Scapular morphology of great apes and humans: A three-dimensional computed tomography-based comparative study.

The primate scapula has been studied widely since its shape has been shown to correlate with how the forelimb is used in daily activities. In this study, we expand on the existing literature and use an image-based methodology that was originally developed for orthopaedic practice to quantify and compare the three-dimensional (3D) morphology of the scapula across humans and great apes. We expect that this image-based approach will allow us to identify differences between great apes and humans that can be related to differences in mobility and loading regime of the shoulder. We hypothesize that gorillas and chimpanzees will have a similar scapular morphology, geared towards stability and weight-bearing in knuckle-walking, whilst the scapular morphology of orangutans is expected to be more similar to that of humans given their high glenohumeral mobility associated with their suspensory lifestyle. We made 3D reconstructions of computed tomography scans of 69 scapulae from four hominid genera (Pongo, Gorilla, Pan and Homo). On these 3D bone meshes, the inferior glenoid plane was determined, and subsequently, a set of bony landmarks on the scapular body, coracoid, and acromion were defined. These landmarks allowed us to measure a set of functionally relevant angles which represent acromial overhang, subacromial space and coracoacromial space. The angles that were measured are: the delto-fulcral triangle (DFT), comprising the alpha, beta, and delta angle, the acromion-glenoid angle (AGA), the coracoid-glenoid centre-posterior acromial angle (CGA), the anterior tilt (TA CGA) and the posterior tilt of the CGA (PT CGA). Three observers placed the landmarks on the 3D bone meshes, allowing us to calculate the inter-observer error. The main differences in the DFT were found between humans and the great apes, with small differences between the great apes. The DFT of humans was significantly lower compared to that of the great apes, with the smallest alpha (32.7°), smallest delta (45.7°) and highest beta angle (101.6°) of all genera. The DFT of chimpanzees was significantly higher compared to that of humans (p < 0.01), with a larger alpha (37.6°) and delta angle (54.5°) and smaller beta angle (87.9°). The mean AGA of humans (59.1°) was significantly smaller (p < 0.001) than that of gorillas (68.8°). The mean CGA of humans (110.1°) was significantly higher (p < 0.001) than in orangutans (92.9°). Humans and gorillas showed mainly a posterior tilt of their coracoacromial complex whilst chimpanzees showed mainly an anterior tilt. The coracoacromial complex of the orangutans was not tilted anteriorly or posteriorly. With our image-based method, we were able to identify morphological features of the scapula that differed significantly between hominid genera. However, we did not find an overall dichotomy in scapular morphology geared towards high stability (Pan/Gorilla) or high mobility (Homo/Pongo). Further research is needed to investigate the functional implications of these differences in scapular morphology.

Covariation between wrist bone morphology and maximal range of motion during ulnar deviation and supination in extant nonhuman primate taxa.

This study investigates the maximal range of motion (ROM) during wrist deviation and forearm rotation for five different primate genera and the possible correlation with the shape of the distal ulna, triquetrum and hamate. A two-block phylogenetic partial least square analysis was performed to test this covariation in a phylogenetic context, using shape coordinates and a matrix of maximal ROM data as input data. The results show that gibbons have the highest ROM for both ulnar deviation and supination, whereas Macaca exhibited the lowest ROM for supination, and Pan had the lowest ROM for ulnar deviation. These results can be attributed to differences in locomotor behaviour, as gibbons need a large wrist mobility in all directions for their highly arboreal lifestyle, whereas Macaca and Pan need a stable wrist during terrestrial locomotion. However, we found no correlation between distal ulna/triquetrum/hamate shape and maximal ROM during ulnar deviation and supination in the different primate taxa. A larger dataset, in combination with behavioural and biomechanical studies, is needed to establish form-function relationships of the primate hand, which will aid the functional interpretation of primate fossil remains.

The different subtalar ligaments show significant differences in their mechanical properties.

BACKGROUND: Today, the relative contribution of each ligamentous structure in the stability of the subtalar joint is still unclear. The purpose of this study is to assess the material properties of the different ligamentous structures of the subtalar joint. METHODS: Eighteen paired fresh-frozen cadaveric feet were used to obtain bone-ligament-bone complexes of the calcaneofibular ligament (CFL), the cervical ligament (CL) and the anterior capsular ligament-interosseous talocalcaneal ligament complex (ACaL-ITCL). The samples were subjected to uniaxial testing to calculate their respective stiffness and failure load. RESULTS: The stiffness of ACaL-ITCL complex (mean: 150 ± 51 N/mm, 95% confidence interval (CI): 125.0-176.6 N/mm) was significantly higher than both CFL (mean: 55.8 ± 23.0 N/mm, CI: 43.8-67.7 N/mm) and CL (mean: 63.9 ± 38.0 N/mm, CI: 44.4-83.3 N/mm). The failure load of both the ACaL-ITCL complex (mean:382.5 ± 158 N, CI: 304.1-460.8 N) and the CFL (mean:320.4 ± 122.0 N, CI: 257.5-383.2 N) were significantly higher than that of the CL (mean:163.5 ± 58.0 N, CI: 131.3-195.7 N). The injury pattern demonstrated a partial rupture in all CFL and ACaL-ITCL specimens and in 60% of the CL specimens. CONCLUSION: The CFL, CL and ACaL-ITCL show significant differences in their intrinsic mechanical properties. Both the CFL and CL are more compliant ligaments and seem to be involved in the development of subtalar instability. Based on the material properties, a gracilis tendon graft seems more appropriate than a synthetic ligament to reconstruct a CL or CFL. A partial rupture was the most commonly seen injury pattern in all ligaments. A fibular avulsion of the CFL was only rarely seen. The injury patterns need further investigation as they are important to optimize diagnosis and treatment.

The presence of persistent symptoms 12 months following a first lateral ankle sprain: A systematic review and meta-analysis.

BACKGROUND: A lateral ankle sprain (LAS) is the most common musculoskeletal injury in the physically active population. It is uncertain what percentage of these patients develop persisting symptoms including pain, recurrent sprains and subjective instability. This systematic review was conducted to assess the presence and duration of persistent symptoms after a first LAS. METHODS: A systematic review of the Medline, Web of Sciences, Embase, CINAHL and Pedro databases was performed to identify peer-reviewed articles concerning the occurrence and duration of remaining symptoms after a first LAS. Inclusion criteria focused on selection of patients without previous ankle injuries and study quality. One of the following outcomes had to be described: subjective instability, resprains, remaining symptoms. RESULTS: In total, 15 studies were included. The occurrence of patients with subjective instability decreased from 37.9% (95%CI [6.0-69.7]) at 3 months to 16.1% (95%CI [7.8-24.3]) at 6 months and 8.1% (95%CI [3.3-13.3]) at 12 months. The occurrence of patients with a recurrent LAS was 15.8% (95%CI [6.3-25.3]) at 12 months. The occurrence of patients with residual pain decreased from 48.6% (95%CI [23.6-73.5]) at 3 months, to 21.5% (95%CI [2.8-40.2]) at 6 months and 6.7% (95%CI [3.2-10.1]) at 12 months. CONCLUSION: This study offers new insights in the presence of remaining symptoms after a first LAS and the development of chronic ankle instability. Twelve months following an initial LAS, a significant number of patients may still have symptoms. The incidence of subjective instability, and pain, continues to decrease until 12 months post-injury. This new information may suggest that a longer period of non-operative treatment may be warranted before recommending surgical intervention in patients with a first LAS.

The forearm and hand musculature of semi-terrestrial rhesus macaques (Macaca mulatta) and arboreal gibbons (fam.Hylobatidae). Part II. Quantitative analysis.

Nonhuman primates have a highly diverse locomotor repertoire defined by an equally diverse hand use. Based on how primates use their hands during locomotion, we can distinguish between terrestrial and arboreal taxa. The 'arboreal' hand is likely adapted towards high wrist mobility and grasping, whereas the 'terrestrial' hand will show adaptations to loading. While the morphology of the forearm and hand bones have been studied extensively, functional adaptations in the forearm and hand musculature to locomotor behaviour have been documented only scarcely. In this paper, we investigate the forelimb musculature of the highly arboreal gibbons (including Hylobates lar,Hylobates pileatus,Nomascus leucogenys,Nomascus concolor and Symphalangus syndactylus) and compare this with the musculature of the semi-terrestrial rhesus macaques (Macaca mulatta). Anatomical data from previous dissections on knuckle-walking bonobos (Pan paniscus) and bipedal humans (Homo sapiens) are also included to further integrate the analyses in the scope of catarrhine hand adaptation. This study indicates that the overall configuration of the arm and hand musculature of these primates is very similar but there are some apparent differences in relative size which can be linked to differences in forelimb function and which might be related to their specific locomotor behaviour. In macaques, there is a large development of wrist deviators, wrist and digital flexors, and m. triceps brachii, as these muscles are important during the different phases of palmi- and digitigrade quadrupedal walking to stabilize the wrist and elbow. In addition, their m. flexor carpi ulnaris is the most important contributor to the total force-generating capacity of the wrist flexors and deviators, and is needed to counteract the adducting torque at the elbow joint during quadrupedal walking. Gibbons show a relatively high force-generating capacity in their forearm rotators, wrist and digital flexors, which are important muscles in brachiation to actively regulate forward movement of the body. The results also stress the importance of the digital flexors in bonobos, during climbing and clambering, and in humans, which is likely linked to our advanced manipulation skills.

A calcaneal tunnel for CFL reconstruction should be directed to the posterior inferior medial edge of the calcaneal tuberosity.

PURPOSE: Anatomical reconstruction of the calcaneofibular ligament (CFL) is a common technique to treat chronic lateral ankle instability. A bone tunnel is used to fix the graft in the calcaneus. The purpose of this study is to provide some recommendations about tunnel entrance and tunnel direction based on anatomical landmarks. METHODS: The study consisted of two parts. The first part assessed the lateral tunnel entrance for location and safety. The second part addressed the tunnel direction and safety upon exiting the calcaneum on the medial side. In the first part, 29 specimens were used to locate the anatomical insertion of the CFL based on the intersection of two lines related to the fibular axis and specific landmarks on the lateral malleolus. In the second part, 22 specimens were dissected to determine the position of the neurovascular structures at risk during tunnel drilling. Therefore, a method based on four imaginary squares using external anatomical landmarks was developed. RESULTS: For the tunnel entrance on the lateral side, the mean distance to the centre of the CFL footprint was 2.8 ± 3.0 mm (0-10.4 mm). The mean distance between both observers was 4.2 ± 3.2 mm (0-10.3 mm). The mean distance to the sural nerve was 1.4 ± 2 mm (0-5.8 mm). The mean distance to the peroneal tendons was 7.3 ± 3.1 mm (1.2-12.4 mm). For the tunnel exit on the medial side, the two anterior squares always contained the neurovascular bundle. A safe zone without important neurovascular structures was found and corresponded to the two posterior squares. CONCLUSION: Lateral landmarks enabled to locate the CFL footprint. Precautions should be taken to protect the nearby sural nerve. A safe zone on the medial side could be determined to guide safe tunnel direction. A calcaneal tunnel should be directed to the posterior inferior medial edge of the calcaneal tuberosity.

The intrinsic subtalar ligaments have a consistent presence, location and morphology.

BACKGROUND: Chronic subtalar instability is a disabling complication after acute ankle sprains. Currently, the literature describing the anatomy of the intrinsic subtalar ligaments is limited and equivocal which causes difficulties in diagnosis and treatment of subtalar instability. The purpose of this study is to assess the anatomical characteristics of the subtalar ligaments and to clarify some points of confusion. METHODS: In 16 cadaveric feet, the dimensions and locations of the subtalar ankle ligaments were assessed and measured. CT-scans before dissection and after indication of the footprints with radio-opaque paint allowed to generate 3D models and assess the footprint characteristics. RESULTS: The cervical ligament (CL) had similar dimensions as the lateral ligaments: anterior length 13.9 ± 1.5 mm, posterior length 18.5 ± 2.9 mm, talar width 13.6 ± 2.2 mm, calcaneal width 15.8 ± 3.7 mm. The anterior capsular ligament (ACaL) and interosseous talocalcaneal ligament (ITCL) were found to be smaller structures with consistent dimensions and locations. CONCLUSION: This study identified consistent characteristics of the intrinsic subtalar ligaments and clarifies the local anatomical situation. The dimensions and footprints of the intrinsic ligaments of the subtalar joint suggest a more important role of the CL and ACaL in the stability of the subtalar joint. The results of this study are relevant to improve diagnostic tools and offer some guidelines when reconstructing the injured ligaments.

The forearm and hand musculature of semi-terrestrial rhesus macaques (Macaca mulatta) and arboreal gibbons (Fam. Hylobatidae). Part I. Description and comparison of the muscle configuration.

Primates live in very diverse environments and, as a consequence, show an equally diverse locomotor behaviour. During locomotion, the primate hand interacts with the superstrate and/or substrate and will therefore probably show adaptive signals linked with this locomotor behaviour. Whereas the morphology of the forearm and hand bones have been studied extensively, the functional adaptations in the hand musculature have been documented only scarcely. To evaluate whether there are potential adaptations in forelimb musculature to locomotor behaviour, we investigated the forearm and hand musculature of the highly arboreal gibbons (including Hylobates lar, Hylobates pileatus, Nomascus leucogenys, Nomascus concolor, Symphalangus syndactylus) and compared this with the musculature of the semi-terrestrial rhesus macaques (Macaca mulatta) by performing complete and detailed dissections on a sample of 15 unembalmed specimens. We found that the overall configuration of the upper arm and hand musculature is highly comparable between arboreal gibbons and semi-terrestrial macaques, and follows the general primate condition. Most of the identified differences in muscle configuration are located in the forearm. In macaques, a prominent m. epitrochleoanconeus is present, which potentially helps to extend the forearm and/or stabilize the elbow joint during quadrupedal walking. The m. flexor carpi radialis shows a more radial insertion in gibbons, which might be advantageous during brachiation, as it can aid radial deviation. The fingers of macaques are controlled in pairs by the m. extensor digiti secondi et tertii proprius and the m. extensor digiti quarti et quinti proprius-a similar organization can also be found in their flexors-which might aid in efficient positioning of the hand and fingers on uneven substrates during quadrupedal walking. In contrast, extension of the little finger in gibbons is controlled by a separate m. extensor digiti minimi, whereas digits 2 to 4 are extended by the m. extensor digitorum brevis, suggesting that simultaneous extension of digits 2-4 in gibbons might be important when reaching or grasping an overhead support during brachiation. In conclusion, the overall configuration of the forelimb and hand musculature is very similar in gibbons and macaques, with some peculiarities which can be linked to differences in forelimb function and which might be related to the specific locomotor behaviour of each group.

The gibbon's Achilles tendon revisited: consequences for the evolution of the great apes?

The well-developed Achilles tendon in humans is generally interpreted as an adaptation for mechanical energy storage and reuse during cyclic locomotion. All other extant great apes have a short tendon and long-fibred triceps surae, which is thought to be beneficial for locomotion in a complex arboreal habitat as this morphology enables a large range of motion. Surprisingly, highly arboreal gibbons show a more human-like triceps surae with a long Achilles tendon. Evidence for a spring-like function similar to humans is not conclusive. We revisit and integrate our anatomical and biomechanical data to calculate the energy that can be recovered from the recoiling Achilles tendon during ankle plantar flexion in bipedal gibbons. Only 7.5% of the required external positive work in a stride can come from tendon recoil, yet it is delivered at an instant when the whole-body energy level drops. Consequently, an additional similar amount of mechanical energy must simultaneously dissipate elsewhere in the system. Altogether, this challenges the concept of an energy-saving function in the gibbon's Achilles tendon. Cercopithecids, sister group of the apes, also have a human-like triceps surae. Therefore, a well-developed Achilles tendon, present in the last common 'Cercopithecoidea-Hominoidea' ancestor, seems plausible. If so, the gibbon's anatomy represents an evolutionary relict (no harm-no benefit), and the large Achilles tendon is not the premised key adaptation in humans (although the spring-like function may have further improved during evolution). Moreover, the triceps surae anatomy of extant non-human great apes must be a convergence, related to muscle control and range of motion. This perspective accords with the suggestions put forward in the literature that the last common hominoid ancestor was not necessarily great ape-like, but might have been more similar to the small-bodied catarrhines.

The digital human forearm and hand.

How changes in anatomy affect joint biomechanics can be studied using musculoskeletal modelling, making it a valuable tool to explore joint function in healthy and pathological joints. However, gathering the anatomical, geometrical and physiological data necessary to create a model can be challenging. Very few integrated datasets exist and even less raw data is openly available to create new models. Therefore, the goal of the present study is to create an integrated digital forearm and make the raw data available via an open-access database. An un-embalmed cadaveric arm was digitized using 7T MRI and CT scans. 3D geometrical models of bones, cartilage, muscle and muscle pathways were created. After MRI and CT scanning, physiological muscle parameters (e.g. muscle volume, mass, length, pennation angle, physiological cross-sectional area, tendon length) were obtained via detailed dissection. After dissection, muscle biopsies were fixated and confocal microscopy was used to visualize and measure sarcomere lengths. This study provides an integrated anatomical dataset on which complete and accurate musculoskeletal models of the hand can be based. By creating a 3D digital human forearm, including all relevant anatomical parameters, a more realistic musculoskeletal model can be created. Furthermore, open access to the anatomical dataset makes it possible for other researchers to use these data in the development of a musculoskeletal model of the hand.

Insights into the musculature of the bonobo hand.

The human hand is well known for its unique dexterity which is largely facilitated by a highly mobile, long and powerful thumb that enables both tool manufacturing and use, a key component of human evolution. The bonobo (Pan paniscus), the closest extant relative to modern humans together with the chimpanzee (Pan troglodytes), also possesses good manipulative capabilities but with a lower level of dexterity compared with modern humans. Despite the close phylogenetic relationship between bonobos and humans, detailed quantitative data of the bonobo forelimb musculature remains largely lacking. To understand how morphology may influence dexterity, we investigated the functional anatomy of the bonobo hand using a unique sample of eight bonobo cadavers, along with one chimpanzee and one human (Homo sapiens) cadaver. We performed detailed dissections of unembalmed specimens to collect quantitative datasets of the extrinsic and intrinsic hand musculature, in addition to qualitative descriptions of the forelimb muscle configurations, allowing estimation of force-generating capacities for each functional group. Furthermore, we used medical imaging to quantify the articular surface of the trapeziometacarpal joint to estimate the intra-articular pressure. Our results show that the force-generating capacity for most functional groups of the extrinsic and intrinsic hand muscles in bonobos is largely similar to that of humans, with differences in relative importance of the extensors and rotators. The bonobo thumb musculature has a lower force-generating capacity than observed in the human specimen, but the estimated maximal intra-articular pressure is higher in bonobos. Most importantly, bonobos show a higher degree of functional coupling between the muscles of the thumb, index and lateral fingers than observed in humans. It is conceivable that differentiation and individualization of the hand muscles rather than relative muscle development explain the higher level of dexterity of humans compared with that of bonobos.

Raising the Joint Line in TKA is Associated With Mid-flexion Laxity: A Study in Cadaver Knees.

BACKGROUND: In a typical osteoarthritic knee with varus deformity, distal femoral resection based off the worn medial femoral condyle may result in an elevated joint line. In a setting of fixed flexion contracture, the surgeon may choose to resect additional distal femur to obtain extension, thus purposefully raising the joint line. However, the biomechanical effect of raising the joint line is not well recognized. QUESTIONS/PURPOSES: (1) What is the effect of the level of the medial joint line (restored versus raised) on coronal plane stability of a TKA? (2) Does coronal alignment technique (mechanical axis versus kinematic technique) affect coronal plane stability of the knee? (3) Can the effect of medial joint-line elevation on coronal plane laxity be predicted by an analytical model? METHODS: A TKA prosthesis was implanted in 10 fresh frozen nonarthritic cadaveric knees with restoration of the medial joint line at its original level (TKA0). Coronal plane stability was measured at 0°, 30°, 60°, 90°, and 120° flexion using a navigation system while applying an instrumented 9.8-Nm varus and valgus force moment. The joint line then was raised in two steps by recutting the distal and posterior femur by an extra 2 mm (TKA2) and 4 mm (TKA4), downsizing the femoral component and, respectively, adding a 2- and a 4-mm thicker insert. This was done with meticulous protection of the ligaments to avoid damage. Second, a simplified two-dimensional analytical model of the superficial medial collateral ligament (MCL) length based on a single flexion-extension axis was developed. The effect of raising the joint line on the length of the superficial MCL was simulated. RESULTS: Despite that at 0° (2.2° ± 1.5° versus 2.3° ± 1.1° versus 2.5° ± 1.1°; p = 0.85) and 90° (7.5° ± 1.9° versus 9.0° ± 3.1° versus 9.0° ± 3.5°; p = 0.66), there was no difference in coronal plane laxity between the TKA0, TKA2, and TKA4 positions, increased laxity at 30° (4.8° ± 1.9° versus 7.9° ± 2.3° versus 10.2° ± 2.0°; p < 0.001) and 60° (5.7° ± 2.7° versus 8.8° ± 2.9° versus 11.3° ± 2.9°; p < 0.001) was observed when the medial joint line was raised 2 and 4 mm. At 30°, this corresponds to an average increase of 64% (3.1°; p < 0.01) in mid-flexion laxity with a 2-mm raised joint line and a 111% (5.4°; p < 0.01) increase with a 4-mm raised joint line compared with the 9-mm baseline resection. No differences in coronal alignment were found between the knees implanted with kinematic alignment versus mechanical alignment at any flexion angle. The analytical model was consistent with the cadaveric findings and showed lengthening of the superficial MCL in mid-flexion. CONCLUSIONS: Despite a well-balanced knee in full extension and at 90° flexion, increased mid-flexion laxity in the coronal plane was evident in the specimens where the joint line was raised. CLINICAL RELEVANCE: When recutting the distal and posterior femur and downsizing the femoral component, surgeons should be aware that this action might increase the laxity in mid-flexion, even if the knee is stable at 0° and 90°.

Impact of Osteoarthritis and Total Joint Arthroplasty on the Kinematics of the Trapeziometacarpal Joint: A Pilot Study.

PURPOSE: To quantify the effect of osteoarthritis (OA) and total trapeziometacarpal (TMC) joint replacement on thumb kinematics during the primary physiological motions of the thumb. METHODS: We included 4 female patients with stage III TMC OA. A computed tomography-based markerless method was used to quantify the 3-dimensional thumb kinematics in patients before and after TMC joint replacement surgery with the Arpe implant. RESULTS: Trapeziometacarpal OA led to a marked decrease of internal rotation and abduction of the first metacarpal (MC1) during thumb flexion and a decrease of MC1 adduction during thumb adduction. As a compensatory phenomenon, the trapezium displayed increased abduction. The absence of MC1 translation in the ball-and-socket implant seems to induce a decrease of MC1 adduction as well as a decrease of trapezium adduction during thumb adduction, compared with OA and healthy joints. Implant replacement displayed an unchanged MC1 flexion during thumb flexion and seemed to slightly increase MC1 axial rotation during thumb flexion and adduction. Abduction and adduction of the MC1 are limited and compensated by this somewhat increased axial rotation, allowing more efficient thumb opposition. CONCLUSIONS: The study highlights that advanced TMC OA mainly restricts the MC1 mobility. We also showed that, whereas total joint arthroplasty is able to restore thumb function, it cannot fully replicate the kinematics of the healthy TMC joint. CLINICAL RELEVANCE: The quantification of TMC joint kinematics in OA and implanted patients is essential to improve our understanding of TMC OA as well as to enhance the functionality of implant designs.

Endoscopic reconstruction of CFL and the ATFL with a gracilis graft: a cadaveric study.

PURPOSE: The purpose of this study was to evaluate a step-by-step approach to endoscopic reconstruction of the anterior talofibular ligament (ATFL) and the calcaneofibular ligament (CFL). METHODS: Fourteen lower extremity cadaveric specimens were used. Four standard portals were defined and used. A step-by-step approach using several anatomical landmarks was used to reconstruct the ATFL and CFL. The feasibility of visualising the anatomical landmarks and both ligaments and their footprints was assessed. Both ligaments were reconstructed using a gracilis graft fixed in bone tunnels. The lateral side of the ankle was completely exposed and dissected. The specimen was assessed for clinical stability of the reconstruction and damage to the surrounding anatomical structures. The distance between the centre of the tunnel and the anatomical insertions of the ligaments was measured. The distance between the portals and the nerves was measured. RESULTS: The step-by-step approach allowed a good visualisation of the entire course of the ATFL and CFL. An endoscopic reconstruction of both ligaments was performed, and good stability was obtained. The measurements revealed a good positioning of the reconstructed ligament insertions with a maximal error of 2 mm in most specimens. Anatomical dissection revealed no damage to the surrounding anatomical structures that were at risk. The average distance to the superficial peroneal nerve was 11.9 ± 5.3 mm (standard deviation), and the average distance to the sural nerve was 17.4 ± 3.2 mm (standard deviation). A safe zone was defined with regard to the surrounding nerves. CONCLUSION: The described technique, which involves an anatomical endoscopic reconstruction of the ATFL and CFL, using a gracilis graft, is a viable option to treat lateral ankle instability. This technique is reproducible and safe with regard to the surrounding anatomical structures.

The Segond fracture: a bony injury of the anterolateral ligament of the knee.

PURPOSE: The purpose of this study was to investigate the relation of the Segond fracture with the anterolateral ligament (ALL) of the knee. METHODS: To identify the soft-tissue structure causative for the Segond fracture, a study was set up to compare anatomic details of the tibial insertion of the recently characterized ALL in cadaveric knees (n = 30) with radiologic data obtained from patients (n = 29) with a possible Segond fracture based on an imaging protocol search. The spatial relation of the ALL footprint with well-identifiable anatomic landmarks at the lateral aspect of the knee was determined, and this was repeated for the Segond fracture bed. RESULTS: In all of the included cadaveric knees, a well-defined ALL was found as a distinct ligamentous structure connecting the lateral femoral epicondyle with the anterolateral proximal tibia. The mean distance of the center of the tibial ALL footprint to the center of the Gerdy tubercle (GT-ALL distance) measured 22.0 ± 4.0 mm. The imaging database search identified 26 patients diagnosed with a Segond fracture. The mean GT-Segond distance measured 22.4 ± 2.6 mm. The observed difference of 0.4 mm (95% confidence interval, -1.5 to 2.2 mm) between the GT-ALL distance and GT-Segond distance was neither statistically significant (P = .70) nor clinically relevant. CONCLUSIONS: The results of this study confirmed the hypothesis that the ALL inserts in the region on the proximal tibia from where Segond fractures consistently avulse, thus suggesting that the Segond fracture is actually a bony avulsion of the ALL. CLINICAL RELEVANCE: Although the Segond fracture remains a useful radiographic clue for indirect detection of anterior cruciate ligament injuries, the Segond fracture should be considered a frank ligamentous avulsion itself.

Bony palmar ridges of the phalanges of the human fingers.

PURPOSE: On imaging studies, bony ridges can be seen at the palmar aspect of the phalanges of the fingers. Our purpose was to address the following: (1) which structures insert on to the ridges and what is the histological appearance? (2) Is there a difference between the different fingers? (3) Is there a correlation between the ridges and age? MATERIALS AND METHODS: Two observers retrospectively evaluated 270 radiographs (135 men; 135 women; mean age 44 years), and 33 CT scans (22 men; 11 women; mean age 46 years). Three cadaveric hands were also studied. The ridges were graded using a 4-point scale. A Chi-square test was used to compare the different fingers (p < 0.05) and to study the prominence of the ridges in relation to age (p < 0.05). RESULTS: On histology with routine stains the A2 pulley was inserted on the ridges of the proximal phalanx, and the flexor superficialis and A4 pulley on the ridges of the middle phalanx. On histology, the insertion showed a transition zone consisting of fibrocartilage. The prominence of the ridges was significantly different between fingers with III and IV categorized higher than II and III. There was a significant correlation with age for all fingers except for the middle phalanx of II and III. CONCLUSION: The bony palmar ridges have characteristics of enthesophytes. They correspond to the insertion site of the A2 pulley, and the flexor superficialis tendon and A4 pulley, at the proximal and middle phalanx, respectively. The ridges become more prominent with age, and their prominence is different between the fingers with III and IV categorized higher than II and V.

Ulnar shape of extant primates: Functional signals and covariation with triquetrum shape.

OBJECTIVES: In this study, we investigated the shape differences of the distal ulna in a phylogenetic context among a broad range of primate taxa. Furthermore, we evaluated covariation between ulnar and triquetrum shape and a possible association between ulnar shape and locomotor behavior. MATERIALS AND METHODS: We applied 3D geometric morphometrics on a large dataset comprising the distal ulna of 124 anthropoid primate specimens belonging to 12 different genera. For each species, a mean shape was calculated using 11 Procrustes-aligned surface landmarks on the distal ulna. These mean shapes are used in a bgPCA, pPCA, and PACA and 3D morphs were used to visualize more subtle differences between taxa. A p2B-PLS analysis was performed to test the covariance between distal ulnar and triquetrum shape. RESULTS: The results show that more closely related species exhibit a similar distal ulnar shape. Overall, extant hominid ulnae show a shape shift compared to those of extant monkeys and hylobatids. This includes a shortening of the ulnar styloid process and dorspalmarly widening of the ulnar head, shape characteristics that are independent of phylogeny. Within the hominids, Pongo pygmaeus seem to possess the most plesiomorphic distal ulnar shape, while Gorilla and Homo sapiens display the most derived distal ulna. Cercopithecoids, hylobatids, and P. pygmaeus are characterized by a relatively deep ECU groove, which is a shape trait dependent of phylogeny. Although there was no significant covariation between distal ulnar shape and triquetrum shape, the shape differences of the distal ulna between the different primate taxa reveal a possible link with locomotor behavior. CONCLUSIONS: The comparative analyses of this study reveal different shape trends in a phylogenetic context. Highly arboreal primates, such as hylobatids and Ateles fusciceps, show a distal ulnar morphology that appears to be adapted to tensile and torsional forces. In primates that use their wrist under more compressive conditions, such as quadrupedal cercopithecoids and great apes, the distal ulnar morphology seems to reflect increased compressive forces. In modern humans, the distal ulnar shape can be associated to enhanced manipulative skills and power grips. There was no significant covariation between distal ulnar shape and triquetrum shape, probably due to the variation in the amount of contact between the triquetrum and ulna. In combination with future research on wrist mobility in diverse primate taxa, the results of this study will allow us to establish form-function relationships of the primate wrist and contribute towards an evidence-based interpretation of fossil remains.

The comparative and functional anatomy of the forelimb muscle architecture of Humboldt's woolly monkey (Lagothrix lagotricha).

Humboldt's woolly monkey (Lagothrix lagortricha) is a ceboid primate that more frequently engages in plantigrade quadrupedalism (~89%) but is, like most other members of the subfamily Atelinae, capable of suspensory postures and "tail assisted" brachiation. That taxon's decreased reliance on suspension is reflected in the skeletal anatomy of the upper limb which is less derived relative to more frequently suspensory atelines (Ateles, Brachyteles) but is in many ways (i.e., phalangeal curvature, enlarged joint surfaces, elongated diaphyses) intermediate between highly suspensory and quadrupedal anthropoids. Although it has been suggested that muscle may have morphogenetic primacy with respect to bone this has not been explicitly tested. The present study employs analyses of Lagothrix upper limb muscle fiber length, relative physiological cross-sectional area and relative muscle mass to test whether muscular adaptations for suspensory postures and locomotion in Lagothrix precede adaptive refinements in the skeletal tissues or appear more gradually in conjunction with related skeletal adaptations. Results demonstrate that Lagothrix upper limb musculature is most like committed quadrupeds but that limited aspects of the relative distribution of segmental muscle mass may approach suspensory hylobatids consistent with only a limited adaptive response in musculature prior to bone. Results specific to the shoulder were inconclusive owing to under-representation of quadrupedal shoulder musculature and future work should be focused more specifically on the adaptive and functional morphology of the muscular anatomy and microstructure of the scapulothoracic joint complex.

Anatomy of the anterolateral ligament of the knee.

In 1879, the French surgeon Segond described the existence of a 'pearly, resistant, fibrous band' at the anterolateral aspect of the human knee, attached to the eponymous Segond fracture. To date, the enigma surrounding this anatomical structure is reflected in confusing names such as '(mid-third) lateral capsular ligament', 'capsulo-osseous layer of the iliotibial band' or 'anterolateral ligament', and no clear anatomical description has yet been provided. In this study, the presence and characteristics of Segond's 'pearly band', hereafter termed anterolateral ligament (ALL), was investigated in 41 unpaired, human cadaveric knees. The femoral and tibial attachment of the ALL, its course and its relationship with nearby anatomical structures were studied both qualitatively and quantitatively. In all but one of 41 cadaveric knees (97%), the ALL was found as a well-defined ligamentous structure, clearly distinguishable from the anterolateral joint capsule. The origin of the ALL was situated at the prominence of the lateral femoral epicondyle, slightly anterior to the origin of the lateral collateral ligament, although connecting fibers between the two structures were observed. The ALL showed an oblique course to the anterolateral aspect of the proximal tibia, with firm attachments to the lateral meniscus, thus enveloping the inferior lateral geniculate artery and vein. Its insertion on the anterolateral tibia was grossly located midway between Gerdy's tubercle and the tip of the fibular head, definitely separate from the iliotibial band (ITB). The ALL was found to be a distinct ligamentous structure at the anterolateral aspect of the human knee with consistent origin and insertion site features. By providing a detailed anatomical characterization of the ALL, this study clarifies the long-standing enigma surrounding the existence of a ligamentous structure connecting the femur with the anterolateral tibia. Given its structure and anatomic location, the ALL is hypothesized to control internal tibial rotation and thus to affect the pivot shift phenomenon, although further studies are needed to investigate its biomechanical function.

The role of hind limb tendons in gibbon locomotion: springs or strings?

Tendon properties have an important effect on the mechanical behaviour of muscles, with compliant tendons allowing near-isometric muscle contraction and facilitating elastic energy storage and recoil. Stiff tendons, in contrast, facilitate rapid force transfer and precise positional control. In humans, the long Achilles tendon contributes to the mechanical efficiency of running via elastic energy storage and recovery, and its presence has been linked to the evolution of habitual bipedalism. Gibbons also possess relatively long hind limb tendons; however, their role is as yet unknown. Based on their large dimensions, and inferring from the situation in humans, we hypothesize that the tendons in the gibbon hind limb will facilitate elastic energy storage and recoil during hind-limb-powered locomotion. To investigate this, we determined the material properties of the gibbon Achilles and patellar tendon in vitro and linked this with available kinematic and kinetic data to evaluate their role in leaping and bipedalism. Tensile tests were conducted on tendon samples using a material testing machine and the load-displacement data were used to calculate stiffness, Young's modulus and hysteresis. In addition, the average stress-in-life and energy absorption capacity of both tendons were estimated. We found a functional difference between the gibbon Achilles and patellar tendon, with the Achilles tendon being more suitable for elastic energy storage and release. The patellar tendon, in contrast, has a relatively high hysteresis, making it less suitable to act as elastic spring. This suggests that the gibbon Achilles tendon might fulfil a similar function as in humans, contributing to reducing the locomotor cost of bipedalism by acting as elastic spring, while the high stiffness of the patellar tendon might favour fast force transfer upon recoil and, possibly, enhance leaping performance.