Aims

Posterior malleolar (PM) fractures are commonly associated with ankle fractures, pilon fractures, and to a lesser extent tibial shaft fractures. The tibialis posterior (TP) tendon entrapment is a rare complication associated with PM fractures. If undiagnosed, TP entrapment is associated with complications, ranging from reduced range of ankle movement to instability and pes planus deformities, which require further surgeries including radical treatments such as arthrodesis.

Post-traumatic elbow stiffness is a disabling condition that remains challenging for upper limb surgeons. Open elbow arthrolysis is commonly used for the treatment of stiff elbow when conservative therapy has failed. Multiple questions commonly arise from surgeons who deal with this disease. These include whether the patient has post-traumatic stiff elbow, how to evaluate the problem, when surgery is appropriate, how to perform an excellent arthrolysis, what the optimal postoperative rehabilitation is, and how to prevent or reduce the incidence of complications. Following these questions, this review provides an update and overview of post-traumatic elbow stiffness with respect to the diagnosis, preoperative evaluation, arthrolysis strategies, postoperative rehabilitation, and prevention of complications, aiming to provide a complete diagnosis and treatment path.

Cite this article: Bone Joint Open 2020;1-9:576–584.

Aims. The aim of this study was to evaluate two hypotheses. First, that disruption of posterior bundle of the medial collateral ligament (PMCL) has to occur for the elbow to subluxate in cases of posteromedial rotatory instability (PMRI) and second, that ulnohumeral contact pressures increase after disruption of the PMCL. Materials and Methods. Six human cadaveric elbows were prepared on a custom-designed apparatus which allowed muscle loading and passive elbow motion under gravitational varus. Joint contact pressures were measured sequentially in the intact elbow (INTACT), followed by an anteromedial subtype two coronoid fracture (COR), a lateral collateral ligament (LCL) tear (COR + LCL), and a PMCL tear (COR + LCL + PMCL). Results. There was no subluxation or joint incongruity in the INTACT, COR, and COR + LCL specimens. All specimens in the COR + LCL + PMCL group subluxated under gravity-varus loads. The mean articular contact pressure of the COR + LCL group was significantly higher than those in the INTACT and the COR groups. The mean articular contact pressure of the COR + LCL + PMCL group was significantly higher than that of the INTACT group, but not higher than that of the COR + LCL group. Conclusion. In the presence of an anteromedial fracture and disruption of the LCL, the posterior bundle of the MCL has to be disrupted for gross subluxation of the elbow to occur. However, elevated joint contact pressures are seen after an anteromedial fracture and LCL disruption even in the absence of such subluxation. Cite this article: Bone Joint J 2018;100-B:1060–5

Objectives

Malalignment of the tibial component could influence the long-term survival of a total knee arthroplasty (TKA). The object of this study was to investigate the biomechanical effect of varus and valgus malalignment on the tibial component under stance-phase gait cycle loading conditions.

Objectives

Malrotation of the femoral component can result in post-operative complications in total knee arthroplasty (TKA), including patellar maltracking. Therefore, we used computational simulation to investigate the influence of femoral malrotation on contact stresses on the polyethylene (PE) insert and on the patellar button as well as on the forces on the collateral ligaments.

The causes of a stiff elbow are numerous including: post-traumatic elbow, burns, head injury, osteoarthritis, inflammatory joint disease and congenital. Types of stiffness include: loss of elbow flexion, loss of elbow extension and loss of forearm rotation. All three have different prognoses in terms of the timing of surgery and the likelihood of restoration of function. Contractures can be classified into extrinsic and intrinsic (all intrinsic develop some extrinsic component). Functional impairment can be assessed medicolegally; however, in clinical practice the patient puts an individual value on the arc of motion. Objectively most functions can be undertaken with an arc of 30 to 130 degrees. The commonest cause of a Post-traumatic Stiff elbow is a radial head fracture or a complex fracture dislocation. Risk factors for stiffness include length of immobilisation, associated fracture with dislocation, intra-articular derangement, delayed surgical treatment, associated head injury, heterotopic ossification. Early restoration of bony columns and joint stability to allow early mobilisation reduces incidence of joint stiffness. Heterotopic ossification (HO) is common in fracture dislocation of the elbow. Neural Axis trauma alone causes HO in elbows in 5%. However, combined neural trauma and elbow trauma the incidence is 89%. Stiffness due to thermal injury is usually related to the degree rather than the site. The majority of patients have greater than 20% total body area involved. Extrinsic contractures are usually managed with a sequential release of soft tissues commencing with a capsular excision (retaining LCL/MCL), posterior bundle of the MCL +/− ulna nerve decompression (if there is loss of flexion to 100 degrees). This reliably achieved via a posterior incision, a lateral column exposure +/− ulna nerve mobilisation. A medial column exposure is a viable alternative. Arthroscopic capsular release although associated with a quicker easier rehabilitation is associated with increased neural injury. Timing of release is specific to the type of contracture, i.e. flexion contractures after approx. six months, extension contractures ASAP but after four months, loss of forearm rotation less 6 to 24 months. The use of Hinged Elbow Fixators is increasing. The indications include reconstructions that require protection whilst allowing early movement, persistent instability or recurrent/late instability or interposition arthroplasty. Post-operative rehabilitation requires good analgesia, joint stability and early movement. The role of CPM is often helpful but still being evaluated

Purpose: The role of the posterior bundle of the medial collateral ligament (PMCL) in stability of the elbow remains poorly defined. The purpose of this study was to determine the effect of sectioning the PMCL on the stability of the elbow. Method: Varus and valgus gravity-loaded passive elbow motion and simulated active vertical elbow motion were performed on 11 cadaveric arms. An in-vitro elbow motion simulator, utilizing computer-controlled pneumatic actuators and servo-motors sutured to tendons, was used to simulate active elbow flexion. Varus/valgus angle and internal/external rotation of the ulna with respect to the humerus were recorded using an electromagnetic tracking system. Testing was performed on the intact elbow and following sectioning of the PMCL. Results: With active flexion in the vertical position the varus/valgus kinematics were unchanged after PMCL sectioning (p=0.08). However, with the forearm in pronation, there was a significant increase in internal rotation after PMCL sectioning compared to the intact elbow (p< 0.05) which was most evident at 0° and 120° degrees of flexion (p< 0.05). This rotational difference was not statistically significant with the forearm in supination (p=0.07). During supinated passive flexion in the varus position, PMCL sectioning resulted in increased varus angulation at all flexion angles (p< 0.05). In pronation varus angulation was only increased at 120° of flexion (p< 0.05). However, internal rotation was increased at flexion angles of 30° to 120° (p< 0.05). In supination, sectioning the PMCL had no significant effect on maximum varus-valgus laxity or maximum internal rotation (p=0.1). However, in pronation, the maximum varus-valgus laxity increased by 3.5° (30%) and maximum internal rotation increased by 1.0° (29%) (p< 0.05). Conclusion: These results indicate that isolated sectioning of the PMCL causes a small increase in varus angulation and internal rotation during both passive varus and active vertical flexion. This study suggests that isolated sectioning of the PMCL may not be completely benign and may contribute to varus and rotation instability of the elbow. In patients with insufficiency of the PMCL appropriate rehabilitation protocols (avoiding forearm pronation and shoulder abduction) should be followed when other injuries permit

Purpose: We undertook a primarily cadaveric study of trabecular architecture of olecranon to link theory of biomechanics and morphological trabecular patterns of olecranon and secondly compare with real-life trabecular pattern in CT scans. Methods & Results: Eight pairs of ulnae (fresh-frozen bones) were obtained from cadavers following road traffic accidents, aged 25 to 60 (mean 34 years). None suffered from previous pathology of elbow. Half of the ulnae were sliced longitudinally, each slice 2–3 mm thick (Group I), and the other half vertically (Group II). After they were radiographed, orientation of trabeculae was studied. CT scans of 8 patients (Group III), originally performed for investigation of fractures of radial head, were studied for comparison of real life trabecular pattern of olecranon. In Group I, two main sets of trabeculae were observed. The first set consists of three bundles, which arise from anterior cortex and support subchondral area – the posterior third bundle curves and spreads to posterior cortex of olecranon. The second set arises from posterior cortex and terminates under subchondral area. In Group II, trabeculae subtend a 900 angle to articular surface. CT scans of 8 patients (Group III), originally performed for investigation of fractures of radial head, ascertained real-life trabecular pattern of olecranon and confirmed cadaveric observations. Conclusion: Trabeculae of olecranon comprise a set to resist compressive loading and a further set to resist tensile stresses. Thicker trabeculae coincide with maximal loading. Prosthetic design of elbow should take into account the trabecular pattern to facilitate stress absorption

Nonunion of the tibia associated with bone loss, previous infection, obliteration of the intramedullary canal or located in the distal metaphysis poses a challenge to the surgeon and significant morbidity to patients. We retrospectively reviewed the records of 24 patients who were treated by central bone grafting and compared them to those of 20 who were treated with a traditional posterolateral graft. Central bone grafting entails a lateral approach, anterior to the fibula and interosseous membrane which is used to create a central space filled with cancellous iliac crest autograft. Upon consolidation, a tibiofibular synostosis is formed that is strong enough for weight-bearing. This procedure has advantages over other methods of treatment for selected nonunions.

Of the 24 patients with central bone grafting, 23 went on to radiographic and clinical union without further intervention. All healed within a mean of 20 weeks (10 to 48). No further bone grafts were required, and few complications were encountered. These results were comparable to those of the 20 patients who underwent posterolateral bone grafting who united at a mean of 31.3 weeks (16 to 60) but one of whom required below-knee amputation for intractable sepsis.

Central bone grafting is a safe and effective treatment for difficult nonunions of the tibia.

Advances in hip arthroscopy have renewed interest in the ligamentum teres. Considered by many to be a developmental vestige, it is now recognised as a significant potential source of pain and mechanical symptoms arising from the hip joint. Despite improvements in imaging, arthroscopy remains the optimum method of diagnosing lesions of the ligamentum teres. Several biological or mechanical roles have been proposed for the ligament. Unless these are disproved, the use of surgical procedures that sacrifice the ligamentum teres, as in surgical dislocation of the hip, should be carefully considered. This paper provides an update on the development, structure and function of the ligamentum teres, and discusses associated clinical implications.

We present the operative technique and clinical results of concomitant reconstruction of the medial collateral ligament (MCL) and the posterior oblique ligament for medial instability of the knee using autogenous semitendinosus tendon with preservation of the tibial attachment. The semitendinosus tendon graft between the screw on the medial epicondyle and the tibial attachment of the graft was overlapped by the MCL, while the graft between the screw and the insertion of the direct head of the semimembranosus tendon was overlapped by the central arm of the posterior oblique ligament. Assessment was by stress radiograph and the Lysholm knee scoring scale. After a mean follow-up of 52.6 months (25 to 92), the medial joint opening of the knee was within 2 mm in 22 of 24 patients. The mean Lysholm score was 91.9 (80 to 100).

Concomitant reconstruction of the MCL and posterior oblique ligament using autogenous semitendinosus tendon provides a good solution to medial instability.

Contracture of the collateral ligaments is considered to be an important factor in post-traumatic stiffness of the elbow. We reviewed the results of isolated release of the medial collateral ligament in a series of 14 patients with post-traumatic loss of elbow flexion treated between 1998 and 2002. There were nine women and five men with a mean age of 45 years (17 to 76). They were reviewed at a mean follow-up of 25 months (9 to 48). The operation was performed through a longitudinal posteromedial incision centred over the ulnar nerve. After decompression of the ulnar nerve, release of the medial collateral ligament was done sequentially starting with the posterior bundle and the transverse component of the ligament, with measurement of the arc of movement after each step. If full flexion was not achieved the posterior half of the anterior bundle of the medial collateral ligament was released. At the latest follow-up, the mean flexion of the elbow improved significantly from 96° (85° to 115°) pre-operatively to 130° (110° to 150°) at final follow-up (p = 0.001). The mean extension improved significantly from 43° (5° to 90°) pre-operatively to 22° (5° to 40°) at final follow-up (p = 0.003). There was a significant improvement in the functional outcome. The mean Broberg and Morrey score increased from a mean of 54 points (29.5 to 85) pre-operatively to 87 points (57 to 99) at final follow-up (p < 0.001). All the patients had normal elbow stability. Our results indicate that partial surgical release of the medial collateral ligament is associated with improved range of movement of the elbow in patients with post-traumatic stiffness, but was less effective in controlling pain

An abnormal lateral position of the tibial tuberosity causes distal malalignment of the extensor mechanism of the knee and can lead to lateral tracking of the patella causing anterior knee pain or objective patellar instability, characterised by recurrent dislocation. Computer tomography is used for a precise pre-operative assessment of the tibial tubercle-trochlear groove distance. A distance of more than 15 mm is considered to be pathological and an indication for surgery in symptomatic patients.

In a prospective study we performed a subtle transfer of the tibial tuberosity according to the information gained from the pre-operative CT scan. This method was applied to two groups of patients, those with painful lateral tracking of the patella, and those with objective patellar instability. We evaluated the clinical results in 30 patients in each group. The outcome was documented at 3, 12 and 24 months using the Lysholm scale, the Kujala score, and a visual analogue pain score.

Post-operatively, all but one patient in the instability group who had a patellar dislocation requiring further surgery reported good improvement with no further subluxation or dislocation. All patients in both groups had a marked improvement in pain and functional score. Two patients sustained a tibial fracture six and seven weeks after surgery. One patient suffered a per-operative fracture of the tibial tubercle which later required further fixation.

If carefully performed, this type of transfer of the tibial tubercle appears to be a satisfactory technique for the treatment of patients with an increased tibial tubercle-trochlear groove distance and who present with symptoms related to lateral maltracking of the patella.

The kinematic effect of tunnel orientation and position, during ACL reconstruction, has been only recently related to the control of rotational instability. This paper presents a detailed computer-assisted in vitro evaluation of two different femoral tunnel orientations with the same tunnel position, at 10.30 ‘o clock, during the intervention of ACL reconstruction with double bundle technique. Results highlighted better kinematic performances of the horizontal tunnel, with respect to the vertical one, in controlling antero-posterior (AP) laxities at 30°, and internal-external (IE) laxities. Elongations of anterior and posterior bundles of reconstructed ACL, for both reconstruction, decreased during PROM respectively by 20% and 40%. Total length of the graft varied during PROM, mainly due to graft elongation during tests, graft length on horizontal tunnel varied from 237 to 213mm while graft length on vertical tunnel varied from 257 to 233mm. Kinematic tests showed a better performance of horizontal tunnel in the control of IE rotations at 30° and 90° and of the Lachman test with respect to the vertical one. Stability was restored with both reconstructions

When performing the Scandinavian Total Ankle Replacement (STAR), the positioning of the talar component and the selection of mobile-bearing thickness are critical. A biomechanical experiment was undertaken to establish the effects of these variables on the range of movement (ROM) of the ankle.

Six cadaver ankles containing a specially-modified STAR prosthesis were subjected to ROM determination, under weight-bearing conditions, while monitoring the strain in the peri-ankle ligaments. Each specimen was tested with the talar component positions in neutral, as well as 3 and 6 mm of anterior and posterior displacement. The sequence was repeated with an anatomical bearing thickness, as well as at 2 mm reduced and increased thicknesses. The movement limits were defined as 10% strain in any ligament, bearing lift-off from the talar component or limitations of the hardware.

Both anterior talar component displacement and bearing thickness reduction caused a decrease in plantar flexion, which was associated with bearing lift-off. With increased bearing thickness, posterior displacement of the talar component decreased plantar flexion, whereas anterior displacement decreased dorsiflexion.

Aim: To test the hypothesis that the meniscofemoral ligaments (MFLs) make a significant contribution to resisting anteroposterior and rotatory laxity of the posterior cruciate ligament (PCL) deficient knee. Methods: The anterior and posterior MFLs of eight cadaveric knees were identified using previously described dissection techniques [. 1. ], which were shown not to affect overall knee stability in control studies. These specimens were tested for anteroposterior and rotatory laxity in a materials testing machine. The posterior cruciate ligament was then divided, followed by division of the MFLs. Laxity results were obtained for intact, PCL-deficient and PCL/MFL-deficient knees. Results were analysed using repeated measures analysis of variance and paired t tests. Results: Division of the MFLs in the PCL-deficient knee significantly increased posterior laxity between 15o and 90o of flexion (p< 0.01). Force/displacement measurements revealed that, at 90° flexion, the MFLs contributed to 28% of total resistance to posterior drawer in the intact knee and 70% in the PCL-deficient knee (p< 0.01). There was no effect on rotatory laxity (p> 0.2). Discussion: Previous studies have demonstrated a high prevalence of the MFLs in knees1 and that these ligaments have a strength similar to the posterior fibre bundle of the PCL [. 2. ]. The current in vitro study suggests that they contribute to overall resistance to posterior drawer, especially in the PCL-deficient knee. If this is confirmed in vivo, patients with PCL injuries may have a reduced posterior drawer sign if their MFLs are intact, and this may result in a more stable knee. Thus the MFLs should be accurately identified and assessed during MRI scanning and arthroscopy [. 3. ]. Conclusion: This is the first study demonstrating a function for the MFLs as secondary restraints to posterior drawer in the PCL-deficient knee. The integrity of these structures should be assessed during both MRI scanning and arthroscopy of PCL-injured patients, as this may affect the diagnosis and management of such injuries

Purpose: Subtalar dislocation is an exceptional finding. En bloc dislocation under the talus leads to talocalcaneal talonavicular luxation, generally observed in young active adults. Prognsosis is related to the risk of infection and talar necrosis. We report a retrospective series searching for featues influencing long-term clinical outcome. Material and methods: Between 1984 and 1990, twelve cases of subtalar dislocation were treated in our unit. There were nine lateral and three medial cases. Six lateral dislocations were open injuries, the head of the talus exposed medially. Treatment consisted in emergency orthopaedic reduction associated with debride-ment and closure in case of open injury. Temporary pinning (45 days) between the talus and the calcaneus was used in six cases. There were two lesions of the posterior tibial bundle which were repaired in the emergency setting. A supramalleolar lateral flap (Masquelet) was needed in one patient who developed cutaneous necrosis exposing the anterior tibial. Postoperative immobilisation consisted in a plaster boot for 45 days in all cases. Results: Mean follow-up was ten years. Clinical outcome was good in eleven patients (slightly limited dorsal flexion, 10°) and fair to poor in one. We did not have any case of talar necrosis or subtalar degeneration. Discussion: This series confirms data in the literature. Pure dislocation has as a rule a good prognosis although there is some discrepancy in the literature. In our series, lateral dislocation was more frequent than medial dislocation. Skin opening is frequent and is not a factor of poor prognosis. The absence of talar necrosis is related to preservation of the deltoid branch of the posterior tibial artery and respect of the fibular artery collaterals which supply the posteriolateral tubercle and the tarsal sinus. Emergency reduction of peritalar dislocations eliminates vascular suffering and limits the risk of infection. A temporary talocalcaneal pin is indispensable if the joint is unstable after reduction

Aim: To accurately assess cross-sectional areas of the MFLs and distinguish between the mechanical properties of the anterior and posterior meniscofemoral ligaments. Methods: Twenty-eight fresh frozen cadaveric knees were dissected to isolate the lateral meniscus and MFLs, which remained attached to the femur. The cross-sectional areas of MFLs were determined using the Race-Amis. 1. casting method for measurement. The ligaments were then tensile tested in an Instron materials testing machine. The stress and strain in each sample was calculated from measurements of cross sectional area, load applied, and increase in length,. Results: The mean cross sectional area for the anterior MFL (aMFL) was 14.7 mm. 2. (±14.8mm. 2. ) whilst that of the posterior MFL (pMFL) was 20.9mm. 2. (±11.6mm. 2. ). The mean loads to failure were 300.5N (±155.0N) for the aMFL and 302.5N (±157.9N) for the pMFL, with elastic moduli of 281MPa (±239MPa) and 227MPa (±128MPa) respectively. There were no significant differences in structural or material properties between the two MFLs. When compared with the posterior cruciate ligament (PCL), the mean ultimate loads of the MFLs were similar to those of the posterior bundle of the PCL (pPC), and their elastic moduli were analogous to the anterior bundle (aPC). Discussion: This is the first study to distinguish between the properties of the aMFL and pMFL, and indicates that both ligaments must be given equal consideration when formulating hypotheses on function. The aMFL and pMFL may also serve mutually distinct functions in the human knee. Previous authors. 2. have commented that the reciprocal tightening and slackening of the aPC (taut in flexion) and pPC (taut in extension) indicates a difference in function of these two components of the PCL. Others. 3. have similarly commented on the reciprocal tightening and slackening of the two MFLs. This may also indicate differing functions for these ligaments. It is proposed that the aMFL supplements the function of the aPC, whilst the pMFL supplements the function of the pPC. This hypothesis stimulates debate on preservation of these structures during PCL reconstruction. Race A., Amis A.A., 1996. Cross-sectional area measurement of soft tissue. A new casting method. Journal of Biomechanics 29(9), 1207–1212. RaceA., Amis A.A., 1994a. The mechanical properties of the two bundles of the human posterior cruciate ligament. Journal of Biomechanics 27(1), (13–24). Friederich N F., O’Brien W., 1990. Functional anatomy of the meniscofemoral ligaments. Fourth Congress of the European Society of Sports Traumatology Knee Surgery and Arthroscopy (ESSKA)

A total of 30 patients who underwent endoscopic reconstruction of the anterior cruciate ligament using quadrupled hamstring tendons, through a single drill hole in the femur, had MRI 24 to 28 months after operation. In 18 patients the scans revealed that both the anterior and posterior portions of the graft ran in parallel from the inside of the femoral to the tibial tunnel. In 12, the posterior bundle had moved anteriorly and the anterior bundle could not be identified at the anterodistal border of the femoral tunnel. The mean difference in the anterior laxity, when compared with the contralateral knee, was 2.0 ± 1.7 mm and 4.3 ± 2.8 mm for the two types, respectively. Damage to the anterior bundle may occur when using the endoscopic technique because of biomechanical disadvantages, including concentration of loading and repetitive bending stress in the anterior bundle at the opening of the femoral tunnel