Aims

The diagnosis of joint infections is an inexact science using combinations of blood inflammatory markers and microscopy, culture, and sensitivity of synovial fluid (SF). There is potential for small molecule metabolites in infected SF to act as infection markers that could improve accuracy and speed of detection. The objective of this study was to use nuclear magnetic resonance (NMR) spectroscopy to identify small molecule differences between infected and noninfected human SF.

Aims

Metabolic profiling is a top-down method of analysis looking at metabolites, which are the intermediate or end products of various cellular pathways. Our primary objective was to perform a systematic review of the published literature to identify metabolites in human synovial fluid (HSF), which have been categorized by metabolic profiling techniques. A secondary objective was to identify any metabolites that may represent potential biomarkers of orthopaedic disease processes.

Objectives

The objective of this study was to perform a meta-analysis of all randomised controlled trials (RCTs) comparing surgical and non-surgical management of fractures of the proximal humerus, and to determine whether further analyses based on complexity of fracture, or the type of surgical intervention, produced disparate findings on patient outcomes.

Aims

The aims of this study were to estimate the cost of surgical treatment of fractures of the proximal humerus using a micro-costing methodology, contrast this cost with the national reimbursement tariff and establish the major determinants of cost.

There have been differing descriptions of the anterolateral structures of the knee, and not all have been named or described clearly. The aim of this study was to provide a clear anatomical interpretation of these structures. We dissected 40 fresh-frozen cadaveric knees to view the relevant anatomy and identified a consistent structure in 33 knees (83%); we termed this the anterolateral ligament of the knee. This structure passes antero-distally from an attachment proximal and posterior to the lateral femoral epicondyle to the margin of the lateral tibial plateau, approximately midway between Gerdy’s tubercle and the head of the fibula. The ligament is superficial to the lateral (fibular) collateral ligament proximally, from which it is distinct, and separate from the capsule of the knee. In the eight knees in which it was measured, we observed that the ligament was isometric from 0° to 60° of flexion of the knee, then slackened when the knee flexed further to 90° and was lengthened by imposing tibial internal rotation.

Cite this article: Bone Joint J 2014;96-B:325–31.

Recent reports have suggested an increase in the number of anterior cruciate ligament (ACL) injuries in children, although their true incidence is unknown.

The prognosis of the ACL-deficient knee in young active individuals is poor because of secondary meniscal tears, persistent instability and early-onset osteoarthritis. The aim of surgical reconstruction is to provide stability while avoiding physeal injury. Techniques of reconstruction include transphyseal, extraphyseal or partial physeal sparing procedures.

In this paper we review the management of ACL tears in skeletally immature patients.

Cite this article: Bone Joint J 2013;95-B:1562–9.

This annotation considers the place of extra-articular reconstruction in the treatment of anterior cruciate ligament (ACL) deficiency. Extra-articular reconstruction has been employed over the last century to address ACL deficiency. However, the technique has not gained favour, primarily due to residual instability and the subsequent development of degenerative changes in the lateral compartment of the knee. Thus intra-articular reconstruction has become the technique of choice. However, intra-articular reconstruction does not restore normal knee kinematics. Some authors have recommended extra-articular reconstruction in conjunction with an intra-articular technique.

The anatomy and biomechanics of the anterolateral structures of the knee remain largely undetermined. Further studies to establish the structure and function of the anterolateral structures may lead to more anatomical extra-articular reconstruction techniques that supplement intra-articular reconstruction. This might reduce residual pivot shift after an intra-articular reconstruction and thus improve the post-operative kinematics of the knee.

We describe a case of septic arthritis of the knee in which the diagnosis of tuberculosis was masked by an initial culture growth of Staphylococcus aureus. This led to a delay in diagnosis and an adverse outcome. In the appropriate clinical setting, we suggest that the index of suspicion for skeletal tuberculosis be raised in developed countries in order to avoid diagnostic delay, by requesting cultures for acid-fast bacilli and synovial biopsies at arthroscopy. Moreover, antituberculosis therapy should be started whilst awaiting the results of culture if the clinical history and biopsies are strongly suggestive of the diagnosis.

We have tested the hypothesis that the meniscofemoral ligaments make a significant contribution to resisting anteroposterior and rotatory laxity of the posterior-cruciate-ligament-deficient knee. Eight cadaver human knees were tested for anteroposterior and rotatory laxity in a materials-testing machine. The posterior cruciate ligament (PCL) was then divided, followed by division of the meniscofemoral ligaments (MFLs). Laxity results were obtained for intact, PCL-deficient, and PCL-MFL-deficient knees.

Division of the MFLs in the PCL-deficient knee increased posterior laxity between 15° and 90° of flexion. Force-displacement measurements showed that the MFLs contributed 28% to the total force resisting posterior drawer at 90° of flexion in the intact knee, and 70.1% in the PCL-deficient knee. There was no effect on rotatory laxity.

This is the first study which shows a function for the MFLs as secondary restraints to posterior tibial translation. The integrity of these structures should be assessed during both imaging and arthroscopic studies of PCL-injured knees since this may affect the diagnosis and management of such injuries.

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-Amis¹ 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 mm² (±14.8mm²) whilst that of the posterior MFL (pMFL) was 20.9mm² (±11.6mm²). 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 authors² 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. Others³ 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.

Aim: To accurately identify the meniscofemoral ligaments in cadaveric human specimens, and to determine anatomical variations in the posterior cruciate ligament that may lead to mis-identification of these structures.

Methods: A total of 79 fresh frozen knees were examined from 45 cadavers Combined anterior and posterior approaches were used to inspect the vicinity of the posterior cruciate ligament (PCL) for the presence of the anterior and posterior meniscofemoral ligaments. The anterior approach utilised a medial parapatellar incision followed by division of the anterior cruciate ligament, whilst a midline posterior arthrotomy was used for the posterior approach. Further dissection facilitated inspection of the meniscal and femoral attachments of the MFLs, and measurement of their lengths. Videos of MFL and PCL motion during passive flexion of the cadaveric were also performed.

Results: In total, 74 (94%) of the 79 specimens contained at least one meniscofemoral ligament. The posterior meniscofemoral ligament (pMFL) was present in 56 (71%) specimens, whilst the anterior meniscofemoral ligament (aMFL) was present in 58 specimens (73%). Both ligaments coexisted in 40 (51%) of knees. In 15 specimens the PCL was seen to have oblique fibres, which attached proximal to the tibial attachment of the main part of the PCL. We termed this “the false pMFL”, as it could be easily mis-identified as the posterior meniscofemoral ligament. Several other anatomical variations were also identified. The mean length of the aMFL was 20.7±3.9mm, whilst that of the pMFL was 23±4.2mm. Although the lengths of the MFLs were relatively constant, there was a wide variation in thickness.

Discussion: This study confirms the high incidence of at least one MFL in humans, which suggests a functional role for these structures. The oblique fibres of the PCL can be readily mis-identfied as the pMFL. These caveats should be borne in mind, during both arthroscopic examination and in the interpretation of magnetic resonance imaging (MRI) scans of the knee. Although some variations of the MFLs have been reported on MRI imaging2, there has been no note of the oblique fibres of the PCL reported in the present study. As this variation was present in almost one in five of our specimens, its appearance on MRI scanning requires investigation.

The function of the meniscofemoral ligaments is undetermined, although many hypotheses comment on a role in guiding the motion of the lateral meniscus during knee flexion. Other possibilities include a function as a secondary restraint supplementing the posterior cruciate ligament.

The meniscofemoral ligaments were studied in 84 fresh-frozen knees from 49 cadavers. Combined anterior and posterior approaches were used to identify the ligaments. In total, 78 specimens (93%) contained at least one meniscofemoral ligament. The anterior meniscofemoral ligament (aMFL) was present in 62 specimens (74%), and the posterior meniscofemoral ligament (pMFL) in 58 (69%). The 42 specimens (50%) in which both ligaments were present were from a significantly younger population than that with one MFL or none (p < 0.05). Several anatomical variations were identified, including oblique fibres of the posterior cruciate ligament (PCL), which were seen in 16 specimens (19%). These were termed the ‘false pMFL’.

The high incidence of MFLs and their anatomical variations should be borne in mind during arthroscopic and radiological examination of the PCL. It is important to recognise the oblique fibres of the PCL on MRI in order to avoid wrongly identifying them as either a pMFL or a tear of the lateral meniscus. The increased incidence of MFLs in younger donors suggests that they degenerate with age.