postoperative complications were observed in only one knee (4.76%), with a surgical site seroma. The mean lameness score at walking was 0.29 (+/- 0.64). The mean score regarding muscular atrophy was 0.95 (+/- 1.56). The mean score of the cranial drawer test, in a range from 0 to 5, was 1.52 (+/- 1.54). The owners rated the dog's quality of life as excellent in 44%, good in 30%, and moderate in 17%. Conclusion: This clinical study supports the affirmation that patients who undergo TTA for treatment of CCL rupture have an acceptable response. Univ Catolica Dom Bosco, Campo Grande, MS, Brazil Vet Med, Campo Grande, MS, Brazil Univ Catolica Dom Bosco, Vet Med, Campo Grande, MS, Brazil Univ Estadual Paulista, UNESP, Coll Agr Sci & Vet Med, Postgrad Program Vet Surg, Jaboticabal, SP, Brazil UNESP, Coll Agr Sci & Vet Med, Vet Med, Jaboticabal, SP, Brazil Univ Estadual Paulista, UNESP, Coll Agr Sci & Vet Med, Postgrad Program Vet Surg, Jaboticabal, SP, Brazil UNESP, Coll Agr Sci & Vet Med, Vet Med, Jaboticabal, SP, Brazil

Background Conventional tests of shoulder laxity have been shown to have poor reliability due to the difficulty in palpating the subtle movements of the shoulder joint beneath the musculature. Modified drawer test that is performed while the soft tissues surrounding the shoulder are loosened has been proposed to facilitate glenohumeral joint movement and improve reliability. We hypothesised that the modified drawer test would have an improved intra- and inter-observer reproducibility in comparison to the drawer and load and shift tests. Correlation of shoulder laxity measured by these tests with generalized joint laxity was also assessed. Methods Forty healthy volunteers underwent bilateral shoulder examination in the clinic using the three tests for anterior and posterior laxity assessment by a consultant shoulder surgeon and a resident. The examination was repeated three months later by the same examiners in the same cohort. Intra- and inter- observer reproducibility was calculated using Kappa values. The correlation of shoulder with generalized joint laxity was also investigated. Results The modified drawer test showed significantly improved intra-observer reproducibility compared to the drawer test, but not to the load and shift (κ = 0.173, −0.042, and 0.009, respectively). There were no significant differences in the inter-observer reproducibility between the three tests (κ = 0.054, 0.055, and 0.056, respectively). Moderate correlation was noted between shoulder and generalized joint laxity when modified drawer test was used (r = 0.417). Conclusions The modified drawer test improves intra- but not inter- observer reproducibility compared to the drawer test. Shoulder laxity assessed by the modified test correlated to generalized joint laxity. The modified drawer test has an improved reproducibility and correlation to generalized joint laxity over the conventional tests.

To investigate the clinical outcomes of arthroscopy-assisted transosseous fixation of tibial eminence fractures with the Versalok suture anchor in adults. A total of 23 adult cases of tibial eminence fractures treated between June 2016 and March 2019 were retrospectively analyzed. The results of the preoperative drawer test and Lachman test were positive. Radiography and computed tomography were performed before and after the procedure. Magnetic resonance imaging was performed in every patient after admission. Arthroscopy-assisted fracture reduction and Orthocord high-strength suture fixation with two Versalok anchors were performed in all the patients. The International Knee Documentation Committee scale and the Lysholm Knee Scoring Scale were used to evaluate outcomes during the follow-up period. Additionally, the KT-2000 knee stability test was performed. At the final follow-up, all the fractures had proceeded to bony union and no wound infection was observed. The average Lysholm Knee Score of the affected knees was 93.1 (range, 90–98), which was not significantly different from that of the healthy knees (t = 0.732, P = .132). Based on the International Knee Documentation Committee scale results, 21 patients were graded as normal and the other 2 patients were graded as nearly normal. The KT-2000 test showed that the anterior displacement of the affected side and the healthy side was less than 3.6 mm in all cases. The outcomes indicated firm fixation and good fracture healing with minimal trauma. Thus, arthroscopy-assisted transosseous fixation with Versalok suture anchors for adult tibial eminence fractures seems to have satisfactory clinical outcomes.

With the current data concentrating on different operative treatment options for plantar plate tears, few data can be found on possible nonoperative treatment strategies for this entity and the specifics of such treatment. In the present case report, the successful nonoperative treatment of a patient with a rupture of the plantar plate in a lesser toe metatarsophalangeal joint is presented. The patient was followed up using repeat clinical examinations and high-resolution magnetic resonance imaging scans for 1 year after the imitation of therapy to provide information on the different stages of the healing process.

Cranial cruciate ligament rupture is the major cause of lameness and degenerative joint disease in the canine stifle. The cause of this disease is multifactorial, especially involving degenerative and inflammatory changes. Many techniques have been described for the management of this condition, and current recommendations include the use of corrective osteotomies, most recently using the Maquet (or modified Maquet) procedure. This technique is fundamentally similar to the classical tibial tuberosity advancement (TTA), but without the use of the bone plate. The main advantages of using this technique are a shorter operative time and less use of implants. The main complication of this technique is an increased risk of tibial crest fracture. This report describes the Maquet technique for the treatment of a three-year-old male West White Terrier dog with rupture of the cranial cruciate ligament. Cruciate ligament rupture was diagnosed by a positive cranial tibial drawer test. Mediolateral stifle radiography performed under anesthesia with the stifle in 135° of extension demonstrated a tibial plateau angle of 22°. A cage of six millimeters was necessary to allow advancement. The Maquet technique produced excellent post-operative results, including early weight-bearing and neutralization of the cranial tibial drawer. The consolidation time of the osteotomy was 63 days.

BAYDIN, AHMET/0000-0003-4987-0878; Tatli, Ozgur/0000-0003-0263-7630; Turedi, Suleyman/0000-0002-6500-3961 WOS: 000389517200004 PubMed: 27450389 Introduction: The aim of this study was to evaluate patients presenting to the emergency department (ED) with wrist trauma using physical examination findings and functional tests and to identify findings with high sensitivity and specificity among the parameters assessed in patients with fracture in the wrist. The ultimate objective was thus to establish a reliable and widely usable clinical decision rule for determining the necessity of radiography in wrist trauma. Methods: This prospective, multicenter study was performed in 8 hospitals. The relation between radiologically determined fracture and clinical findings consisting of physical examination findings and functional tests was assessed in terms of whether or not these were markers of radiography requirement, with the aim of identifying predictive values for fracture. Results: A total of 603 eligible trauma patients presented to the participating EDs during the study period. Fracture was identified in 24.5% of patients (n= 148). The 4-way combination with the highest sensitivity was identified as axial compression and the positive distal radioulnar drawer test, and pain with radial deviation and dorsal flexion. Sensitivity at distal ulna palpation was added as a fifth parameter, and sensitivity and negative predictive value thus increased to 100%. Conclusion: With their 100% sensitivity and 100% negative predictive values, the Karadeniz wrist rules may represent a clinical decision rule that can be used in practice in EDs. If all 5 findings are negative, there is no indication for wrist radiography. (C) 2016 Elsevier Inc. All rights reserved.

Anterior cruciate ligament (ACL) deficiency can result in serious degenerative stifle injuries. Although tibial plateau leveling osteotomy (TPLO) is a common method for the surgical treatment of ACL deficiency, alternative osteotomies, such as a leveling osteotomy based on the center of rotation of angulation (CBLO) are described in the literature. However, whether a CBLO could represent a viable alternative to a TPLO remains to be established. The aim of this study is to compare TPLO and CBLO effectiveness in treating ACL rupture. First, a computational multibody model of a physiological stifle was created using three-dimensional surfaces of a medium-sized canine femur, tibia, fibula and patella. Articular contacts were modeled by means of a formulation describing the contact force as function of the interpenetration between surfaces. Moreover, ligaments were represented by vector forces connecting origin and insertion points. The lengths of the ligaments at rest were optimized simulating the drawer test. The ACL-deficient model was obtained by deactivating the ACL related forces in the optimized physiological one. Then, TPLO and CBLO treatments were virtually performed on the pathological stifle. Finally, the drawer test and a weight-bearing squat movement were performed to compare the treatments effectiveness in terms of tibial anteroposterior translation, patellar ligament force, intra-articular compressive force and quadriceps force. Results from drawer test simulations showed that ACL-deficiency causes an increase of the anterior tibial translation by up to 5.2 mm, while no remarkable differences between CBLO and TPLO were recorded. Overall, squat simulations have demonstrated that both treatments lead to an increase of all considered forces compared to the physiological model. Specifically, CBLO and TPLO produce an increase in compressive forces of 54% and 37%, respectively, at 90° flexion. However, TPLO produces higher compressive forces (up to 16%) with respect to CBLO for wider flexion angles ranging from 135° to 117°. Conversely, TPLO generates lower forces in patellar ligament and quadriceps muscle, compared to CBLO. In light of the higher intra-articular compressive force over the physiological walking range of flexion, which was observed to result from TPLO in the current study, the use of this technique should be carefully considered.

A new instrumented device was developed to quantify ankle joint stability during an anterior talar drawer test. The aim of the present study was to validate this device comparing bone kinematics with arthrometer measurement outcomes. An anterior talar drawer test was performed with 14 cadaver legs using a custom instrumented ankle arthrometer. Using clusters of bone-pin markers, the relative three-dimensional movement of calcaneus, talus, and fibula was simultaneously measured. Anterior drawer test was applied on the intact foot and after sequentially sectioning the anterior talofibular ligament, the calcaneofibular ligament, and the posterior talofibular ligament. Cutting the anterior talofibular ligament caused a significant increase in bone-pin measured anterior translations of calcaneus and talus as well as in the anterior translation of the arthrometer. Analysis of receiver operating characteristic curves indicates a fair to good ability to discriminate between the intact and the sectioned conditions with the arthrometer. Distal distraction, inversion, and internal rotation movements were observed when two and three ligaments were cut. Results revealed that the ankle arthrometer was sensitive to detect changes in bone-to-bone movements during an anterior talar drawer test, when the anterior talofibular ligament was sectioned. Presumably due to movements in additional planes of motion, the arthrometer was not able to differentiate between situations with one or more ligaments cut. In conclusion, the instrumented anterior talar drawer tester may augment current procedures in assessing ankle instability primarily caused by ruptures of the anterior talofibular ligament. © 2019 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 37:2019-2026, 2019.

Purpose The lateral ulnar collateral ligament (LUCL) is considered to be the portion of the lateral collateral ligament playing the most important stabilizing role. Iatrogenic forms of posterolateral rotatory instability have been described. The Kocher approach is a popular approach to the lateral side of the elbow. The aim of this study was to describe the relationship between the LUCL and the Kocher interval. Methods The Kocher interval was identified and marked in 20 cadavers. The LUCL was identified and the distance between the LUCL insertion on the tubercle of the cresta supinatoris and the Kocher interval was calculated (TK distance). This distance was considered 0 if the Kocher interval was directly above the tubercle, as a positive value if it was anterior to the tubercle, and as a negative value if it was posterior. Finally, the Kocher interval was sharply opened, and elbow stability was tested using the posterolateral rotatory drawer test. Results A discrete LUCL was identified in 16 specimens. The mean TK distance was –2.3 ± 4.4 mm (range, –11 to +10). The median TK distance was –3 mm. The posterolateral rotatory drawer test was positive for subluxation after the sharp incision of the Kocher interval in 15 specimens. The median TK distance was significantly higher in the stable group (+2 mm) than in the unstable group (–3 mm). Conclusions The LUCL often lies beneath the Kocher interval and is at risk during the Kocher approach. Clinical relevance Iatrogenic forms of posterolateral rotatory instability could result from this approach.

Li Q, Tu Y, Chen J et al. Reverse Anterolateral Drawer Test Is More Sensitive and Accurate for Diagnosing Chronic Anterior Talofibular Ligament Injury. Knee Surg Sports Traumatol Arthrosc 2020; 28: 55–62. doi: 10.1007/s00167-019-05705-x

Although clinical tests can detect posterolateral rotatory instability (PLRI) of the elbow, the ability of ultrasound to evaluate PLRI has not been assessed.To determine whether increasing stages of posterolateral rotatory subluxation of the elbow could be assessed accurately with a sonographic posterolateral rotatory stress test.Cadaveric study.Laboratory.Ten, unpaired, cadaveric upper limbs.Posterolateral ulnohumeral distance was measured by ultrasound at rest and during manual sonographic posterolateral rotatory stress testing at 4 stages of increasing instability: (1) intact elbow, (2) extensor carpi radialis brevis (ECRB) release, (3) ECRB release + lateral collateral ligament complex (LCLC) release to produce a positive posterolateral drawer test, and (4) ECRB release + LCLC and capsule release to produce a positive lateral pivot-shift test. Mean values for sonographic resting ulnohumeral distance, stressed ulnohumeral distance, and laxity were calculated for each stage and compared between stages.Posterolateral ulnohumeral laxity.Mean ulnohumeral laxities were 1, 3, 6, and 10 mm (P.001) for stages 1-4, respectively. Pairwise comparison of mean laxity between the intact elbow (Stage 1) and each pathologic state (Stages 2-4) demonstrated differences of 2 mm (Stage 1 versus 2); 5 mm (Stage 1 versus 3); and 9 mm (Stage 1 versus 4) (P.001). The minimal difference in ulnohumeral laxity noted between the intact elbow and an elbow with a clinically positive posterolateral rotatory drawer test (Stage 3) was 4 mm.The sonographic posterolateral rotatory stress test detected increasing posterolateral ulnohumeral laxity as a function of increasing clinical PLRI. This test may be used as an adjunct to history, examination, and static imaging to assess ulnohumeral laxity in patients with lateral elbow pain syndromes. Within the limits of this investigation, sonographic posterolateral ulnohumeral laxity of4 mm should raise suspicion of underlying instability.IV.

To diagnose chronic anterior talofibular ligament (ATFL) injury, three different physical examinations were compared: the anterior drawer test (ADT), the anterolateral drawer test (ALDT), and the reverse anterolateral drawer test (RALDT). A total of 72 ankles from potential ATFL-injured patients and the normal population were included and examined using the ADT, ALDT, and RALDT by two examiners without knowing the injury histories of any of the participants. Ultrasound examination was then applied as the gold standard to divide the ankles into the ATFL-injured group and the control group. The sensitivity (Se), specificity (Sp), false negative rate (FNR), false positive rate (FPR), accuracy, κ value, and p value of the two examiners’ diagnoses were calculated to assess the diagnostic ability of each examination. There were 38 ankles in the injured group and 34 ankles in the control group. No significant difference was found between the two groups in terms of gender, age, body mass index (BMI), and included ankles. In the ADT and ALDT groups, the specificity reached one, while the sensitivity was relatively low (0.053 and 0.477 for the junior examiner and 0.395 and 0.500 for the senior examiner). In the RALDT, both the sensitivity and specificity were greater than 85% (0.868 and 0.912 for the senior examiner and 0.921 and 0.882 for the junior examiner). The κ value of the RALDT (0.639) was higher than that of the ALDT (0.528) and the ADT (0.196), whereas all the p values were less than 0.05. The ADT and ALDT are valuable physical tests to assess ATFL injuries. Compared with the traditional ADT and ALDT, however, the RALDT is more sensitive and accurate in diagnosing chronic ATFL injuries. II (diagnostic).

Background The presence of cranial tibial subluxation can aid in the detection of joint instability as a result of CrCL injury. Detection of cranial tibial subluxation has been described using the tibial compression test (TCT) and cranial drawer test (CDT); however, diagnosis of CrCL insufficiency by assessing cranial subluxation motion of the tibia is subjective and difficult to quantify accurately. The aim of this study was to investigate a measurement technique to assess the degree of cranial tibial displacement relative to the femoral condyles on mediolateral projection stifle radiographs at varying degrees of stifle flexion (90°, 110°, and 135°) in CrCL intact, partially, and completely transected conditions. Radiographic measurements included: CrCL length and intercondylar distance (ICD), defined as the distance between the tibial mechanical axis (TMA) and the femoral condylar axis (FCA). The influence of CrCL status, stifle flexion angle, and measurement type on measured distance was evaluated. The relationship between CrCL length and ICD measurement was also assessed. Results Complete transection of the CrCL resulted in significant cranial tibial displacement. Stifle flexion angle affected ICD, but not CrCL length. Normalized measured CrCL length and ICD were significantly different; however, no differences existed between the change in distance detected by CrCL length and ICD measurements as CrCL transection status changed. Correlation coefficients detected a significant positive correlation between measured CrCL and ICD. Conclusion The ICD measurement technique was able to quantify tibial displacement at various stifle flexion angles in the intact and completely transected CrCL conditions. The ICD measurement was more affected by stifle flexion angle than was the CrCL length. Electronic supplementary material The online version of this article (10.1186/s12917-018-1599-5) contains supplementary material, which is available to authorized users.

Background Lateral collateral ligament (LCL) insufficiency may occur in patients with chronic lateral epicondylitis (LE). We report on 14 consecutive patients with chronic LE and LCL insufficiency. Methods We performed a retrospective review of 14 patients with LE and LCL insufficiency diagnosed between 2006 and 2015. The patients had undergone debridement for LE and ligament reconstruction for LCL insufficiency. The study included 9 men and 5 women with an average age of 53 years (range, 41-69 years). The mean follow-up period was 36 months (range, 24-97 months). We analyzed the pain visual analog scale score; Mayo Elbow Performance Score; Disabilities of the Arm, Shoulder and Hand score; range of motion; and posterolateral rotatory drawer test. We compared histories of steroid injection, trauma, and surgery. Results The pain visual analog scale score, Mayo Elbow Performance Score, and Disabilities of the Arm, Shoulder and Hand score were significantly improved postoperatively and improved in all patients. Three patients had mild instability on the stress test at final follow-up. All patients had a history of steroid injection, 2 had a history of trauma, and 3 had a history of surgery. The number of steroid injections and the number of cases receiving steroid injections more than 3 times were significantly higher in patients with LCL insufficiency. Conclusions Assessment of stability is important in patients with chronic LE and risk factors such as multiple steroid injections. Simultaneous surgical treatment including open debridement and ligament reconstruction provides satisfactory pain relief and functional improvement in patients with LE and LCL insufficiency.

This study aimed at evaluating whether the prevalence of knee injuries and morphological features are different among pre-and-post menarche dancers; Sixty-seven pre-and-post menarche dancers were screened for anthropometric parameters; knee laxity; patella femoral pain syndrome (PFPS), pathologies and anatomical structure of the knees. Both groups showed a high and similar prevalence of PFPS. The post-menarche dancers produced a significantly higher rate of Tanner stages 3–4 (p = .010), greater weight (p

Background: Significantly better stability may be achieved with a Single Bundle Lateral Plasty (SBLP) reconstruction compared with the Single Bundle (SB) and Double Bundle (DB) procedures. Methods: The study included 42 patients who underwent ACL reconstruction. Patients were randomly selected for one of the following surgical procedure defining three study groups: Single-Bundle-Lateral-Plasty, Single-Bundle and Double-Bundle procedures. Laxity evaluation was performed with an intraoperative navigation system. Lachman test (AP30), Drawer test (AP90), Varus-Valgus stress test at 0° and 30° knee flexion (VV0, VV30), Internal-External rotation (IE30, IE90), and pivot shift (PS) test are the clinical test executed for the laxity evaluation. Laxity reduction was defined as the difference between laxity before the fixation of the graft used for the reconstruction and the laxity just after its fixation. Findings: For all the analyzed surgical techniques, the pre-reconstruction laxity values were statistically higher (P < 0.05) than the post-reconstruction values for all the analyzed tests. The analysis of the Drawer test and Internal-External rotation at 30° and 90° of knee flexion, highlighted a significant difference at time zero after surgery among the three study groups. The results showed that the SBLP technique had the highest reduction values compared to SB (PIE90 = 0.001) and DB (PAP90 = 0.012; PIE30 = 0.021; PIE90 = 0.003) techniques. Interpretation: SBLP technique showed significantly superior results in terms of antero-posterior and internal-external laxity reduction at time-zero after ACL reconstruction.

The purpose of this study was to describe and assess the feasibility of a new intra-articular approach in the treatment of cranial cruciate ligament deficiency in dogs using an artificial ligament and a new bone-anchor system. Twelve canine cadavers weighting 26 to 45 kg were used in this ex-vivo study. Special tibial and femoral screws, two helicoils, and a high resistance artificial fiber compose the implant. Surgery was performed using the cranio-lateral approach to the stifle joint. Helicoil and tibial screw, connected to the fiber, were inserted in the center of the tibial insertion area of the cranial cruciate ligament. The fiber was passed over-the-top, tensioned, and fixed to the femoral screw, previously inserted with the helicoil in the distal part of the femur. Surgery was completed in all the cases. Occasional problems found during the insertion of the helicoils and screws were resolved with simple procedures. Post-operative clinical assessment showed negative cranial drawer test, negative cranial tibial thrust, and normal range of motion. Radiographic evaluation showed an appropriate positioning of both tibial and femoral implants in all the cases. The results of the first surgical appraisal of this new technique are encouraging, although further studies are necessary to demonstrate the in vivo efficacy of this procedure.

Purpose Quantifying the effects of anterior cruciate ligament (ACL) deficiency on knee joint laxity is fundamental for understanding the outcomes of its reconstruction techniques. The general aim of this study was to determine intra-operatively the main modifications in knee laxity before and after standard isolated intra-articular and additional extra-articular anterolateral reinforcement. Our main hypothesis was that laxity abnormalities, particularly axial rotation, can still result from these ACL reconstruction techniques. Methods Thirty-two patients with primary ACL deficiency were analysed by a navigation system immediately before and after each of the two reconstructions. Laxity measurements in terms of knee translations and rotations were taken during the anteroposterior drawer test, with internal–external rotation at 20° and 90° of flexion, and varus–valgus and pivot-shift tests. All these laxity measures were also taken originally from the contralateral healthy knee. Results With respect to the contralateral healthy knee, in the ACL-deficient knee significantly increased laxity (expressed in %) was found in the medial compared with that of the lateral compartment, respectively, 115 and 68 % in the drawer test at 20° flexion, and 55 and 46 % at 90° flexion. In the medial compartment, a significant 35 % increment was also observed for the coupled tibial anteroposterior translation during axial knee rotation at 20° of flexion. After isolated intra-articular reconstruction, normal values of anteroposterior laxity were found restored in the pivot-shift and drawer tests in the lateral compartment, but not fully in the medial compartment. After the reinforcement, laxity in the medial compartment was also found restored in the axial rotation test at 20° flexion. Conclusion In ACL reconstruction, with respect to the contralateral knee, intra-articular plus additional anterolateral reinforcement procedures do not restore normal joint laxity. This combined procedure over-constrained the lateral compartment, while excessive laxity still persists at the medial one. Level of evidence III.

Canine cranial cruciate ligament rupture (CCLR) is the most common cause of pelvic limb lameness in dogs. CCLR results in palpable stifle instability secondary to cranial translation of the tibial relative to the femur, and it can be diagnosed during the orthopedic exam using the cranial drawer test (CDT) and tibial compression test (TCT). Accurate diagnosis of CCLR depends on the efficacy in performing these tests. In this study, two three-dimensional canine pelvic limb models were developed: one simulating a normal stifle and one simulating CCLR. Thirty-eight veterinary student participants answered questionnaires and performed both the CDT and TCT on a randomly assigned model. Twenty-one participants also manipulated the models one week later to assess skill retention in the short term. Mean levels of reported confidence in diagnosing CCLR and finding anatomic landmarks for CDT/TCT were significantly higher following model manipulation. Nearly all participants reported that they desired a model for teaching the diagnosis of CCLR. Most participants (92.5%) felt that the tested model would be useful for teaching CCLR diagnosis. Accuracy in diagnosing CCLR with the TCT significantly improved over time. Participant response indicated that while the tested model was effective and desirable, an ideal model would be more durable and lifelike. Further studies are needed to evaluate the developed models' effectiveness for teaching CCLR diagnosis compared to traditional teaching methods.