Surgical restabilization reduces the progression of post-traumatic osteoarthritis initiated by ACL rupture in mice.

OBJECTIVE: People who sustain joint injuries such as anterior cruciate ligament (ACL) rupture often develop post-traumatic osteoarthritis (PTOA). In human patients, ACL injuries are often treated with ACL reconstruction. However, it is still unclear how effective joint restabilization is for reducing the progression of PTOA. The goal of this study was to determine how surgical restabilization of a mouse knee joint following non-invasive ACL injury affects PTOA progression. DESIGN: In this study, 187 mice were subjected to non-invasive ACL injury or no injury. After injury, mice underwent restabilization surgery, sham surgery, or no surgery. Mice were then euthanized on day 14 or day 49 after injury/surgery. Functional analyses were performed at multiple time points to assess voluntary movement, gait, and pain. Knees were analyzed ex vivo with micro-computed tomography, RT-PCR, and whole-joint histology to assess articular cartilage degeneration, synovitis, and osteophyte formation. RESULTS: Both ACL injury and surgery resulted in loss of epiphyseal trabecular bone (-27-32%) and reduced voluntary movement at early time points. Joint restabilization successfully lowered OA score (-78% relative to injured at day 14, p < 0.0001), and synovitis scores (-37% relative to injured at day 14, p = 0.042), and diminished the formation of chondrophytes/osteophytes (-97% relative to injured at day 14, p < 0.001, -78% at day 49, p < 0.001). CONCLUSIONS: This study confirmed that surgical knee restabilization was effective at reducing articular cartilage degeneration and diminishing chondrophyte/osteophyte formation after ACL injury in mice, suggesting that these processes are largely driven by joint instability in this mouse model. However, restabilization was not able to mitigate the early inflammatory response and the loss of epiphyseal trabecular bone, indicating that these processes are independent of joint instability.

Semiquantitative index of symptomatic minor instability of the lateral elbow at CT arthrography (SMILE index): clinical applicability and reproducibility study.

OBJECTIVE: To assess the applicability of a semiquantitative index for symptomatic minor instability of the lateral elbow (SMILE). MATERIALS AND METHODS: CT arthrograms of consecutive patients with lateral elbow pain who underwent ultrasound-guided CT arthrography at our orthopedic center between April 2019 and May 2022 were included. Images were acquired at 100 kVp and 80 mAs. An expert radiologist (R1) and a radiology resident (R2) retrospectively performed an independent, blinded evaluation of the arthrograms to assess the presence of imaging findings suggestive of elbow instability. The SMILE index (0-8) was obtained adding (I) radial head chondromalacia (0 - 1); (II) humeral capitellum chondromalacia (0 - 1); (III) humeral trochlear ridge chondromalacia (0 - 1); (IV) annular ligament laxity (0 - 2); (V) synovial thickening (0 - 1); (VI) humeroradial joint asymmetry (0 - 1); and (VII) capsular tear (0 - 1). R1 repeated the assessment after 14 days. Cohen's weighted κ statistic and raw concordance were used to appraise reproducibility. RESULTS: Eighty patients (median age 49 years, interquartile range 40-53 years, 49, 61% males) underwent CT arthrography at our center, and 10 (12%) of them underwent bilateral elbow examination, leading to 90 included CT arthrograms. Median SMILE index was 4 (IQR: 2-5) for R1, 4 (IQR: 2-5) for R2, and 4 (IQR: 2-5) for the second assessment by R1. Intra-reader agreement was excellent (κ = 0.94, concordance 87%), while inter-reader agreement was substantial (κ = 0.75, concordance 67%). CONCLUSION: The proposed SMILE index showed good reproducibility; further studies are warranted to correlate our index with clinical and surgical data. CLINICAL RELEVANCE STATEMENT: Our scoring system allows a standardized evaluation of patients with lateral elbow pain and instability suitable for application into clinical practice, complementing the orthopedic surgeon's clinical diagnosis with imaging findings that may aid treatment choices. KEY POINTS: • Lateral elbow pain is often interpreted clinically as lateral epicondylitis, but it can also encompass intra-articular pathology. • The proposed arthrographic index allows comprehensive quantification of lateral elbow pathology with good reproducibility and application times. • Our index provides the orthopedic surgeon with information regarding intra-articular findings, aiding treatment choices.

The need for primary care providers in the clinical management of hypermobility spectrum disorders and ehlers-danlos syndrome: a call to action.

Patients with joint-hypermobility and joint-hypermobility spectrum disorders (HSD), including hypermobile Ehlers-Danlos Syndromes (EDS) present numerous co-morbid concerns, and multidisciplinary care has been recommended. The complexity of these patient's needs and increased demand for medical services have resulted in long delays for diagnosis and treatment and exhausted extant clinical resources. Strategies must be considered to ensure patient needs are met in a timely fashion. This opinion piece discusses several potential models of care for joint-hypermobility disorders, several ways in which primary providers can be involved, and argues that primary providers should be an essential and integrated part of the management of these patients, in collaboration with multidisciplinary teams and pediatric subspecialists. We review several strategies and educational opportunities that may better incorporate primary providers into the care and management of these patients, and we also discuss some of the limitations and barriers that need to be addressed to improve provision of care. This includes establishing primary care physicians as the medical home, providing initial diagnostic and treatment referrals while connecting patients with specialty care, and collaboration and coordination with multi-disciplinary teams for more complex needs. Several barriers exist that may hamper these efforts, including a lack of available specialty trainings for providers interested in providing care to patients with EDS and HSD, a lack of expertly derived consensus guidelines, and limited time resources in extant primary care practices. Also, primary providers should have an active voice in the future for the further consideration and development of these presented strategies.

Posterolateral dislocation and incarceration of the long head of the biceps tendon: a rare cause of irreducible anterior glenohumeral joint dislocation-a case report and brief review of the literature.

Failure of closed reduction of anterior glenohumeral joint dislocation is infrequent. It can be secondary to osseous (e.g., fracture fragments or Hill-Sachs lesion) or soft tissue (e.g., labrum or rotator cuff tendon) impediments. Herein, we present a case of a prolonged irreducible glenohumeral joint secondary to a posterolaterally dislocated and incarcerated long head of the biceps tendon after an episode of anterior instability, highlight the utility of MR imaging for guiding management, and review the literature of this sporadic diagnosis.

Imaging evaluation of hip capsule disorders: a comprehensive review.

The hip capsule and capsular ligaments play crucial roles in providing hip stability and mobility. Their role in hip pathologies is being increasingly recognized, underscoring the need for thorough imaging evaluation, which is better performed through MRI-arthrography. Various diseases affect the hip capsule directly or indirectly. Improper mechanical loading, as seen in conditions such as femoroacetabular impingement or chondrolabral pathology, can induce capsule thickening, whereas thinning and laxity of the capsule are characteristics of microinstability. Inflammatory conditions, including adhesive capsulitis of the hip, crystal deposition disease, polymyalgia rheumatica, and infections, also lead to capsular changes. Traumatic events, particularly posterior hip dislocations, cause capsule ligament disruption and may lead to hip macroinstability. Friction syndromes can lead to capsular edema due to impingement of the adjacent capsule. Hip arthroscopy can result in various postoperative findings ranging from fibrotic adhesions to focal or extensive capsule discontinuation. Although the significance of hip capsule thickness and morphology in the pathogenesis of hip diseases remains unclear, radiologists must recognize capsule alterations on imaging evaluation. These insights can aid clinicians in accurately diagnosing and effectively managing patients with hip conditions.

Anterior talofibular ligament's superior fascicle as a cause of ankle microinstability can be routinely identified by ultrasound.

PURPOSE: Chronic pain can affect up to 40% of patients after ankle inversion sprains. The current hypothesis to explain this high percentage of chronic pain is a partial/total rupture of anterior talofibular ligament (ATFL) superior fascicle, a structure that has recently been described as intra-articular and as having a different function than ATFL's inferior fascicle. This has created the need for diagnosing ATFL superior and inferior fascicles independently. Therefore, the objective of this study is to investigate if the ATFL's superior fascicle can be visualized on ultrasound, and to describe its ultrasonographic appearance. METHODS: Twenty fresh-frozen ankle specimens were used in this 4-phases study. First, the specimens were scanned on US to identify what was believed to be ATFL's superior fascicle. Second, ATFL's superior fascicle was sutured under direct arthroscopic vision. Next, the specimens were scanned on US to obtain an image of the sutured structure. Finally, the specimens were dissected to confirm that the suture was indeed placed on ATFL's superior fascicle. RESULTS: On the 20 specimens studied, full correlation was obtained between US, arthroscopic suture and specimen dissection. ATFL's superior fascicle US appearance is provided. CONCLUSION: ATFL's superior fascicle can be visualized on US, which will allow to undergo diagnosis of isolated injuries to that fascicle, a common finding in ankle microinstability. The results of this study will facilitate the diagnosis of partial or complete rupture of ATFL's superior fascicle, likely increasing the amount of ankle microinstability diagnosis, impacting clinical management of ankle sprain consequences.

10-Year Cumulative Incidence and Indications for Revision Total Joint Arthroplasty for Patients Who Have Ehlers-Danlos Syndrome.

BACKGROUND: Long-term complications following total joint arthroplasty are not well established for patients who have Ehlers-Danlos syndrome (EDS), a group of connective tissue disorders. This study compared 10-year incidence of revision surgery after total hip arthroplasty (THA) and total knee arthroplasty (TKA) in patients who have and do not have EDS. METHODS: A retrospective cohort analysis was conducted using a national all-payer claims database from 2010 to 2021 to identify patients who underwent primary TKA or THA. Patients who had and did not have EDS were propensity score-matched by age, sex, and a comorbidity index. Kaplan-Meier analyses and Cox proportional hazard models were used to determine the cumulative incidence and risks of revision experienced by patients who have and do not have EDS. RESULTS: The EDS patients who underwent TKA had a higher risk of all-cause revision (hazard ratio [HR]: 1.50, 95% confidence interval [95% CI]: 1.09 to 2.07, P < .014) and risk of revision due to instability (HR = 2.49, 95% CI: 1.37 to 4.52, P < .003). The EDS patients who underwent THA had a higher risk of all-cause revision (HR = 2.32, 95% CI: 1.47 to 3.65, P < .001), revision due to instability (HR = 4.26, 95% CI: 2.17 to 8.36, P < .001), and mechanical loosening (HR = 3.63, 95% CI: 2.05 to 6.44, P < .001). CONCLUSIONS: Patients who had EDS were found to have a higher incidence of revision within 10 years of undergoing TKA and THA compared to matched controls, especially for instability. Patients who have EDS should be counseled accordingly. Surgical technique and implant selection should include consideration for increased constraint in TKA and larger femoral heads or dual mobility articulations for THA.

Analyzing the reduction quality of the distal radioulnar joint after closed K-wire transfixation in a cadaver model: is supination or neutral position superior?

INTRODUCTION: Distal radioulnar joint (DRUJ) instabilities are challenging and their optimal treatment is controversial. In special cases or when reconstruction of the stabilizing triangular fibrocartilage complex (TFCC) fails, K-wire transfixation can be performed. However, no consensus has been reached regarding the rotational position of the forearm in which this should be done. Therefore, it was investigated whether anatomical reduction would best be achieved by transfixation in neutral position or supination of the forearm. MATERIALS AND METHODS: Twelve cadaveric upper limbs were examined before dissection of the DRUJ stabilizing ligaments and after closed transfixation in both positions by C-arm cone-beam CT. Whether this was first done in neutral position or in supination was randomized. The change in the radioulnar ratio (RR) in percentage points (%points) was analyzed using Student's t-test. RR was used since it is a common and sensitive method to evaluate DRUJ reduction, expressing the ulnar head's position in the sigmoid notch as a length ratio. RESULTS: The analysis showed an increased change in RR in neutral position with 5.4 ± 9.7%points compared to fixation in supination with 0.2 ± 16.1%points, yet this was not statistically significant (p = 0.404). CONCLUSIONS: Neither position leads to a superior reduction in general. However, the result was slightly closer to the anatomical position in supination. Thus, transfixation of the DRUJ should be performed in the position in which reduction could best be achieved and based on these data, that tends to be in supination. Further studies are necessary to validate these findings and to identify influential factors.

Weight-bearing test of traumatic triangular fibrocartilage complex lesion with unstable radioulnar joint.

BACKGROUND: Ulnar-sided wrist pain might be caused by a lesion of the triangular fibrocartilage complex (TFCC). Patients with TFCC lesion may show an instability of the distal radioulnar joint (DRUJ). Before arthroscopic assessment, conservative therapy using a brace or splint may result in alleviation of symptoms. The results of our previous study showed that patients with a traumatic TFCC lesion and instability of the DRUJ had the smallest weight-bearing capacity and had the largest increase in application of the wrist brace (WristWidget). PURPOSE: In this prospective study, we wanted to test if the weight-bearing capacity with and without the wrist brace can be used as a diagnostic tool to differentiate between patients with traumatic TFCC lesion and instability of the DRUJ. We tested if patients with traumatic TFCC lesion and instability of the DRUJ (1) have a lower weight-bearing capacity and (2) show a higher increase of weight-bearing capacity after application of a wrist brace compared to all other types of injury. STUDY DESIGN: This was a prospective cohort study. METHODS: Forty-eight patients presented to an outpatient clinic with suspected TFCC lesion. We measured the dynamic weight-bearing capacity of both hands with and without the wrist brace (WristWidget) by letting the patients lean on an analog scale with extended arm and wrist. The stability of the DRUJ was assessed by clinical examination by a hand surgeon preoperatively and intraoperatively. Forty-five patients received an arthroscopy and were included in the analysis. During arthroscopy, the surgeon determined if there was a traumatic TFCC lesion and DRUJ instability. Patients with a traumatic lesion of the TFCC and DRUJ instability were compared to all other cases. We used the t-test for normally distributed values, Mann-Whitney U test for nonnormally distributed values, and the Chi-square test for categorical variables, respectively Fisher's exact if the expected cell count was less than five. RESULTS: Patients with a traumatic TFCC lesion and DRUJ instability had a higher weight-bearing capacity (22.8 kg) than all other cases (13.8 kg; p < 0.01). This is in contrast to our previous study, in which patients with a traumatic lesion of the TFCC had the tendency to show lower values of weight-bearing capacity than those with a degenerative lesion. While the wrist brace was worn, the relative gain was not significantly lower in patients with traumatic TFCC lesions and DRUJ instability compared to all other cases (21% vs 54%, p = 0.16). All included cases showed the same absolute increase of about 4 kg in weight-bearing capacity with the wrist brace (p = 0.93) CONCLUSIONS: The weight-bearing test cannot be used to identify patients with traumatic TFCC lesion and DRUJ instability among those with suspected TFCC lesion. The results of our previous study could be confirmed that the weight-bearing capacity on the injured side was higher with brace than without.

Evaluation of the Healing Status of Lateral Ankle Ligaments 6 Weeks After an Acute Ankle Sprain.

We aimed to investigate whether there is clinical and MRI evidence of healing of lateral ligaments 6 weeks after acute lateral ankle sprain (LAS). We prospectively enrolled 18 participants (age 32.7 ± 7.5 years) who sustained an acute LAS and underwent conservative treatment. An ankle MRI was acquired up to 48 hours and 6 weeks following the LAS. A partial tear of the anterior talofibular ligament (ATFL) was observed in 10/18 and a complete tear in 8/18 of the patients. The calcaneofibular ligament (CFL) was partially torn in 11/18 and completely torn in 1/18 of the patients. The healing status, intensity, and thickness of the ligaments, Anterior Drawer Test (ADT), and FAOS scale were assessed. A control group (CG) was composed by 17 participants (age 40 ± 13.9 years). Six weeks after the LAS, 89% of the participants presented MRI evidence of ATFL healing. The repaired ATFL was thicker in comparison with the CG (p < .001). The cut-off of 2.5 mm for ATFL thickness in the 6th week maximized sensitivity (62.5%) and specificity (100%). CFL and PTFL presented 94% and 100% of healing signs, respectively. In the 6th week, 11/18 (61%) participants showed mild residual instability and a mean FAOS of 80 ± 11. The MRI revealed signs of the repair process in 89% of ATFL and 94% of CFL tears, 6 weeks after a moderate or severe LAS. The MRI findings were concomitant with enhancements in mechanical ankle stability and function.

Displaced sigmoid notch fracture and higher patient age are associated with distal radioulnar joint subluxation.

Background/aim: Distal radius fractures (DRFs) are frequently associated with distal radioulnar joint (DRUJ) instability. The purpose of this study is to evaluate the effect of the sigmoid notch and ulna styloid fracture types on DRUJ subluxation following closed reduction and casting of DRFs via calculating radioulnar ratio (RUR) on postreduction computed tomography (CT) images. Materials and methods: In our study, postreduction CT images of 202 patients with distal radius fractures were evaluated retrospectively. CT images were evaluated for RUR, sigmoid notch fracture, and ulna styloid types. Sigmoid notch fractures were classified as nondisplaced in the sigmoid notch fractures (NDS) and displaced sigmoid notch (DS) fractures; ulna styloid fractures were grouped as the proximal half ulna styloid (PHUS) and distal half ulna styloid (DHUS) fractures. Results: The mean age of Rozental type 3b (62.8 years) was significantly higher among others. The mean RUR value was significantly higher in Rozental type 3a in compared to type 1a and type 2 fractures. PHUS fractures were more common with DS fractures than DHUS fractures. Conclusion: DS fractures and higher patient age are associated with DRUJ subluxation on postreduction CT images following DRFs. DS fractures are seen more commonly with PHUS fractures than DHUS. Patients with PHUS should be carefully assessed for sigmoid notch fractures and DRUJ congruency. These findings could be helpful for preoperative decision making in the treatment of DRFs.

Midterm outcomes of the modified Lapidus arthrodesis using the Phantom® Intramedullary Nail System for the treatment of hallux valgus.

BACKGROUND: Lapidus arthrodesis is one of the most commonly used techniques in the correction of moderate and severe hallux valgus. We analyzed the clinical and radiological outcomes after using the Phantom® Lapidus intramedullary nail to find an effective technique with low complications. METHODS: We retrospectively analyzed data of 52 patients who underwent a modified Lapidus arthrodesis with an intramedullary nail at our center from November 2019 to September 2022. The mean follow-up period was 27 (range, 18-34) months. Clinical results were evaluated using the visual analog scale (VAS), the European Foot and Ankle Society score (EFAS) and the American Orthopaedic Foot and Ankle Society score (AOFAS); three different radiological measures were analyzed. RESULTS: The mean AOFAS score increased from 44.8 to 82 points. The mean EFAS score increased from 11.2 to 20.1 points. The mean VAS score decreased by 4.7 points. The mean EFAS Sport score was increased from 9.2 (SD 4.6) to 12.6 (SD 5.4) points. The intermetatarsal angle decreased from 15° to 6.9° and the hallux valgus angle by a mean of 17.9°. The forefoot width reduced from 93.6 to 84.7 mm. All results were statistically significant (p < .001). One case of nonunion was recorded. No implant-related complications were observed. CONCLUSIONS: This device was effective in correcting moderate to severe hallux valgus, with significant patient satisfaction. Its complication rate was not higher than that of other fixation devices. Correct compression of the arthrodesis, absence of extraosseous material, and multidirectional stability are important qualities of this implant for the correct treatment of this pathology. LEVEL OF EVIDENCE: Level IV, retrospective case series.

Reverse shoulder arthroplasty with a 155° neck-shaft angle inlay implant design without reattachment of the subscapularis tendon results in satisfactory functional internal rotation and no instability: a cohort study.

BACKGROUND: The aim of this study was to use the Activities of Daily Living which require Internal Rotation (ADLIR) questionnaire to assess the functional internal rotation in patients who had undergone reverse shoulder arthroplasty (RSA) without reattachment of the subscapularis (SSc) tendon at a minimum follow-up of 2 years. The secondary aim was to report the objective range of motion (ROM) and the rate of postoperative instability. MATERIALS AND METHODS: All consecutive primary RSA procedures without reattachment of the SSc tendon that were performed using a Delta Xtend prosthesis (an inlay system with a 155° neck-shaft angle) between January 2015 and December 2020 were identified to ensure a minimum follow-up of 2 years. Patients were contacted and requested to fill in several questionnaires, including the ADLIR and Auto-Constant scores. RESULTS: In total, 210 patients met the inclusion criteria; among those patients, 187 could be contacted and 151 completed questionnaires (response rate: 81%). The SSc tendon was fully detached without repair in all cases, and a superolateral approach was used in 130 (86%) cases. The median follow-up was 4.5 years (range: 2.0-7.6). At final follow-up, the mean ADLIR score was 88/100 (interquartile range (IQR): 81-96). The median level reached in internal rotation was the 3rd lumbar vertebra (IQR: lumbosacral region-12th thoracic vertebra). Of the 210 eligible patients, one required a revision for a dislocation within the first month after primary surgery. With regards to regression analysis with ADLIR score as the outcome, none of the factors were associated with the ADLIR score, although age and smoking approached significance (0.0677 and 0.0594, respectively). None of the explanatory variables were associated with ROM in internal rotation (p > 0.05). CONCLUSIONS: This study demonstrates that satisfactory ADLIR scores and internal rotation ROM were obtained at mid-term follow-up after RSA leaving the SSc detached. Leaving the SSc detached also did not lead to high instability rates; only one out of 210 prostheses was revised for dislocation within the first month after primary surgery.

Anterolateral ligament MRI of the knee in ACL injuries: MRI abnormalities association with instability.

OBJECTIVE: To evaluate anterolateral ligament abnormalities (ALL) at MRI scans and correlate with data from clinical instability tests (Lachman and pivot shift) performed under anesthesia in patients with acute anterior cruciate ligament (ACL) tears. Furthermore, perform multivariate analysis with other variables to isolate the ALL contribution to instability from other abnormalities. METHODS: Retrospective analysis of MRI and instability tests of 95 patients with ACL tears. The ALL was classified as no abnormality, abnormality without discontinuity, and discontinuity. Injuries in other knee ligament structures and menisci were also assessed. Results of instability tests (pivot shift and Lachman) with the patient anesthetized for arthroscopic ACL reconstruction were obtained from the patient database. Statistical analysis was performed using the IBM SPSS 22. RESULTS: ALL abnormalities and iliotibial band (ITB), lateral (LCL), and medial (MCL) collateral ligament injuries showed a statistically significant correlation with the pivot shift test. The ALL MRI abnormalities were associated with the high-grade pivot shift results (p < 0.0005), with an odds ratio of 55.9 for high degrees of pivot shift in patients with abnormal ALL. The logistic model for all variables analyzed with the results of the pivot shift test demonstrated that the ALL was the only variable with a statistically significant correlation in the model (p < 0.0005). CONCLUSION: MRI ALL abnormalities in patients with ACL injuries have a significant association with pivot shift test results in patients under anesthesia. The logistic model for high - grade pivot shift test results demonstrated that ALL abnormalities were the only variable with significant correlation. KEY POINTS: • Evaluating the anterolateral ligament with MRI in acute anterior cruciate ligament injuries is useful to predict higher grades of pivot shift test in the moment of the arthroscopic reconstruction. • An abnormal anterolateral ligament presented an odds ratio of 55 for high degrees of pivot shift. • ALL MRI abnormalities association with knee instability is independent from other internal knee injuries.

Radiological assessment and surgical management of cervical spine involvement in patients with rheumatoid arthritis.

The purpose of the present systematic review was to describe the diagnostic evaluation of rheumatoid arthritis in the cervical spine to provide a better understanding of the indications and options of surgical intervention. We performed a literature review of Pub-med, Embase, and Scopus database. Upon implementing specific inclusion and exclusion criteria, all eligible articles were identified. A total of 1878 patients with Rheumatoid Arthritis (RA) were evaluated for cervical spine involvement with plain radiographs. Atlantoaxial subluxation (AAS) ranged from 16.4 to 95.7% in plain radiographs while sub-axial subluxation ranged from 10 to 43.6% of cases. Anterior atlantodental interval (AADI) was found to between 2.5 mm and 4.61 mm in neutral and flexion position respectively, while Posterior Atlantodental Interval (PADI) was between 20.4 and 24.92 mm. 660 patients with RA had undergone an MRI. A pannus diagnosis ranged from 13.33 to 85.36% while spinal cord compression was reported in 0-13% of cases. When it comes to surgical outcomes, Atlanto-axial joint (AAJ) fusion success rates ranged from 45.16 to 100% of cases. Furthermore, the incidence of postoperative subluxation ranged from 0 to 77.7%. With regards to AADI it is evident that its value decreased in all studies. Furthermore, an improvement in Ranawat classification was variable between studies with a report improvement frequency by at least one class ranging from 0 to 54.5%. In conclusion, through careful radiographic and clinical evaluation, cervical spine involvement in patients with RA can be detected. Surgery is a valuable option for these patients and can lead to improvement in their symptoms.

Clinical characteristics of patients with hypermobile type Ehlers-Danlos syndrome (hEDS) and generalized hypermobility spectrum disorders (G-HSD): an online survey.

To examine the perspective of individuals with Hypermobile Ehlers-Danlos Syndrome (hEDS) and Generalized Hypermobility Spectrum Disorder (G-HSD), needed to help identify priorities and improve the lives of people living with these conditions. We conducted an online survey between November 2021 and January 2023. Participants were recruited through the Ehlers-Danlos Society's Research Surveys website. We obtained 483 responses and 396 were analyzed. 80% of the survey's respondents were individuals with hEDS, 90% were females, 30% were between 21 and 30, and 76% lived in North America, with 85% of the participants living in North America indicated being White or European American. Participants reported exercising from none to less than three times per week, with no physical therapy treatment. Ninety-eight percent of participants reported pain mainly at the neck (76%), lower (76%) and upper back (66%), knees (64%), shoulders (60%), and hips (60%). Approximately 80% of participants reported fatigue, joint hypermobility, joint instability, interference with daily activities, gastrointestinal problems, orthostatic hypotension, muscle weakness, and emotional distress. About 60% of respondents indicated walking issues, balance issues, and reduced joint proprioception. Nearly 40% of participants reported pelvic floor dysfunction and cardiovascular problems. Participants with hEDS and G-HSD reported pain on an average (SD) of 6.4 (± 1.3) and 5.9 (± 1.5) days in a typical week, respectively. People with hEDS and G-HSD desperately need more effective treatment options, a better diagnostic process, and education among health care providers.

Reconstruction of the interosseous talocalcaneal ligament using allograft for subtalar joint stabilization is effective.

PURPOSE: The aim of this study was to assess the biomechanical effects of subtalar ligament injury and reconstruction on stability of the subtalar joint in all three spatial planes. METHODS: Fifteen fresh frozen cadaveric legs were used, with transfixed tibiotalar joints to isolate motion to the subtalar joint. An arthrometer fixed to the lateral aspect of the calcaneus measured angular displacement in all three spatial planes on the inversion and eversion stress tests. Stress manoeuvres were tested with the intact joint, and then repeated after sequentially sectioning the inferior extensor retinaculum (IER), cervical ligament (CL), interosseous talocalcaneal ligament (ITCL), arthroscopic graft reconstruction of the ITCL, and sectioning of the calcaneo-fibular ligament (CFL). RESULTS: Sectioning the ITCL significantly increased angular displacement upon inversion and eversion in the coronal and sagittal planes. Reconstruction of the ITCL significantly improved angular stability against eversion in the axial and sagittal planes, and against inversion in the axial and coronal planes, at the zero time point after reconstruction. After sectioning the CFL, resistance to eversion decreased significantly in all three planes. CONCLUSION: Progressive injury of ligamentous stabilisers, particularly the ITCL, led to increasing angular displacement of the subtalar joint measured with the inversion and eversion stress tests, used in clinical practice. Reconstruction of the ITCL using tendon graft significantly stabilised the subtalar joint in the axial and sagittal planes against eversion and in the axial and coronal planes against inversion, immediately after surgery.

Correlation Between Dynamic 4-Dimensional Computed Tomography Data and Arthroscopic Testing of Scapholunate Instability: A Preliminary Study.

PURPOSE: The aim of this study was to test the validity and reliability of the assessments of scapholunate (SL) instability status on 4-dimensional (4D) computed tomography (CT) using wrist arthroscopy as a reference standard. METHODS: Thirty-three patients (16 men, 17 women; mean age, 48 ± 13 years) with suspected SL instability were evaluated prospectively with 4D-CT and wrist arthroscopy. Based on the arthroscopic testing of SL joint, 2 groups were defined: group 1 (n = 8) consisted of patients who had no, or slight, SL malalignment in the midcarpal space and group 2 (n = 25) consisted of patients who had moderate or severe SL malalignment. Two independent readers, who did not know the arthroscopic findings, used 4D-CT to evaluate the SL gap, lunocapitate angle (LCA), and radioscaphoid angle (mean and range values) during radioulnar deviation. RESULTS: The interobserver reliability was deemed good or excellent for most of the 4D-CT variables, except for the LCA range (moderate) and SL gap range (poor). For both readers, the SL gap mean, maximum, and minimum values were significantly higher (+67%, +78%, and +39%, respectively) and the LCA mean was significantly lower (-17%) in group 2 than in group 1. The radioscaphoid angle range values were lower (-34%) and the radioscaphoid angle mean values slightly higher (+4%) in group 2, but there was no significant difference between the 2 groups. The SL gap range values were also higher (+86% for R1 and +40% for R2) and the LCA range values also lower (-50% for R1 and -31% for R2) in group 2. CONCLUSIONS: Quantitative 4D-CT data corresponded well with the arthroscopic dynamic analysis of the SL joint in patients with suspected chronic SL instability. TYPE OF STUDY/LEVEL OF EVIDENCE: Diagnostic II.

Superior clinical results for early arthroscopic treatment of grade IIIb and V acromioclavicular joint instability compared to delayed operative treatment.

BACKGROUND: Arthroscopy-assisted cortical fixation devices have been increasingly used in the operative management of both acute and chronic cases of acromioclavicular joint instability (ACJI). It has been hypothesized that delayed surgical management leads to inferior clinical and radiologic outcomes compared to acute treatment. The purpose of this study is to compare clinical and radiologic outcomes, scapula dyskinesia, and failure or revision rates of arthroscopically treated acute and chronic ACJI. METHODS: This retrospective study of prospectively collected data included all surgically treated patients with grade IIIb and V chronic ACJI between 2013 and 2017, matched 1:1 to a group of acute grade IIIb and V ACJI patients treated during the same time period. Chronic ACJI was defined as delayed surgical treatment >21 days after injury. Chronic cases received an additional hamstring autograft next to the suture pulley systems. Follow-up was obtained at an average of 3.2 years (range: 1.4-6.2). Clinical outcome scores included the Constant-Murley Score (CMS), Taft Score (TF), Nottingham Clavicle Score (NCS), ACJI Score, Sick Scapula Score (SSS), Subjective Shoulder Value (SSV), Subjective Shoulder Test (SST), American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES) score, and the visual analog scale pain score. Radiologic follow-up was obtained pre- and postoperatively and at final follow-up. The 2-year results were compared to the results of a 1:1 matched-pair group comprising patients who were treated with an acute ACJI during the same period. RESULTS: Thirty-three (80.5%) of 41 chronic ACJI cases were available for follow-up and were compared with 33 matched-pair cases of acute ACJI (of 41). The clinical scores were significantly better in the acute cohort for the CMS (92 ± 8 vs. 88 ± 8, P = .030), ASES (91 ± 13 vs. 85 ± 13, P = .002), SSS (1.4 ± 1.6 vs. 3.4 ± 2.5, P = .0004), NCS (86 ± 13 vs. 81 ± 13, P = .049), TF (9.9 ± 1.9 vs. 9.0 ± 2.1, P = .030), and ACJI (83 ± 13 vs. 75 ± 1, P = .003). In contrast to the chronic cohort, the acute cohort illustrated a significant loss of reduction at follow-up (P = .020). CONCLUSION: Based on the results of this study, early arthroscopy-assisted operative treatment of grade IIIb and V ACJIs seems superior to delayed surgical intervention of grade IIIb and V ACJIs. Furthermore, an additional autograft loop leads to less loss of reduction compared with suture pulley/suspensory loop fixation standalones.

Iatrogenic instability of the acromioclavicular joint leads to ongoing impairment of shoulder function even following secondary surgical stabilization.

PURPOSE: Iatrogenic instability of the acromioclavicular joint (ACJ) following distal clavicle excision (DCE) represents an infrequent pathology. Revision surgery to restore ACJ stability and alleviate concomitant pain is challenging due to altered anatomic relationships. The purpose of this study was to evaluate the used salvage techniques and postoperative functional and radiological outcomes in retrospectively identify patients with a painful ACJ following DCE. We hypothesized that iatrogenic instability leads to ongoing impairment of shoulder function despite secondary surgical stabilization. METHODS: 9 patients with a painful ACJ after DCE (6 men, 3 women, 43.3 ± 9.4 years) were followed up at a minimum of 36 months after revision surgery. Besides range of motion (ROM), strength and function were evaluated with validated evaluation tools including the Constant score and the DASH score (Disability of the Arm, Shoulder and Hand questionnaire), specific AC Score (SACS), Nottingham Clavicle Score (NCS), Taft score and Acromioclavicular Joint Instability Score (AJI). Additionally, postoperative X-rays were compared to the unaffected side, measuring the coracoclavicular (CC) and acromioclavicular (AC) distance. RESULTS: At follow-up survey (55.8 ± 18.8 months) all patients but one demonstrated clinical ACJ stability after arthroscopically assisted anatomical ACJ reconstruction with an autologous hamstring graft. Reconstruction techniques were dependent on the direction of instability. The functional results demonstrated moderate shoulder and ACJ scores with a Constant Score of 77.3 ± 15.4, DASH-score of 51.2 ± 23.4, SACS 32.6 ± 23.8, NCS 77.8 ± 14.2, AJI 75 ± 14.7 points and Taft Score 7.6 ± 3.4 points. All patients stated they would undergo the revision surgery again. Mean postoperative CC-distance (8.3 ± 2.8 mm) did not differ significantly from the contralateral side (8.5 ± 1.6 mm) (p > 0,05). However, the mean AC distance was significantly greater with 16.5 ± 5.8 mm compared to the contralateral side (3.5 ± 1.9 mm) (p = 0.012). CONCLUSION: Symptomatic iatrogenic ACJ instability following DCE is rare. Arthroscopically assisted revision surgery with an autologous hamstring graft improved ACJ stability in eight out of nine cases (88.9%). However, the functional scores showed ongoing impairment of shoulder function and a relatively high overall complication rate (33.3%). Therefore, this study underlines the importance of precise preoperative indication and planning and, especially, the preservation of ACJ stability when performing AC joint resection procedures. LEVEL OF EVIDENCE: Case series, LEVEL IV.