INTRODUCTION. This study aimed to intra-operatively quantify the improvements in knee stability given both by anatomic double-bundle (ADB) and single-bundle with additional lateral plasty (SBLP) ACL reconstruction using a navigation system. MATERIALS AND METHODS. We prospectively included 35 consecutive patients, with an isolated anterior cruciate ligament injury, that underwent both ADB and SBLP ACL reconstruction (15 ADB, 20 SBLP). The testing protocol included anterior/posterior displacement at 30° and 90° of flexion (AP30–AP90), internal/external rotation at 30° and 90° of flexion (IE 30–IE90) and varus/valgus test at 0° and 30° of flexion (VV0–VV30); pivot-shift (PS) test was used to determine dynamic laxity. The tests were manually performed before and after the ACL reconstruction and the data were acquired by means a surgical navigation system (BLU-IGS, Orthokey, USA). Comparisons of pre- and post-reconstruction laxities were made using paired Student t-test (P=0.05) within the same group; comparison between ADB and SBLP groups was indeed performed using independent Student t-test (P=0.05), analysing both starting pre-operative condition and post-operative one. RESULTS. Statistically significant reduction of the global amount of laxity and global displacement was observed for both reconstructions (p<0.05) in all the performed clinical tests. Statistical differences was found between the two reconstruction considering the recovery (pre-post laxities) due to the each reconstruction, in VV0 (SBLP: 3.7±0.2° and ADB: 2.3±0.5°, p<0.0001) and in IE90 (SBLP: 9.2±3.1° and ADB: 5.0±2.8°, p=0.0022). Statistical differences were also found between the two reconstruction considering the recovery of global displacement, in particular for the lateral compartment during AP90 SBLP: 8.8±1.0 mm, ADB: 6.4±0.4 mm, p<0.0001), for the maximal lateral joint opening during VV0 (SBLP: 4.5±1.2 mm, ADB: 1.2±1.1 mm, p<0.0001) and VV30 (SBLP 3.5±1.3 mm, ADB 1.8±0.1 mm, p=0.0013) and both for the medial and lateral AP displacement during IE90 (in in medial compartment SBLP:5.6±0.6 mm, ADB: 2.7±0.7 mm, p<0.0001, in lateral compartment SBLP:8.2±1.0 mm, ADB: 3.9±0.8 mm, p<0.0001). During PS test ADB patients revealed less “hysteresis” after reconstruction (p=0.0005). Moreover SBLP patients presented more acceleration after the reconstruction compared to ADB and more evident displacement (p=0.0009). DISCUSSION. Both the reconstructions worked similarly for what concerns knee static laxity. The considered extra-articular procedure plays an important role in better controlling lateral tibial compartment displacement in drawer test and in controlling maximal lateral joint opening both at 0° and 30° of flexion. On the other hand the ADB reconstruction better restores the dynamic behaviour of the joint under PS test

Introduction. Anterior tibial translation (ATT) is assessed in the acutely injured knee to investigate for ligamentous injury and rotational laxity. Specifically, there is a growing recognition of the significance of anterior medial rotary laxity (AMRI) as a crucial element in assessing knee stability. Anterior cruciate ligament (ACL) injuries are often accompanied with medial collateral ligament (MCL) damage. It has been suggested that Deep MCL (dMCL) fibres are a primary restraint in rotational displacement. This research aims to quantify the difference in rotational laxity of patients with ACL and MCL injuries to deem if the Feagin-Thomas test can robustly capture metrics of AMRI. 2. Methods. AMRI was assessed using the Feagin-Thomas test in 7 isolated ACL (iACL) injured participants, 3 combined ACL and superficial fibre MCL (sMCL) injuries, 5 combined ACL and deep fibre MCL injuries, and 21 healthy controls. Displacement values were recorded using an optical motion capture (OMC) system and bespoke processing pipeline which map and model the knee's anterior displacement values relative to the medial compartment. Since absolute values (mm) of rotational laxity vary dependant on the person, values were recorded as a proportion of the rotational laxity obtained from the subject's contralateral leg. Values were compared between each patient group using an ANOVA test and Tukey's honesty significant difference post hoc test. 3. Results. The healthy control group had a median proportion of 0.97 (3SF), whilst the iACL was 1.12 (3SF), a 12% increase in rotational laxity in the injured leg. The sMCL group yielded a result of 1.64 (3SF), a 64% increase in rotational laxity in the injured leg; finally, dMCL resulted in a proportion of rotational laxity of 1.90 (3SF), a 90% increase in rotational laxity [table 1]. Whilst all groups showed differences in the increase of rotational laxity, dMCL was significantly different from the healthy control group (P value 0.0041). 4. Conclusion. ACL injuries with MCL involvement led to an increase in anterior medial rotary laxity and this is more evident in patients where deep MCL fibres are involved. The Feagin-Thomas test appears to be sensitive in detecting differences in AMRI and should be considered when performing comprehensive clinical knee examination. For any figures or tables, please contact authors directly

Introduction. To determine if elite athletes can return to professional sport after MCL or posterolateral (PLC) reconstruction using LARS ligaments. The secondary aims are to demonstrate the safety and efficacy of LARS by reporting sport longevity, subsequent surgeries, and complications. Methods. A retrospective review of all extra-articular knee ligament reconstructions, utilising a LARS synthetic ligament, by 3 sports knee surgeons between 2013 and 2020 was undertaken. All elite athletes aged over 16 years and a minimum of 2 years post reconstruction were included. No LARS were used for ACL reconstructions, and they were excluded if a LARS ligament was used for a PCL reconstruction. Return to play (RTP) was defined as competing at professional level or national/ international level in amateur sport. Results. Sixty-four (84.2%) MCL reconstructions and 12 (15.8%) PLC reconstructions were included. 52 (68.4%) underwent concomitant autograft cruciate(s) reconstruction including 6 (7.8%) bicruciate reconstructions. The mean age was 25.1 years (SD +/− 4.50). 35 (46.1%) were footballers and 35 (46.1%) were rugby players. Sixty-seven athletes (88.2%) returned to elite sport, 7 (9.2%) did not RTP and RTP status was unknown for 2 (2.6%) (Figure 1). 65 out of 67 (97.0%) RTP at the same/higher Tegner level. 56 (83.6%) and 20 (57.1%) were still playing at 2- and 5-years post-surgery Six (7.9%) players required further surgery due to irritation from the metal fixation implants. One had an inflammation adjacent to the synthetic material at the femoral end and the other cases involved the tibial staples. All six cases were able to RTP. One athlete, following bicruciate /MCL surgery had the LARS removed due to laxity. There was one MCL re-rupture, sustained while jumping, 4 years after returning to football. Conclusions. Utilising LARS in extra-articular knee ligament reconstructions allows 88.2% of athletes with a variety of knee ligament injuries to return to elite sport. The results compare well regarding RTP, complication, and revision rates with the published evidence for other types of MCL and PLC grafts. This, coupled with 57% of athletes still playing 5 years post-surgery suggests the LARS is safe and effective in these cases. For any figures or tables, please contact authors directly

Introduction. In valgus knees, ligament balance remain difficult when implanting a total knee arthroplasty (TKA), this leads some authors to systematically propose the use of constrained devices. Others prefer reserving higher constraints to cases where it is not possible to obtain final satisfactory balance: less than 5 of residual frontal laxity in extension in each compartment, and a tibiofemoral gap difference not in excess to 3mm between flexion and extension. The goal of the study was to assess if is possible to establish preoperative criteria that can predict a constrained design prosthetic implantation at surgery. Materials and Methods. A consecutive series of 93 total knee prostheses, implanted to treat a valgus deformity of more than 5 was retrospectively analysed. Preoperatively, full weight bearing long axis AP views A-P were performed: hip knee angle (HKA) averaged 195 (186 to 226), 36 knees had more than 15 of valgus, and 19 others more than 20 of valgus. Laxity was measured by stress radiographies with a TelosTM system at 100 N. Fifty-two knees had preoperative laxity in the coronal plane of more than 10. Fourteen knees had more than 5 laxity on the convex (medial) side, 21 knees had more than 10 laxity on the concave (lateral) side. Statistical assessment, using univariate analysis, identified the factors that led, at surgery, to an elevated constraint selection level; these factors of independence were tested by multivariate analysis. Logistical regression permitted the classification of the said factors by their odds ratios (OR). Results. High-constraints prostheses (CCK type) were used in 26 out of 93 TKA, the other TKA were regular posterostabilized (PS) prostheses. Statistically, the preoperative factors that led to the choice of a constrained prosthesis were: (1) valgus severity as measured by HKA (PS = (PS = 193, CCK = 198), (2) increased posterior tibial slope (PS = 4.8, CCK = 6.5), (3) low patellar height (using Blackburne and Peel index PS = 0.89, CCK = 0.77), (4) severity of laxity in valgus (PS = 2.3, CCK = 4.3). Among all these factors, the only independent one was laxity in valgus (convex side laxity) (p = 0.0008). OR analysis showed a two-fold increased probability of implanting an elevated constraints prosthesis for each one degree increment of laxity in valgus. Discussion. This study demonstrated that it was not the valgus angle severity but rather the convex medial side laxity that increased the frequency of constrained prostheses implantation. Other factors, as a low patellar height or an elevated posterior tibial slope, when associated, potentiate this possible prosthetic switch (to higher constraints) and should make surgeons aware, in these situations, of encountering difficulties when establishing ligament balance

Conventional computer navigation systems using bone fixation have been validated in measuring anteroposterior (AP) translation of the tibia. Recent developments in non-invasive skin-mounted systems may allow quantification of AP laxity in the out-patient setting. We tested cadaveric lower limbs (n=12) with a commercial image free navigation system using passive trackers secured by bone screws. We then tested a non-invasive fabric-strap system. The lower limb was secured at 10° intervals from 0° to 60° knee flexion and 100N of force applied perpendicular to the tibial tuberosity using a secured dynamometer. Repeatability coefficient was calculated both to reflect precision within each system, and demonstrate agreement between the two systems at each flexion interval. An acceptable repeatability coefficient of ≤3mm was set based on diagnostic criteria for ACL insufficiency when using other mechanical devices to measure AP tibial translation. Precision within the individual invasive and non-invasive systems measuring AP translation of the tibia was acceptable throughout the range of flexion tested (repeatability coefficient ≤1.6 mm). Agreement between the two systems was acceptable when measuring AP laxity between full extension and 40° knee flexion (repeatability coefficient ≤2.1 mm). Beyond 40° of flexion, agreement between the systems was unacceptable (repeatability coefficient >3 mm). These results indicate that from full knee extension to 40° flexion, non-invasive navigation-based quantification of AP tibial translation is as accurate as the standard invasive system, particularly in the clinically and functionally important range of 20° to 30° knee flexion. This could be useful in diagnosis and post-operative follow-up of ACL pathology

Aim. To investigate the biomechanical behaviours of the TL-Hex & Taylor Spatial Frame (TSF) Hexapod external fixators, with comparison to traditional ring-fixator constructs. Methods. Standardised four-ring TL-Hex and TSF constructs, as well as matched ilizarov threaded-rod constructs for each set of components, were tested alone and mounted with an acrylic bone model with simulated fracture gap using fine-wires. Load-deformation properties for each construct and mode of loading were calculated and analysed statistically using ANOVA. Results and Conclusions. Under axial loading the Ilizarov construct utilising TL-Hex components demonstrated greatest rigidity followed by the TL-Hex Ilizarov using TSF components (p<0.01). Under torsional loading both hexapod frames were seen to be significantly more rigid than the Ilizarov (p<0.01), with the TSF demonstrating greater rigidity than the TL-Hex. Under cantilever bending loads the difference in rigidity seen across all constructs was less marked. When loaded with the bone model both hexapods demonstrated reduced axial rigidity as compared to Ilizarov constructs, but without any appreciable difference in translational shear strain. Under cantilever bending the Ilizarov construct using TL-Hex components p<0.01) demonstrated less translational shear strain than the TSF and TSF using Ilizarov components. In conclusion, both hexapod designs were less rigid axially, but more so under bending and torsional loads, than their Ilizarov construct counterparts, producing greater overall planar shear strain, largely due to the observed “toe-in” laxity. Overall, the TL-Hex was seen to be more rigid that the TSF under bending loads although the difference in shear strain at the fracture site was not significantly different

The present study sought to assess the clinical and radiological results and long-term joint impact of different techniques of lateral ankle ligament reconstruction. Material and methods. A multicenter retrospective review was performed on 310 lateral ankle reconstructions, with a mean 13 years’ follow-up (minimum FU of 5 years with a maximum of 30). Male subjects (53%) and sports trauma (78%) predominated. Mean duration of instability was 92 months; mean age at surgery was 28 years. 28% of cases showed subtalar joint involvement. Four classes of surgical technique were distinguished: C1, direct capsulo-ligamentary repair; C2, augmented repair; C3, ligamentoplasty using part of the peroneus brevis tendon; and C4, ligamentoplasty using the whole peroneus brevis tendon. Clinical and functional assessment used Karlsson and Good-Jones-Livingstone scores; radiologic assessment combined centered AP and lateral views, hindfoot weight-bearing Méary views and dynamic views (manual technique, TelosR or self-imposed varus). Results. The majority of results (92%) were satisfactory. The mean Karlsson score of 90 [19–100] (i.e., 87% good and very good results) correlated with the subjective assessment, and did not evolve over time. Postoperative complications (20%), particularly when neurologic, were associated with poorer results. Control X-ray confirmed the very minor progression in osteoarthritis (2 %), with improved stability (88%); there was, however, no correlation between functional result and residual laxity on X-ray. Unstable and painful ankles showed poorer clinical results and more secondary osteoarthritis. Analysis by class of technique found poorer results in C4-type plasties and poorer control of laxity on X-ray in C1-type tension restoration. Discussion. The present series is the largest to be reported with so long a follow-up. We applied the same study criteria as in the present series to each article reviewed in the literature, in order to expose the compared results. The occurence of complex instability is noted. Conclusion. The present results confirm the interest 1) of lateral ankle ligamentoplasty in the management of instability and protection against secondary osteoarthritis, and 2) of precise lesion assessment (CT-scan/MRI) to adapt surgery to the ligamentary and associated lesions

Introduction. Numerous types of graft can be used for revision of anterior cruciate ligament (ACL) reconstruction. The goal of our studies was to analyze mid term outcomes of revision of anterior cruciate ligament reconstructions conducted by means of ipsilateral bone -patellar tendon -bone (B-PT-B) transplant. Materials and methods. We conducted a retrospective study on a consecutive series of 44 patients. All patients were operated on by the same senior surgeon in our institution between 2003 and 2009. All patients had undergone a first ACL reconstruction with B-PT-B transplant. They all had ACL revision under arthroscopic assistance and by means of ipsilateral B-PT-B transplant after a minimum of 18 months after primary surgery. At time of ACL revision, the mean patients age was 28 years (range, 17–49 years). The average postoperative follow up after revision was 55 months (range, 12–88 months). We had no patient lost to follow up. All patients were evaluated by an independent observer using IKDC scoring system and KT 2000. Results. The postoperative IKDC score averaged 78.2 (range, 41,4–97,7). 10 patients (22.7%) had their knee graded A, 25 patients (56.8%) grade B, 8 patients (18.2%) grade C and one patient (2.3%) grade D. The post operative maxi manual differential KT 2000 averaged 1,52 mm (range, −1mm/12mm). The identified aetiologies for poor clinical outcomes were menisectomy in the first ACL reconstruction (p<0.01) and articular cartilage lesions (ICRS grade III and IV) found during ACL revision. In most cases, return to sport activities was achieved but not at the same level. We had no specific complication after second harvesting of the patellar tendon. Discussion. The type of graft used in revision of ACL reconstructions is a controversy. In the literature, many studies reported the results of revision of ACL reconstructions but with poor methodology and few data for every type of graft. In our study, we found clinical results comparable to those classically reported in the literature. Clinical evaluation showed good control of the laxity and no specific patellar tendon complication. Conclusion. The clinical results of revision of ACL reconstructions is lower than in primary surgery. We did not noticed specific patellar tendon complication after second harvesting of BPTB transplant. The revision of ACL reconstruction with ipsilateral BPTB transplant showed good clinical results and good control of the anteroposterior laxity

In rheumatoid arthritis (RA), non constrained or semi-constrained prostheses can be used. The authors used the Kudo III, IV or V or iBP prostheses 54 times from 1994 to 2003. After initial satisfactory results, they had to change one or both implants for several reasons: humeral stem fracture (5 cases), unipolar humeral loosening (1 case), ulnar loosening without laxity (8 cases), polyethylene wear (11 cases), due to progressive ulnar collateral ligament lengthening and progressive valgus deformity, without or with metallosis, due to contact between Cr-Co humeral component and titanium alloy ulnar component, chronic infection (1 case). When the local conditions were satisfactory (bone stock, ligament balance), the fractured or loosened component was changed. When the conditions were bad (poor bone stock, ligament misbalance, metallosis), both implants were removed; posterior humeral and/or medial or lateral ulnar window were used to removed the uncemented stems still osteointegrated. All the bipolar operations used the Coonrad-Morrey prosthesis, but the last case a Discovery prosthesis. The operative tricks are described, the management of the extensor apparatus is discussed, the clinical outcomes (especially the extensor apparatus function, most often weak) and the radiographic outcomes are presented

It appears that double bundle anterior cruciate ligament reconstruction can reproduce the original anatomy of the ligament, restoring normal kinematics and rotational control of the tibia. But an anatomical single bundle reconstruction may present very similar results, with minor technical difficulties and lower costs. We compared two groups of 25 patients each, that underwent ACL reconstruction by the same surgeon, with a follow-up of 12–36 months. One group had double bundle reconstruction with hamstring and the other had single bundle anatomical reconstruction with patellar tendon. Patients underwent a subjective evaluation and clinical testing with instrumented laxity with Rolimeter, and the data entered in the IKDC 2000 scale Double tunnel hamstring Vs bone-tendon-bone: Functional outcome of 85.6% Global Class A and B vs. 82.1% Class A and B. The subjective outcome (IKDC 2000) was 90.93 vs. 91.47. Pivot-shift test with 87% patients in class A and class B at 9.7% Vs 75% patients in class A, 21.4% for class B. The Rolimeter gave an average Lachman value of 2,56 and anterior drawer test of 2,88 Vs average Lachman value of 3.59 and anterior drawer test of 2.92. One leg hop test showed 85.7% knees class A, 9.5% knees class B vs. 90.4% knees class A and, 2.8% knees class B. The subjective score was slightly higher in the single bundle anatomical reconstruction with patellar tendon, despite the overall functional outcome being higher in the double tunnel technique with hamstrings. The average Lachmann in the patellar tendon group was 1 mm higher. The rotational stability in the double tunnel was higher. The same surgeon had better results in the double tunnel hamstrings technique, despite less experienced with this technique, which is more demanding, probably reflecting objective advantages over the single bundle reconstruction with patellar tendon

INTRODUCTION. Analysis of retrieved ceramic components have shown areas of localized ‘stripe wear’, which have been attributed to joint laxity and/or impingement resulting in subluxation of the head, causing wear on the edge of the cup. Studies have been conducted into the effects of mild subluxation, however few in vitro tests have looked at severe subluxation. The aim of this study was to develop a more clinically relevant subluxation protocol. MATERIALS & METHODS. Seven (Subluxation n=4; standard test n=3) of 36mm Biolox Forte (R3, Smith & Nephew) ceramic devices were tested for 0.5m cycles (mc). Two of the subluxed joints were further tested to 1 Mc. The devices were subjected to subluxation under standard testing conditions. The flex/ext was 30° and 15° respectively, with internal/external rotation of ±10°. The force was Paul type stance phase loading with a maximum load of 3 kN, and a standard ISO swing phase load of 0.3 kN at 1 Hz. The test was conducted on a ProSim hip joint wear simulator (SimSol, UK). The simulator is equipped with a novel mechanism to achieve translation of the head, to achieve subluxation. During the ISO swing phase load of 0.3kN, a controlled lateral force required for the translation of the head is applied by a cam mechanism, head retraction then occurs during heel strike. The lubricant used was new born calf serum diluted with de-ionised water to achieve average protein concentration of 20 g/l, with 0.2 wt % concentration NaN3, and changed every 250k cycles. Measurements have been taken at 0.5 & 1 mc stages. RESULTS. Linear wear measurements conducted on the subluxed joints resulted in stripe wear similar to that reported in vivo. Average length, width and depth dimensions were 25.34±1.96 mm, 8±1.60 mm and 16.95±3.87 μm (± 95% CL) respectively. Linear wear at 0.5 Mc for standard joints, were undistinguishable from the original profile. Gravimetrically, weight loss was undetectable for joints tested under standard conditions. The volume loss of the joints under subluxation was 1.9± 0.7 mm3 at 0.5 mc. Two joints tested to 1mc generated an average volume loss of 3.1±2.3 mm3. The stripe wear length, width and depth at 1 Mc were 25.30±3.33mm, 8±3.92mm and 35±17.07 μm respectiveley. DISCUSSION. The current study presents test results of a hip joint simulator with a novel subluxation mechanism to simulate severe and clinically relevant hip joint. Past techniques have had to reduce the swing phase load to achieve stripe wear patches of varying size and depth. The subluxed joints produced significantly higher volumetric wear than the standard joints. Dimensional measurements in terms of length, width and depth of wear patches of subluxed joints generated similar results to that which have been observed following retrieval analysis. Tests that can simulate different types of activity in hip joint simulators will help to improve the design and understanding of implant behaviour in vivo

We have compared the results at a mean follow-up of 13 years (11 to 14) of two groups of supination-external rotation type-4 fractures of the ankle, in one of which there was a fracture of the medial malleolus and in the other the medial deltoid ligament had been partially or completely ruptured.

Of 66 patients treated operatively between 1993 and 1997, 36 were available for follow-up. Arthroscopy had been performed in all patients pre-operatively to assess the extent of the intra-articular lesions. The American Orthopaedic Foot and Ankle Society hind-foot score was used for clinical evaluation and showed a significant difference in both the total and the functional scores (p < 0.05), but not in those for pain or alignment, in favour of the group with a damaged deltoid ligament (p < 0.05). The only significant difference between the groups on the short-form 36 quality-of-life score was for bodily pain, again in favour of the group with a damaged deltoid ligament. There was no significant difference between the groups in the subjective visual analogue scores or in the modified Kannus radiological score.

Arthroscopically, there was a significant difference with an increased risk of loose bodies in the group with an intact deltoid ligament (p < 0.005), although there was no significant increased risk of deep cartilage lesions in the two groups.

At a mean follow-up of 13 years after operative treatment of a supination-external rotation type-4 ankle fracture patients with partial or complete rupture of the medial deltoid ligament tended to have a better result than those with a medial malleolar fracture.

We used an inverted shoulder arthroplasty in 43 consecutive patients with a mean age of 78 years (65 to 97) who had sustained a three- or four-part fracture of the upper humerus. All except two were reviewed with a mean follow-up of 22 months (6 to 58).

The clinical outcome was satisfactory with a mean active anterior elevation of 97° (35° to 160°) and a mean active external rotation in abduction of 30° (0° to 80°). The mean Constant and the mean modified Constant scores were respectively 44 (16 to 69) and 66% (25% to 97%). Complications included three patients with reflex sympathetic dystrophy, five with neurological complications, most of which resolved, and one with an anterior dislocation. Radiography showed peri-prosthetic calcification in 36 patients (90%), displacement of the tuberosities in 19 (53%) and a scapular notch in ten (25%). Compared with conventional hemiarthroplasty, satisfactory mobility was obtained despite frequent migration of the tuberosities. However, long-term results are required before reverse shoulder arthroplasty can be recommended as a routine procedure in complex fractures of the upper humerus in the elderly.