Ankle fractures are the fourth most common fracture requiring surgical management. The deltoid ligament is considered the primary stabilizer of the ankle against a valgus force. The management of the deltoid ligament in ankle fractures is currently a controversial topic no consensus exists regarding repair in the setting of ankle fractures. The purpose of this systematic review is to examine the role and indications for deltoid ligament repair in ankle fractures. A systematic database search was conducted with Medline, Pubmed and Embase for relevant studies discussing patients with ankle fractures involving deltoid ligament rupture and repair. The papers were screened independently and in duplicate by two reviewers. Study quality was evaluated using the MINORs criteria. Data extraction included post-operative outcomes, pain, range of motion (ROM), function, medial clear space (MCS), syndesmotic malreduction and complication rates. Following title, abstract and full text screening, 10 eligible studies published between 1987 and 2017 remained for data extraction (n = 528). The studies include 325 Weber B and 203 Weber C type fractures. Malreduction rate in studies with deltoid ligament repair was 7.4% in comparison to those without repair at 33.3% (p < 0.05). Eleven (4%) of deltoid ligament repair patients returned for re-operation to have implants removed in comparison to eighty three (42%) of those without repair (p < 0.05). There was no significant difference for pain, function, ROM, MCS and complication rates (p < 0.05). The mean operating time of deltoid ligament repair groups was 20 minutes longer than non-repair groups(p < 0.05). Deltoid ligament repair offers significantly lower syndesmotic malreduction rates and reduced re-operation rates for hardware removal when performed instead of transsyndesmotic screw fixation. When compared to non-repair groups, there are no significant differences in pain, function, ROM, MCS and complication rates. Deltoid ligament repair should be considered for ankle fracture patients with syndesmotic injury, especially those with Weber C. Other alternative syndesmotic fixation methods such as suture button fixation should be explored. A large multi-patient randomized control trial is required to further examine the outcomes of ankle fracture patients with deltoid ligament repair

Objective. To evaluate early mobilization with the ‘STRONG regime’ is safe after lateral ankle ligament repair with suture tape augmentation. Background. The ESSKA-AFAS ankle instability group presented in 2016 evidence-based guidelines for rehabilitation and return to activity after lateral ankle ligament repair. Early mobilization is considered an important element of postoperative rehabilitation. Patients have to be immobilized for approximately six weeks to protect the delicate repair. Lateral ankle ligament repair with suture tape augmentation results in greater strength compared with standard repairs and early mobilization proved to be successful in small sample size studies. Augmented surgery technique is getting increasingly popular. However, it is unknown which rehabilitation regimes are used. It is essential to establish a clear evidence-based guideline for rehabilitation after surgery. Methods. A systematic literature search was performed to obtain the best evidence research regarding this surgery. In cooperation between the orthopaedic- and physical therapy department a post-operative rehabilitation protocol with early mobilization was established. This STRONG protocol (figure 1) is based on milestones and three stages. Results. In February 2016 the first patients were selected for the early mobilization regime. In total 102 patients with a lateral ankle ligament repair were treated with the STRONG protocol. No re-ruptures were observed with a follow up of a year. In a subgroup of athletes hop tests showed a symmetry index of 100,5% for triple hop, 98,6 for side hop and 103,6 for figure of 8 hop. First return to sport was achieved between 9–12 weeks, with full return to competition after a mean of 4 months. Conclusions. An early postoperative mobilization regime based on supervised exercises seems to be a safe intervention after a lateral ankle ligament reconstruction. Clinical implications. Augmented ankle ligament surgery with early mobilization could be an important advancement in treating patients with chronic ankle injuries. For any figures or tables, please contact authors directly

Background. Lateral ligament injuries of the ankle are common. They account for up to 50% of all sporting injuries. Recovery times vary, leading to time away from sport and training for the professional athlete. Predicting this time is important for the treating surgeon, the athlete and the rehabilitation team. This can be difficult as associated ankle injuries occurring at the time of the trauma may alter recovery and rehabilitation. Aim. To compare the time to return to training and sports of isolated lateral ligament injuries with more complex injuries of the ankle treated surgically and to evaluate if lateral ligament repair is safe and effective in the professional athlete. Study design: Case series; level of evidence 4. Methods. A consecutive series of professional sportsmen and women were treated operatively for radiologically and clinically confirmed grade III lateral ligament injury between 2005 and 2009. The patients were split into two groups; isolated lateral ligament injuries and those with other associated injuries. The end points studied were the time to return to training in weeks and the time to return to play in weeks. Results. There were 26 ankles in 26 patients. 16 were isolated injuries (Group A) and 10 had associated injuries (Group B). The associated injuries included, osteochondral defects (OCD) (3), deltoid ligament injury (5), syndesmotic injury (1) and deltoid ligament injury combined with an OCD (1). The mean time to return to training in group A was 61.3 days (range 55–110) and in group B was 99.5 days (63–152). The mean time to return to play in Group A was 78.2 days (range 63–127) and group B 116.7 days (82–178). The time to return to training and play was significantly shorter for the isolated lateral ligament injury group, (p=0.0003) and (p=0.0004) respectively. The only complications were two minor wound infections that responded to oral antibiotics. No patient returned for recurrent instability and all returned to their pre-injury level of play. Conclusion. Lateral ligament repair was a successful and safe procedure leading to return to pre-injury level of play for all the athletes. Time to return to training and play was significantly shorter if there were no associated injuries to the ankle. NO DISCLOSURES

Aim: We prove the importance of the medial ligamentary system of the elbow for its stability and the usefulness of the ligamentoplasty by palmaris longus tendon as reconstructive technique. Methods and patients: 9 patients aged between 17 and 58 (17,18,28,32,35,38,40,56,58,), 6 male, 3 female suffered the following injuries:1)elbow luxation or sub-luxation with rupture of the medial collateral elbow ligament, associated with: 1)Forearm bone fractures, 2)Ulnar nerve pulsy, 3)fracture of the coronoidal process, 4)Fracture of the radius head, 5)fracture of the humerus with radial and musculocutaneous nerve pulsy. The lesions happened since 2 week, 2 month and 2 yrs respectively. The 17 yrs old young man was injured during a weightlifting championship game and the next 4 suffered traffic and work accidents, while the 18 yrs old last one suffered an iatrogenic ligamentary lesion, the rest of the lesions have been caused to work accidents or to motor vehicle accidents. All patients were operated by ligamentoplasty with palmaris longus by medial incision, fenestration of the medial epicondyl and olecranon and transoseus pivoting of the palmaris longus which was enforced by 2 anchor sutures. An elbow flexion-extension functional splint was applied postoperatively, initially fixated between 110–85 degrees. The splint was removed 2 months postoperatively, while full rang of motion has been obtained. Results: Follow up was between 6 and 18 month. The 16 yrs old boy return in full sport activity and obtained at the elbow joint full range of motion. the second –young man-patient presents an extension defect of 15 degrees and the 56 yrs old women has a 25degreed deficit of both extension and flexion but she continues the therapy program. Conclusion: The medial ligamentary system lesion with elbow instability must be repaired by medial ligamentoplasty and the well done technique followed by correct therapy program improved results

Abstract. Objectives. Tendon and ligament injury poses an increasingly large burden to society. With surgical repair and grafting susceptible to high failure rates, tissue engineering provides novel avenues for treatment. This systematic review explores in vivo evidence whether mesenchymal stem cell-derived extracellular vesicles (MSC-EVs) can facilitate tendon and ligament repair in animal models. Methods. On May 26th 2021, a systematic search was performed on PubMed, Web of Science, Cochrane Library, Embase, using search terms ‘mesenchymal stem cell’ or ‘multipotent stem cell’ AND ‘extracellular vesicles’ or ‘exosomes’ AND ‘tendon’ or ‘ligament’ or ‘connective tissue’. Risk of bias was assessed using SYstematic Review Center for Laboratory animal Experimentation (SYRCLE) tool. Studies administering EVs isolated from human or animal-derived MSCs into in vivo models of tendon/ligament injury were included. In vitro, ex vivo, in silico studies were excluded, and studies without a control group were excluded. Data on isolation and characterisation of MSCs and EVs, and in vivo findings in animal models were extracted. Results. Out of 383 relevant studies, 11 case-control studies were included for data extraction, including a total of 448 animal subjects (range 10–90). Six studies utilised bone marrow-derived MSCs. All studies characterised their MSCs via flow cytometry, which expressed CD44 and CD90, and isolated EVs via ultracentrifugation (average diameter 125nm). Five studies utilised histological scoring systems, all of which reported a lower score with EV treatment, suggesting improved healing ability. Four studies reported increased anti-inflammatory cytokine expression (IL-10, TGF-β1); three studies reported decreased endogenous M1/M2 macrophage ratio with EV treatment. Eight studies reported increased maximum stiffness, breaking load, tensile strength in EV-treated tendons. Conclusion. MSC-EVs are effective therapeutic agents for tendon/ligament pathologies, attenuating the initial inflammatory response, and accelerating tendon matrix regeneration. Future randomised controlled trials are needed to definitely demonstrate MSC-EVs superiority in management of tendon/ligament injury

Purpose: Trapezometacarpal osteoarthritis is frequent in women aged over 50 years. Surgical cure may be needed after failure of well conducted medical treatment. When the trapezeal bone stock is insufficient for implantation of a total prosthesis, total trapezectomy can relieve the pain. This procedure is generally associated with stabilization ligamentoplasty of the first ray. The purpose of this study was to demonstrate the feasibility of this procedure using an arthroscopic approach and to detail the technique and its limitations. Material and methods: This study was conducted on twelve cadaver specimens from eleven women and one man, mean age 85 years. Radiographs were obtained to confirm the trapezometacarpal osteoarthritis. Standard arthroscopic material used for the wrist was employed (2.4 mm optic, mini-shaver). Two portals on either side of the abductor pollicis lungus tendon were used to approach the trapezometacarpal joint. Total trapezectomy was performed with the mini-shaver distal to proximal. A tendon band measuring 6 to 7 cm was fashioned from the abductor pollicis longus tendon via a proximal contraincision. This band inserted on the first metacarpal was passed through two bone tunnels bored in the base of the first and second metacarpals then fixed to the base of the second metacarpal. Operative time was noted. The quality of the bone resection was determined on postoperative radiographs and open inspection. Results: Arthroscopic total trapezectomy with stabilisation ligamentoplasty was achieved in all cases and evaluated radiographically and at open inspection. No lesions to noble elements were observed. Discussion: This minimally invasive technique for trapezectomy associated with stabilisation ligamentoplasty was found to be feasible but did require a certain degree of learning. We were unable to identify any procedure-related morbidity, particularly concerning the sensorial branch of the radial nerve to the thumb. Conclusion: The results of this preliminary study are encouraging and suggest a clinical trial should be conducted to prove the advantages of this technique in terms of morbidity and socioeconomical cost

The Achilles tendon is the most commonly ruptured tendon in the body and yet its management remains controversial due to potential surgical complications. We believe that primary repair using LARS ligament augmentation, combined with early mobilisation will significantly reduce all these potential problems and lead to improved functional outcomes. Nine patients with acute Achilles tendon ruptures underwent primary repair using augmentation with a Ligament Augmentation and Reconstruction System (LARS) ligament. Day one postoperatively each patient was started on active range of motion exercises. Clinical parameters, isokinetic strength and outcome measurements (The American Orthopaedic Foot and Ankle Society (AOFAS) ankle and hindfoot score and Lower Extremity Functional Scale (LEFS) was utilised to assess pain and function, Tegner score to evaluate activity) were evaluated at an average follow-up of 17 months. Complications, if any, were also recorded. There were no re-ruptures and all patients returned to normal work (average time 9.2 weeks) and all but one returned to their previous level of recreational sporting activity (average time 20.8 weeks). The postoperative performance testing showed positive results with the mean decrease in calf circumference of affected leg was 1.0 cm (range, −0.5 to 2.0), and every patient was able to perform at least one heel-raise with the mean heel raise difference being −3.8 repetitions (range, −1 to −10 reps) when compared to the other leg. In terms of functional outcomes, all patients reported very good results. The mean AOFAS score postoperatively was 83.4% (range, 74% to 100%) and the mean LEFS score was 82.5% (range, 45 to 100%). The mean preoperative Tegner score was 4.75 (range, 2 to 8) and the postoperative score was 3.75 (range, 2 to 7). The results of our preliminary clinical series indicate that LARS ligament repair of acute Achilles tendon ruptures provides a reliable and effective technique for repair. It eliminates the need for graft harvesting, it decreases postoperative complications, but most importantly, patients have improved functional outcomes

Purpose of the study: The hypothesis of this study was that age over 50 years is not a contraindication for hamstring reconstruction of the anterior cruciate ligament (ACL). Material and methods: Study period: September 1998 to September 2003. Type of study: prospective, consecutive series. The patient included in this study met the following criteria: age over 50 years at surgery; chronic anterior laxity, alone or associated with meniscal injury; one or more episodes of instability; absence of preoperative medial femorotibial osteoarthritis; no prior history of ligament surgery on the same knee. The same technique was used for all patients: four-strand single fiber arthroscopic hamstring ligamentoplasty using a blind femoral tunnel drilled via an anteromedial arthroscopic portal. All grafts were fixed with resorbable screws in the femur and tibia. The same rehabilitation protocol was used for all patients. IKDC scores were recorded. Plain x-rays were obtained (single leg stance ap and lateral views) as well as 30° patellar and passive Lachman (Telos). Results: Eighteen patients were included, 12 women, mean age 59.5 years (range 51–66 years. Mean follow-up was 35 months (range 12–59 months). There were no cases of recurrent ACL tears, no loss of extension. Three patients complained of hpoesthesia involving the internal saphenous nerve and two patients presented postoperative knee pain. At last follow-up, the overall IKDC score was 7A, and 11B. All patients considered they had a normal or nearly normal knee. All were satisfied or very satisfied. None of the patients presented instability. The Lachman-Trillat test was hard stop in 13 cases and late hard stop in 5. The pivot test was negative in 16 knees and questionable in two. Mean residual differential laxity was 3.3 mm (range −1 mm to +7 mm) in passive Lachman. There was no evidence of osteoarthritic progression on the x-rays. Discussion and conclusion: This series demonstrated that age over 50 years is not a contraindication for arthroscopic hamstring ACL grafting. This operation can be used to restore knee stability

Purpose: The purpose of this study was to compare, at ten years follow-up, the clinical and radiological results obtained in two series of patients who underwent patellar tendon ligmentoplasty for anterior cruciate ligament tears. One series was operated in an acute setting (before 45 days) and the other for chronic lesions. Material and methods: In 1986 and 1987, we performed patellar ligamentoplasty for anterior cruciate ligament tears in 230 knees. Mean delay to surgery was ten days for 77 knees (53 reviewed with clinical and radiological evaluation and 12 with questionnaires, i.e. 84%). For 153 knees surgery was performed for chronic lesions (107 reviewed with clinical and radiological evaluation and 12 with questionnaires, i.e. 77%). The IKDC chart was used to assess outcome with KT 2000 measurements on the loaded images. Results: There was a significant difference between the two series for: overt meniscal tears at the time of surgery (58% in the chronic series and 11% in the acute series, p < < 1%); osteoarthritic (26% chronic versus 6% acute, p < 1%); overall IKDC score (96% for acute versus 84% for chronic, p < 3%). The same was true for subjective assessment (normal for 95% of the acute knees versus 65% for the chronic knees) and for rate of recurrent tears (2% for acute and 9% for chronic). There was no significant difference between the series for clinical signs (pain, swelling, apprehension), mean residual laxity as measured by KT 2000, although it was greater for the chronic knees (+2.6%) than for the acute knees (+2.3%). Permanent flexion was not significantly different between the series (31% for chronic and 28% for acute) although the reason was different since for the chronic series, subsequent meniscectomy was necessary. Conclusion: Patellar ligamentoplasty performed in an acute setting provides better clinical and radiological outcome. It stabilises the knee better before possible development of a meniscal lesion that may precipitate osteoarthritis

Ligament integrity is directly associated with ankle stability. Nearly 40% of ankle sprains result in chronic ankle instability, affecting biomechanics and potentially causing osteoarthritis. Ligament replacement could restore stability and avoid this degenerative pathway, but a greater understanding of ankle ligament behaviour is required. Additionally, autograft or allograft use is limited by donor-site morbidity and inflammatory responses respectively. Decellularised porcine grafts could address this, by removing cellular material to prevent acute immune responses, while preserving mechanical properties.

This project will characterise commonly injured ankle ligaments and damage mechanisms, identify ligament reconstruction requirements, and investigate the potential of decellularised porcine grafts as a replacement material.

Several porcine tendons were evaluated to identify suitable candidates for decellularisation. The viscoelastic properties of native tissues were assessed using dynamic mechanical analysis (DMA), followed by ramp to ‘sub-rupture’ at 1% strain/s, and further DMA. Multiple samples (n=5) were taken along the graft to assess variation along the tendon.

When identifying suitable porcine tendons, a lack of literature on human ankle ligaments was identified. Inconsistencies in measurement methods and properties reported makes comparison between studies difficult.

Preliminary testing on porcine tendons suggested there is little variation in viscoelastic properties along the length of tendon. Testing also suggested strain rates of 1%/s sub-rupture was not large enough to affect viscoelastic properties (no changes in storage or loss moduli or tanẟ). Further testing is underway to improve upon low initial sample numbers and confirm these results, with varying strain rates to identify suitable sub-rupture sprain conditions.

This work highlights need for new data on human ankle ligaments to address knowledge gaps and identify suitable replacement materials. Future work will generate this data and decellularise porcine tendons of similar dimensions. Collagen damage will be investigated using histology and lightsheet microscopy, and viscoelastic changes through DMA.

INTRODUCTION: The authors present the results of a surgical technique for lateral ankle chronic instability, derived from Castaing and Duquennoy procedures. It uses a half peroneus brevis with a tightening of the antero- lateral capsule. A Plasty with the extensorum digitorum brevis was used in the event of associated subtalar instability. MATERIAL AND METHODS: Between 2001 and 2005, 38 cases of ligamentoplasties have been performed for chronic instability of the ankle. 32 (25 men and 7 women) of them have been reviewed with a mean delay of 26 months (extremes of 10 months to 5 years). They were middle-aged of 28,5 years. All the patients have been reviewed with stress X-Ray in varus of the both ankles (measure of tibio talar angle, arthritis) and had a strength measure in eversion by the same examiner. The functional evaluation was performed with Molander and Olerud ankle score. RESULTS: There were 20% of complications, especially cutaneous cicatrisation problems and algodystrophy. After surgery, no patient had instability; only one, had apprehension of the ankle. 90 % retrieved the same sport with the same level. No body changed of job. 3 patients were disappointed because of pain in sports and stiffness. At revision, the functional score was 90 against 59 at the pre operative time. The difference of strength in eversion between the two ankles was about 7%. Laxity had a good correction seeing the average tibio talar angle between the both ankle is 0,5°. DISCUSSION: The results of this procedure show a distinct improvement of stability, radiological laxity and functional activity. The arthrotomy performed in Duquennoy procedure, is useful for diagnosis and treatment. It shows the cartilage and allows the removal of impingement and foreign bodies. A plasty that uses the single evertor deprives the ankle of a part of active and proprioceptive control. However, the patients didn’t feel a difference or a discomfort. The patients who had the surgery on the jump foot side had no significative difference of strength in eversion between the both ankles. CONCLUSION: This anatomical procedure gives 91% of satisfaction, for these active young people. The postoperative physiotherapy allows the complete recovery of activities from the sixth month after surgery

Purpose: The purpose of our study was to evaluate, in a context of laxity, the incidence of meniscal lesions and their treatment on the osteoarthritic evolution after more than ten years. In 1986 and 1987, we operated 230 knees with tears of the anterior cruciate ligament using a patellar graft. Among these knees, 184 (80%) were reviewed clinically and radiographically for this study. Material and methods: Ninety patients (49%) had healthy menisci at the operation and did not have a secondary meniscal procedure; 94 patients (51%) had a meniscal procedure before, during or after the plasty. Among these, 13 (14%) had had an earlier meniscectomy, 18 (19%) had had meniscectomy at the time of the plasty (two revisions), 35 (37%) had had sutures (five secondary failures), ten (11%) had had a long injury left in place (four revisons), and 18 (19%) with normal knees at the time of the plasty had a secondary meniscectomy. Results: We compared the radiological results in these different populations (osteoarthritis with remodelling compared with normal images). There was a significant difference between the population with normal knee images and the population with meniscal lesions irrespective of the time of treatment (prior meniscectomy, concomitant meniscectomy and plasty, healthy menisci at the time of plasty but secondary meniscectomy). There was no significant difference between the knees with normal menisci and those with sutured menisci. Conclusion: Saving the meniscus has a major effect on the radiological evolution of the knee. Thus isolated meniscectomy should not be performed for laxity in young patients; meniscal lesions should be sutured at the time of ligamentoplasty

Summary

Our study shows that a tendon rupture can be successfully augmented with Demineralised Cortical Bone (DCB) giving initial appropriate mechanical strength suitable for in vivo use providing the biological reactions to the graft are favourable.

Treatment of tendon and ligament injuries remains challenging; the aim is to find a biocompatible substance with mechanical and structural properties that replicate those of normal tendon and ligament. We examined the mechanical properties of Demineralised Cortical Bone (DCB) after gamma irradiation (GI) and freeze drying (FD). We also used different techniques for repairing bone-tendon-bone with DCB in order to measure the mechanical performance of the construct. DCB specimens were allocated into 4 groups; FD, GI, combination of both or none. The maximum tensile forces and stresses were measured. 4 cadaveric models of repair of 1cm patellar tendon defect using DCB were designed; model-1 using one bone anchor, Model-2 using 2 bone anchors, Model-3 off-loading by continuous thread looped twice through bony tunnels, Model-4 off-loading with 3 hand braided threads. Force to failure and mode were recorded for each sample. FD groups results were statistically higher (p=<0.05) compared to non-FD groups, while there was no statistical difference between GI and non-GI groups. The median failure force for model-1: 250N, model-2: 290N, model-3: 767N and model-4: 934N. There was no statistical significance between model-1 and model-2 (p=0.249), however statistical significance was found between other models (p=<0.006). GI has no significant effect on mechanical strength of the CDB while FD may have positive effect on its mechanical strength. Our study shows that a tendon rupture can be successfully augmented with CDB giving initial appropriate mechanical strength suitable for in vivo use providing the biological reactions to the graft are favourable.

Aims: The results of surgical repair and reconstruction of knee dislocations were reviewed at average follow-up of 32 months. Methods: Twenty-one patients with 22 knee dislocations presented between 1994 and 2001. There was one vascular and one common peroneal nerve injury. Eight (38%) patients were treated in the acute period (< 14 days), the remainder were late reconstructions. The patients were evaluated at mean follow-up of 32 months (11 to 77). This included ROM measurement, clinical and instrumented ligament laxity testing. Posterior stress view with 10kg weight was used to evaluate the PCL reconstruction. Function was evaluated using the IKDC chart, the Lysholm Score and the Tegner Activity Level. Results: The mean Lysholm score in the acute group was 87 (range 81 to 93) and in the delayed group 75 (range 53 to 100), the mean Tegner activity rating was 5 in the acute group and 4.4 in the delayed group. IKDC assessment revealed no differences between the two patient groups. Instrumented testing of knee stability indicated better results for ACL reconstructions performed in the acute phase but no difference in the outcome of PCL reconstruction. There was no difference in loss of knee movement between the two groups. Conclusions: Good function can be obtained in the operatively treated knee dislocations at 1–7 years. Although the differences were small, the outcome in terms of overall knee function, activity levels and anterior tibial translation were better in those knees reconstructed within two weeks of injury.

Aim

To correlate the surgical and MRI findings in acute lateral patellar dislocation and to determine the accuracy of MRI in identifying location of MFPL injury.

Aims: This in vitro study investigates the use of Collagen/PRP Hydrogels as a biological matrix for containing genetically modified human ACL cells, and supporting transgene expression. Methods: Adenoviral vectors encoding marker genes (green fluorescent protein (GFP)) and bioactive) where used to infect cultured human ACL cells?genes (TGF- ex vivo. The cells were seeded in Collagen/PRP Hydrogels and maintained in culture. To expression over time, ELISA was performed at days 4, 8, 15, 23,?measure TGFand 29. GFP positive cells within the gel were viewed by fluorescence microscopy at the same time points. After 29 days, the cultures were fixed, sectioned and various sections were stained with H& E, toluidine blue to detect proteoglycans and by immunhistocemistry for collagen type I and II. Results: Collagen/PRP Hydrogels were transgenes for up to 29 days.?able to support expression of GFP and TGF- expressing gel/cell constructs produced an abundant?Compared to controls, TGF- amount of type I collagen, consistent with the ligament phenotype and appeared more cellular. Little or no proteoglycan staining was observed in either group. Conclusion: These results demonstrate that genetically modified human ACL cells can support persistent transgene expression in vitro, sufficient to stimulate growth of ligamentlike tissue within a Collagen/PRP Hydrogel. The high levels of transgene expression suggest that the Collagen/PRP Hydrogel can function as an effective gene delivery system for tendon repair in vivo.

Purpose of study: To report the use of a forearm fascial strip to repair the annular ligament and treat late diagnosed or irreducible Monteggia fracture.

Methods: Through Boyd’s approach nineteen patients with Monteggia fractures were treated with a technique to reconstruct the annular ligament using forearm fascia, retaining its proximal attachment to the ulna. The radial head was dislocated and the fascial strip wound around the neck of the radius. After reducing the radial head, forearm rotation was checked. The strip was sutured to the residual annular ligament on the proximal ulna after correction of any ulna deformity. In late diagnosis, the ulna deformity was managed with ulna lengthening of approximately 0.5 cm and stabilization with a 4- or 5- hole semi-tubular AO plate. The stability of the radial head was then assessed using intra-operative fluoroscopy.

Results: Stability of the radial head was achieved in all cases. According to the Anderson classification, the final outcome was excellent in ten cases satisfactory in eight cases and unsatisfactory in one late diagnosed patient with an associated radioulnar synostosis secondary to a compartment syndrome. There were no failures. Two radiocapitellar K-wires broke while in plaster in the initial period, so the use of a K wire was subsequently abandoned.

Conclusions: We have found this technique to be reliable for stabilizing the proximal radioulnar joint. The length of the incision is less than that required for the Bell Tawse (triceps tendon) technique and permits a tourniquet on the upper arm. Poorer results were achieved with delay in diagnosis beyond 6 months.

Patients must be warned of potential reduction of forearm rotation.

This in-vitro study evaluated the influence of ligament tensioning and the effectiveness of lateral collateral ligament (LCL) repair using transosseous sutures on the initial kinematics and stability of the elbow.

Six fresh upper-extremities were mounted in a motion simulator with tracking system, which enabled both passive and simulated active elbow flexion. The intact elbow was tested then the LCL was sectioned from its humeral origin and repaired with a transosseous suture technique. Locking sutures were placed in the LCL and passed through a humeral bone tunnel entering at the centre of curvature of the capitellum with exit holes in the lateral epicondyle. An actuator pulled on the sutures to achieve 20, 40 and 60 N of LCL repair tension and the sutures were then secured. The dependent variable of this study was the motion pathways of the ulna relative to the humerus. The data were analyzed using a two-way, repeated-measures ANOVA with relevant post-hoc paired t-tests.

With the arm oriented in the horizontal position under varus gravity loading, the repairs tracked in greater valgus than the intact LCL regardless of the repair tension. The larger the initial repair tension, the more the elbows tracked in valgus. Initial tension of 60 N was statistically different than the intact LCL with the forearm in pronation (p=0.04). Both the 40 and 60 N initial tensions were statistically different than the intact LCL with the forearm in supination (p< 0.01).

Repair of the LCL using transosseous sutures effectively restores the varus stability of the elbow. The initial tension of LCL repairs affects the kinematics of the elbow, with a tendency to over-tighten the ligament and pull the elbow into valgus. These data suggest that acute repair of the LCL should be performed using a transosseous suture technique, and that a tension of 20N or perhaps less is sufficient to restore stability.

Purpose: Treatment of recent lesions of the posterior cruciate ligament (PCL) is not standardised. Decisions depend on the patients age and activity level, the degree of laxity, and the presence of combined lesions. Surgical solutions included PCL repair with suture, reconstruction with an autograft or allograft, or synthetic plasty. The purpose of this study was to analyse the results of synthetic reconstruction plasty for knees with important recent laxity of the PCL alone or in association with other lesions (triads, pentades, dislocations). We hypothesised that the synthetic ligament serves as a tutor guiding healing of the ruptured ligament.

Material and methods: The series included 14 consecutive patients, 1 women, 13 men, mean age 27 years who were reviewed retrospectively. These patients were treated for isolated PCL tears (laxity > 15 mm) (n=3), PCL tears combined with laxity (medial or lateral) (n=6) or dislocation (n=5). Mean posterior laxity was 24 mm. The operation was performed 3 to 50 days after trauma using the LARS method (polyester ligament, 6 or 8 mm, 1 or 2 strands). All associated lesions were repaired during the same procedure except one A CL and one posterolateral angle which were treated secondarily. Mean follow-up was 36 months (10–88). All patients were seen for consultation except one who responded to a questionnaire. The IKDC score and Telos laxity measurements were noted.

Results: In five knees, stiffness required mobilisation or arthroscopic arthrolysis. A secondary tear confirmed arthroscopically occurred in one case after a new trauma. Subjectively, two patients were very satisfied, eight were satisfied and three were disappointed. Final motion was: 6/0/130. Direct clinical posterior drawer was present in twelve cases: the Telos differential was 8 mm (24 mm preoperatively). The overall IKDC score was A=0, B=7, C=3, D=2. Persistent posterior laxity was the worst item. Outcome was less satisfactory for all items for posterolateral laxity. There was no difference between the one- and two-strand plasties.

Discussion: We did not have any complications directly related to the synthetic ligament (synovitis, spontaneous tear). There was a significant gain in posterior laxity. Outcome depended on associated lesions, particularly lateral lesions (stiffness, IKDC score), rather than the surgical technique used to repair the PCL. The synthetic ligament appears to play its role as a tutor, a single strand measuring 6 mm in diameter is sufficient.

Conclusion: This technique spares the tendon stock and can be proposed for recent tears of the PCL with major laxity. A longer term follow-up is needed to confirm the persistence of the improvement in laxity.