The anteromedial retinaculum in ACL-injured knees: An overlooked injury?

PURPOSE: The purpose of this study was to retrospectively analyse the pattern of injury to the medial knee structures in anterior cruciate ligament (ACL) injured patients. It was hypothesised that anteromedial injuries would be more common than posteromedial lesions. METHODS: One hundred and twenty subjects aged 18-25 years with a primary ACL injury were included. Patients were excluded if the time between injury and magnetic resonance imaging (MRI) was more than 28 days or if a knee dislocation or fracture was present. The MRIs were analysed with particular emphasis on injuries to the medial knee structures, menisci and bone bruise patterns. Injuries to the ligaments and anteromedial retinaculum (AMR) were graded according to severity, ranging from periligamentous oedema (grade I), partial fibre disruption of less or more than 50% (grade IIa or IIb) to complete tears (grade III). RESULTS: AMR injury was seen in 87 subjects (72.5%) on the coronal plane and in 88 (73.3%) on the axial plane, with grade III lesions observed in 27 (22.5%) and 29 knees (24.2%). Injuries to the superficial medial collateral ligament (sMCL), deep MCL (dMCL) and posterior oblique ligament (POL) were detected in 60 patients (50%), 93 patients (77.5%) and 38 patients (31.6%). However, grade III injuries to the POL were observed in only seven knees (5.8%). Medial meniscus injuries were associated with lesions of the sMCL and AMR (p < 0.05), while lateral meniscus injuries were significantly more common in patients with dMCL rupture (p < 0.05). CONCLUSION: Data from this study suggest that injuries to the AMR are much more common than posteromedial lesions in subjects with ACL injuries. LEVEL OF EVIDENCE: Level IV.

Combined PCL instabilities cannot be identified using posterior stress radiographs in external or internal rotation: A cadaveric study.

PURPOSE: Posterior stress radiography is recommended to identify isolated or combined posterior cruciate ligament (PCL) deficiencies. The posterior drawer in internal (IR) or external rotation (ER) helps to differentiate between these combined instabilities. The purpose of this study was to evaluate posterior stress radiography (PSR) in isolated and combined PCL deficiency with IR and ER compared to PSR in neutral rotation (NR) for diagnosing combined PCL instabilities. METHODS: Six paired fresh-frozen human cadaveric legs (n = 12) were mounted in a Telos device for PSR. The tibia was rotated using an attached foot apparatus capable of rotating the foot 30° internally and externally. A posterior tibial load of 15 kp (147.1 N) was applied to the tibial tubercle at 90° knee flexion, and a lateral radiograph was obtained. This was repeated with the foot in 30° IR and ER. The PCL, posterolateral complex (PLC), and posteromedial complex (PMC) were sectioned in six knees, while the PMC was sectioned before the PLC in the other six knees. Posterior tibial displacement (PTD) was measured radiographically. Statistical analysis was performed using a two-way ANOVA and a mixed model with Bonferroni correction, and the significance was set at p < 0.05. Furthermore, intra- and interobserver reliability was determined. RESULTS: Cutting the PCL significantly increased the radiographic PTD by 9.8 ± 1.8 mm (side-to-side difference compared to the intact state of the knee, n = 12; p < 0.001). This further increased to 12.2 ± 2.3 mm (n = 6; p < 0.01) with an additional PLC deficiency and to 15.4 ± 3.4 mm (n = 6; p < 0.05) with an additional PMC deficiency. A combined PLC and PMC deficiency resulted in an increase of the PTD to 15.9 ± 4.5 mm (n = 12; p < 0.01). In the PCL/PLC deficient state, ER did not demonstrate a higher PTD, compared to the NR and IR posterior drawer. In the PCL/PMC deficient state in IR, PTD was 1.6 ± 0.7 mm (p < 0.01) higher compared to NR and 3.2 ± 1.9 mm (p < 0.05) higher compared to ER. We showed excellent intra- and interobserver reliability (0.987-0.997). CONCLUSION: Combined PCL instabilities resulted in a significant increase in posterior tibial displacement in posterior stress radiographs. However, PSR in IR or ER was unable to differentiate between these combined instabilities. Based on our data, additional stress radiographs in rotation are unlikely to provide any diagnostic benefit in the clinical setting. LEVEL OF EVIDENCE: There is no level of evidence as this study was an experimental laboratory study.

Outcomes and performance following posteromedial elbow débridement in Major League Baseball players.

BACKGROUND: Overhead athletes are particularly susceptible to elbow valgus extension overload syndrome and development of pathologic changes in the posteromedial elbow. Though arthroscopic débridement/osteophyte resection is frequently performed, few studies have analyzed the outcomes of this procedure and none have specifically addressed professional level athletes. HYPOTHESIS: We hypothesized that following posteromedial elbow débridement, Major League Baseball (MLB) pitchers would exhibit a higher rate of ulnar collateral ligament (UCL) reconstruction than baseline incidence in the existing literature, along with a decline in pitching performance. METHODS: Using publicly accessible websites, MLB athletes undergoing posteromedial elbow débridement from 2007 to 2022 were identified. Demographic information, procedure details, return to play (RTP) information, return to the disabled/injured list (DL/IL), subsequent UCL reconstruction, and pitching statistics were analyzed. Pitching performance metrics included earned runs average, walks plus hits per innings pitched, innings pitched, and fastball velocity. RESULTS: A total of 39 MLB players, including 26 pitchers, were included. Within the first three seasons after surgery, 82.1% (n = 32) of players returned to play at the MLB level at a mean time of 176.1 ± 69 days. Pitchers exhibited a RTP rate of 76.9% (n = 20) at 175.8 ± 16 days. A total of 38.5% (n = 10) of pitchers returned to the DL/IL for elbow-related issues within three seasons. Subsequent UCL reconstruction was seen only in pitchers, with a frequency of 19.2% (n = 5). No statistically significant differences between single season preoperative/postoperative pitching metrics were identified. A small but significant (P < .05) decrease in fastball velocity (94.4 vs. 92.84; P = .02) was observed over a three-season comparison. CONCLUSION: Contrary to our hypothesis, this study demonstrates that posteromedial elbow débridement is a viable surgery in MLB athletes, with RTP rate of 82.1% and no increase in rate of UCL reconstruction. Furthermore, there was no significant difference in single season preoperative and postoperative statistical pitching performance. However, over three years postoperatively, there was a 38.5% rate of return to the DL/IL for ongoing elbow ailment and a significant decrease in pitch velocity, raising some concern over the longevity of postoperative improvements.

Predraft elbow magnetic resonance imaging in Major League Baseball pitchers.

BACKGROUND: Prior to the Major League Baseball (MLB) draft, some pitchers undergo predraft magnetic resonance imaging (MRI). This study aimed to evaluate pre-draft elbow MRI on baseball pitchers who were entering the MLB draft to determine the presence or absence of pathology, the associations between these pathologies and ulnar collateral ligament (UCL) tears, and interobserver reliability regarding common MRI pathology. METHODS: Predraft elbow MRI performed on prospective MLB pitchers between 2011 and 2017 were deidentified and then reviewed by two separate authors. The authors graded the MRI on several factors including presence or absence of: UCL ossification, UCL appearance (heterogeneous or not), UCL thickening (and location), UCL tear (partial vs. full thickness and location), muscle strain, flexor tendon tear, posteromedial osteophyte, sublime tubercle enthesophyte, and osseous stress reactions. RESULTS: Overall, 245 predraft elbow MRI were reviewed. MRI abnormalities were found in 70% (171/245) of pitchers. UCL thickening was found in 20% (50/245) of pitchers. Regarding UCL tears, 3% had a full thickness tear and 24% had a partial thickness tear. Of full thickness tears, 86% were distal and 1 was midsubstance. Of partial thickness tears, 41% (24/58) were distal, 12% (7/58) were midsubstance, and 47% (27/58) were proximal. Periligamentous edema was present in 36% of pitchers while 14% had a flexor pronator muscle strain. CONCLUSION: The majority (70%) of pitchers entering the MLB draft had abnormal findings on their MRI, most commonly involving changes to the UCL. Interobserver reliability was acceptable following the definition of pathology when reading predraft elbow MRI on MLB prospects.

Three-Dimensional Quantitative Study and Functional Outcome Analysis of Coronoid Fracture in Different Elbow Injury Patterns.

BACKGROUND: Coronoid fractures are often part of a complex fracture-dislocation of the elbow. For an optimum prognosis, it is important to understand the characteristics of coronoid fractures in different elbow injury patterns. Significant differences in these characteristics have been observed in various studies, but these previous studies have suffered from limitations, such as insufficient quantification and unknown prognostic differences among different injury patterns. Therefore, we aimed to quantitatively analyze coronoid fracture characteristics and functional outcomes in different elbow injury patterns using 3D-CT. METHODS: All patients with coronoid fractures surgically treated at our hospital between January and December 2017 were categorized into three groups according to elbow injury pattern: PLRI, VPMRI and OFD. 3D models were reconstructed using Mimics 17.0, and the total volume (TV) and number of coronoid fragments (NCF) were measured. The coronoid process edge was classified into different anatomical regions, and each region was assigned a number to quantify the distribution of fracture lines. At the last follow-up, the ROM, VAS, MEPS, complications and reoperations were recorded. RESULTS: The ninety-two patients enrolled had an average age of 42±15 years and a male-to-female ratio of 66:26. The median TV in PLRI patients was less than that in VPMRI patients [431 (132, 818)mm3 vs. 1125 (746,1421)mm3,adjusted P<0.001] and OFD patients [431 (132, 818) mm3 vs. 2565 (381, 4076)mm3, adjusted P =0.001]. The median NCF in PLRI patients was also less than that in VPMRI patients [1 (1, 2) vs. 2 (1, 3), adjusted P=0.043]. Most of the PCFL-Rs (79%) were located around the volar edge of the lesser sigmoid notch. Compared with that of PLRI, the PCFL-Us of the VPMRI and OFD tended to be located on the more ulnodorsal side of the coronoid process edge. The median ROM [110 (90, 133), P=0.001] and the median MEPS [85 (68, 95), P=0.038] of patients with OFD were significantly less than those of patients with the other two patterns. The incidence of elbow stiffness (56%, 5/9, P=0.001) and implant-related irritation (44%, 4/9, P<0.001) in the OFD group was significantly higher than that in the other two groups. CONCLUSION: Coronoid fractures differ significantly in fragment volume, comminution severity and fracture line distribution among different elbow injury patterns. OFD has the worst functional outcomes among complex elbow injury patterns.

Lengthening in congenital posteromedial bowing of tibia: a follow-up series at skeletal maturity.

PURPOSE: Congenital posteromedial bowing (CPMB) of tibia is a rare, usually self-resolving condition that is present at birth. The data on the long-term outcome of lengthening, choice of fixator, outcome in early and late age groups, and complications is sparse, hence the need for this study. METHODS: This retrospective study included 93 patients with 94 affected legs from 1991 to 2023. The patients were categorized into early (under 10 years) and late (10 years or above) intervention groups. Eighteen patients with nineteen lengthening episodes who attained skeletal maturity made the basis of this study and will be discussed in detail. RESULTS: The outcome for the lengthening group at maturity was satisfactory, with 5.53 cm of average length gained per lengthening episode, a mean LLD of 0.31 cm at final follow-up, a mean age of 23.63 years (range 14-38 years), and an average follow-up of 12.51 years (range 3-28 years) post-lengthening, but the procedure was associated with difficulties like ankle stiffness, tibial valgus, pin tract infections, and fractures through regenerate. CONCLUSION: This study represents a large single-centre series on CPMB. We recommend that surgery for lengthening should be done at an older age, close to skeletal maturity, wherever possible to reduce the risk of repeat lengthening procedures. Based on our experience, we recommend the use of a circular fixator. Uniplanar distractors should have an adequate number and spread of Schanz screws in each segment to reduce the risk of valgus malalignment of distracting segments of bone.

Ventral posteromedial nucleus of the thalamus gates the spread of trigeminal neuropathic pain.

BACKGROUND: Widespread neuropathic pain usually affects a wide range of body areas and inflicts huge suffering on patients. However, little is known about how it happens and effective therapeutic interventions are lacking. METHODS: Widespread neuropathic pain was induced by partial infraorbital nerve transection (p-IONX) and evaluated by measuring nociceptive thresholds. In vivo/vitro electrophysiology were used to evaluate neuronal activity. Virus tracing strategies, combined with optogenetics and chemogenetics, were used to clarify the role of remodeling circuit in widespread neuropathic pain. RESULTS: We found that in mice receiving p-IONX, along with pain sensitization spreading from the orofacial area to distal body parts, glutamatergic neurons in the ventral posteromedial nucleus of the thalamus (VPMGlu) were hyperactive and more responsive to stimulations applied to the hind paw or tail. Tracing experiments revealed that a remodeling was induced by p-IONX in the afferent circuitry of VPMGlu, notably evidenced by more projections from glutamatergic neurons in the dorsal column nuclei (DCNGlu). Moreover, VPMGlu receiving afferents from the DCN extended projections further to glutamatergic neurons in the posterior insular cortex (pIC). Selective inhibition of the terminals of DCNGlu in the VPM, the soma of VPMGlu or the terminals of VPMGlu in the pIC all alleviated trigeminal and widespread neuropathic pain. CONCLUSION: These results demonstrate that hyperactive VPMGlu recruit new afferents from the DCN and relay the extra-cephalic input to the pIC after p-IONX, thus hold a key position in trigeminal neuropathic pain and its spreading. This study provides novel insights into the circuit mechanism and preclinical evidence for potential therapeutic targets of widespread neuropathic pain.

Safety and exposure area in three different posteromedial surgical approaches for the treatment of ankle fractures. A cadaveric study.

INTRODUCTION: This study aimed to compare the degree of posterior malleolar exposure, the tension of the flap containing the posteromedial neurovascular bundle (NVB), and the distance between the surgical incision and the NVB using three different posteromedial ankle approaches. METHODS: Three approaches were compared: medial posteromedial (MePM) modified posteromedial (MoPM) and posteromedial (PM). We measured the minimal tension of the flap containing the NVB that allowed proper exposure. In the second stage, an axial cut was performed, and we measured the degree of posterior malleolar exposure and the distance between the incision and the NVB RESULTS: There were significant differences between the three approaches examined regarding the degree of posterior malleolar exposure and distance from the incision to the NBV,favoring the PM approach (71,00% ± 1.83 and 25.50 mm ± 4.20). The PM approach provided a significantly lower tension to the flap containing the posteromedial NVB (6.18 N ± 1.28) compared to the other two approaches CONCLUSION: The PM approach achieved the highest degree of posterior malleolar exposure, the lowest tension to the posteromedial NVB, and the greatest distance between the incision and the NBV. Thus, we believe it should be considered the approach of choicefor large fractures of the posteromedial aspect of the PM.

Ventral posterolateral and ventral posteromedial thalamocortical neurons have distinct physiological properties.

Somatosensory information is propagated from the periphery to the cerebral cortex by two parallel pathways through the ventral posterolateral (VPL) and ventral posteromedial (VPM) thalamus. VPL and VPM neurons receive somatosensory signals from the body and head, respectively. VPL and VPM neurons may also receive cell type-specific GABAergic input from the reticular nucleus of the thalamus. Although VPL and VPM neurons have distinct connectivity and physiological roles, differences in their functional properties remain unclear as they are often studied as one ventrobasal thalamus neuron population. Here, we directly compared synaptic and intrinsic properties of VPL and VPM neurons in C57Bl/6J mice of both sexes aged P25-P32. VPL neurons showed greater depolarization-induced spike firing and spike frequency adaptation than VPM neurons. VPL and VPM neurons fired similar numbers of spikes during hyperpolarization rebound bursts, but VPM neurons exhibited shorter burst latency compared with VPL neurons, which correlated with larger sag potential. VPM neurons had larger membrane capacitance and more complex dendritic arbors. Recordings of spontaneous and evoked synaptic transmission suggested that VPL neurons receive stronger excitatory synaptic input, whereas inhibitory synapse strength was stronger in VPM neurons. This work indicates that VPL and VPM thalamocortical neurons have distinct intrinsic and synaptic properties. The observed functional differences could have important implications for their specific physiological and pathophysiological roles within the somatosensory thalamocortical network.NEW & NOTEWORTHY This study revealed that somatosensory thalamocortical neurons in the VPL and VPM have substantial differences in excitatory synaptic input and intrinsic firing properties. The distinct properties suggest that VPL and VPM neurons could process somatosensory information differently and have selective vulnerability to disease. This work improves our understanding of nucleus-specific neuron function in the thalamus and demonstrates the critical importance of studying these parallel somatosensory pathways separately.

Microsurgical anatomy of the isthmic cingulum: a new white matter crossroad and neurosurgical implications in the posteromedial interhemispheric approaches and the glioma invasion patterns.

ABTRACT: The dichotomy of the cingulum bundle into the dorsal supracallosal and ventral parahippocampal parts is widely accepted; however, the retrosplenial component with its multiple alternative connections has not been revealed. The aim of this study was to delineate the microsurgical anatomy of a connectionally transition zone, the isthmic cingulum, in relation to the posteromedial interhemispheric access to the atrium and discuss the relevant patterns of glioma invasion on the basis of its fiber connections. White matter (WM) fibers were dissected layer by layer in a medial-to-lateral, lateral-to-medial, and posterior-to-anterior fashion. All related tracts and their connections were generated using deterministic tractography. The magnetic resonance imaging (MRI) tractography findings were correlated with those of fiber dissection. A medial parieto-occipital approach to reach the atrium was performed with special emphasis on the cingulate isthmus and underlying WM connections. The isthmic cingulum, introduced as a retrosplenial connectional crossroad for the first time, displayed multiple connections to the splenium and the superior thalamic radiations. Another new finding was the demonstration of lateral hemispheric extension of the isthmic cingulum fibers through the base of the posterior part of the precuneus at the base of the parieto-occipital sulcus. The laterally crossing cingulum fibers were interconnected with three distinct association tracts: the middle longitudinal (MdLF), the inferior frontooccipital fasciculi (IFOF), and the claustro-cortical fibers (CCF). In the process of entry to the atrium during posterior interhemispheric approaches, the splenial and thalamic connections, as well as the laterally crossing fibers of the isthmic cingulum, were all in jeopardy. The connectional anatomy of the retrosplenial area is much more complicated than previously known. The isthmic cingulum connections may explain the concept of interhemispheric and medial to lateral cerebral hemisphere invasion patterns in medial parieto-occipital and posteromesial temporal gliomas. The isthmic cingulum is of key importance in posteromedial interhemispheric approaches to both: the atrium and the posterior mesial temporal lobe.

Magnetic resonance imaging of the knee anteromedial quadrant.

OBJECTIVE: This study aims to evaluate the possibility of characterizing an extra-articular thickening in the knee anteromedial quadrant in routine MRI scans. MATERIALS AND METHODS: Firstly, in a pilot study, for a better understanding of this extra-articular thickening trajectory in MRI, polytetrafluoroethylene (PTFE) tubes were attached to the ligament structure topography in two dissected pieces. Afterward, 100 knee MRI studies were randomly selected from our database, and 97 met the inclusion criteria. Two musculoskeletal radiologists interpreted the exams separately. Both had previously studied the ligament in the cadaveric knee MRI with the PTFE tube. RESULTS: The intraobserver and interobserver agreement for the ligament identification was calculated using Cohen's Kappa coefficient. The first radiologist identified the structure in 41 of the 97 scans (42.2%), and the second radiologist in 38 scans (39.2%). The interobserver agreement was substantial, with a Kappa of 0.68 and an agreement of 84.5%. The results suggest that this extra-articular thickening, recently called Anterior Oblique Ligament (AOL) in the literature, is a structure that can be frequently visualized on MRI scans with a high level of interobserver agreement in a relatively large number of exams. CONCLUSION: Therefore, this study indicates that MRI is a promising method for evaluating this anteromedial thickening, and it may be used for future studies of the Anterior Oblique Ligament.

Effect of posteromedial vertical capsulotomy with medial collateral ligament liberation on intraoperative medial component gap mismatch between extension and mid-flexion during total knee arthroplasty.

PURPOSE: The aim of this study was to quantify the effect of posteromedial vertical capsulotomy on intraoperative component gaps and angles from extension through mid-flexion to flexion during total knee arthroplasty (TKA). METHODS: In the present study, 47 cases of primary posterior-stabilized TKA using the measured resection technique for varus knee osteoarthritis (hip-knee-ankle angles < 0°) were reviewed. Component gaps and angles at 0°, 10°, 45°, 90°, and maximum flexion were measured intraoperatively, before and after posteromedial vertical capsulotomy. Differences in pre- and post-posteromedial vertical capsulotomy medial and lateral component gaps and angles and medial component gap mismatches among knee flexion angles were assessed using the Wilcoxon signed rank test for two paired samples. RESULTS: The medial component gaps at 0° and 10° of flexion of post-posteromedial vertical capsulotomy were significantly greater, exceeding the minimal detectable change, than those pre posteromedial vertical capsulotomy (change of the gap after the procedure at 0° of flexion was 0.7 ± 0.7 mm and at 10° of flexion was 0.8 ± 0.8 mm; all P values < 0.05). The medial component gap mismatches between both 0° and 10°, and 45°, 90°, and maximum flexion were significantly smaller post posteromedial vertical capsulotomy than pre posteromedial vertical capsulotomy, with the values of the change exceeding the minimal detectable change (change of the gap mismatch after the procedure: knee flexion at 0° and 45° was - 0.6 ± 0.9 [mm], at 0° and 90° was 0.7 ± 1.0, at 0° and maximum flexion was - 0.6 ± 1.2, at 10° and 45° was - 0.7 ± 0.9, at 10° and 90° was - 0.8 ± 0.9, at 10° and maximum flexion was - 0.7 ± 1.1; all P values < 0.05). CONCLUSIONS: Posteromedial vertical capsulotomy increased the medial component gaps during knee extension but not during mid-flexion or full flexion during posterior-stabilized TKA. Posteromedial vertical capsulotomy improved mild medial component gap mismatch between extension and mid-flexion and full flexion during posterior-stabilized TKA. Surgeons can consider posteromedial vertical capsulotomy when there is intraoperative constriction of the medial component gap during extension in patients undergoing posterior-stabilized TKA.

Posteromedial vertical capsulotomy selectively expands the intraoperative extension gap in cruciate-retaining total knee arthroplasty.

PURPOSE: Effective soft-tissue balancing procedures for expanding the extension gap (EG) are needed in cases of gap mismatch in total knee arthroplasty (TKA). A posteromedial vertical capsulotomy (PMVC) is performed to restore mobility in a knee with a flexion contracture. The purpose of this study was to evaluate the effectiveness and safety of PMVC for intraoperative gap adjustment in cruciate-retaining TKA. METHODS: A total of 120 consecutive knees undergoing cruciate-retaining TKA for varus osteoarthritis were examined. The EG and flexion gap (FG) with a trial femoral component were measured using spacer blocks before and after PMVC. PMVC was performed when the first FG was larger than the first EG by > 2 mm. RESULTS: Sixty-five knees underwent PMVC, and the mean EG significantly increased by 2.4 mm (p < 0.001). This increase was significantly larger than that of the FG by 2.0 mm (p < 0.001). The preoperative extension range of motion (ROM) was negatively correlated with the EG change after PMVC (r = - 0.39, p = 0.001). A receiver operating characteristic (ROC) curve indicated a preoperative extension ROM cut-off of -10° for predicting PMVC (sensitivity 72.3%, specificity 56.4%). No associated complications were observed during a minimum 2-year follow-up period, and there was no difference in the postoperative Knee Society Score between the PMVC and non-PMVC groups. CONCLUSION: PMVC may be a useful soft-tissue treatment for gap adjustment with a selective EG expansion in TKA, especially in cases of a limited preoperative extension of - 10° or less. LEVEL OF EVIDENCE: Therapeutic study, level III.

Outcomes following arthroscopic posteromedial osteophyte resection and risk of future ulnar collateral ligament reconstruction.

BACKGROUND AND HYPOTHESIS: Despite successful return-to-sport (RTS) outcomes after posteromedial osteophyte resection, one possible consequence of osteophyte removal is increased stress on the ulnar collateral ligament (UCL), leading to a UCL injury. It is currently unknown how often overhead athletes who undergo isolated posteromedial osteophyte resection subsequently require UCL reconstruction (UCLR). Therefore, the purpose of this study was to report outcomes following arthroscopic resection of posteromedial osteophytes in overhead athletes and determine whether overhead athletes who underwent arthroscopic posteromedial osteophyte resection for posteromedial impingement went on to require UCL surgery. We hypothesized that there would be a high rate of RTS following osteophyte resection and that players who underwent arthroscopic posteromedial osteophyte resection would have a >10% risk of requiring subsequent UCLR or UCL repair. MATERIALS AND METHODS: All patients who underwent elbow arthroscopy from 2010-2020 at a single institution were reviewed. Patients were included if they underwent isolated arthroscopic posteromedial osteophyte resection without concomitant UCL surgery, were overhead athletes at the onset of posteromedial impingement symptoms, and had no history of elbow surgery. Primary outcomes included RTS rate, complications, and subsequent shoulder and/or elbow injury and surgery, as well as several patient-reported outcome measures (Kerlan-Jobe Orthopaedic Clinic score, Timmerman-Andrews elbow score, and Conway-Jobe score). RESULTS: Overall, 36 overhead athletes were evaluated at 5.1 ± 3.4 years postoperatively, including 28 baseball pitchers, 3 baseball catchers, 3 softball players, 1 tennis player, and 1 volleyball player. Of the overhead athletes, 77% were able to RTS; the mean Kerlan-Jobe Orthopaedic Clinic and satisfaction scores were 70 and 75, respectively; and 89% of athletes had either excellent (73%) or good (16%) Conway-Jobe scores at long-term follow-up. Subsequent UCLR was required in 18% of baseball pitchers (n = 5) at a median of 13 months postoperatively. Of the 5 UCLRs, 3 were performed shortly after posteromedial osteophyte resection (6, 7, and 13 months postoperatively) whereas the other 2 were performed at 6.2 and 7.5 years postoperatively. CONCLUSION: Following arthroscopic posteromedial osteophyte resection, 77% of athletes were able to RTS. Baseball pitchers who undergo arthroscopic resection of posteromedial osteophytes for posteromedial impingement have an 18% risk of subsequent UCLR.

Outcomes and complications after treatment for anteromedial facet fracture of the coronoid process: A systematic review.

BACKGROUND: Fracture of the anteromedial facet (AMF) of the coronoid process is associated with varus posteromedial rotatory instability (VPMRI). However, there is still controversy regarding the optimal treatment for AMF fracture. The purpose of this study is to report on a systematic review of the outcomes and complications after treatment for AMF fracture. METHODS: This study was conducted using electronic databases, PubMed, EMBASE and Scopus. Studies reporting outcome scores and complications were included. Studies that did not utilize O'Driscoll classification for AMF fractures were excluded. Through conduct of a thorough review of included studies, definite VPMRI were identified and cases involving other injury mechanisms were excluded. RESULTS: Fifteen articles reporting on 246 patients were included. According to O'Driscoll classification, 6.2% of cases were anteromedial subtype I, 73.7% were subtype II, and 20.1% were subtype III. Two-hundred sixteen patients (87.8%) were treated surgically and 30 patients (12.2%) were treated conservatively. Lateral collateral ligament (LCL) injuries were 76.2% (157/206) and medial collateral ligament injuries were 16.9% (33/195). Among 216 cases who underwent surgical treatment, depending on the fragment size, displacement, and instability, coronoid fixation was performed in 189 cases and LCL repair alone was performed in 27 cases. The mean final Mayo Elbow Performance Score was 92.1 and the Broberg & Morrey score was 89.5. The overall complication and reoperation rates were 17.7% (41/232) and 12.9% (26/202). CONCLUSIONS: Both surgical and conservative treatment for AMF fractures resulted in satisfactory final clinical outcomes. However, high complication and reoperation rates were observed.

Comparison of buttress plate and cannulated screw in the treatment of anteromedial coronoid fracture with elbow posteromedial rotatory instability.

PURPOSE: The purpose of this study is to compare the effect of buttress plate and cannulated screw in the treatment of anteromedial coronoid fracture with posteromedial rotatory instability (PMRI). METHODS: We retrospectively evaluated patients who were diagnosed with O'Driscoll type 2 fractures combined with elbow posteromedial rotatory instability and underwent surgery for anteromedial coronoid fracture between August 2014 and March 2019. They were divided into buttress plate (n=16) and cannulated screw (n=11) groups. The elbow range of motion, visual analog scale (VAS), Mayo elbow performance score (MEPS), and disabilities of the arm, shoulder, and hand score (DASH) were used for clinical outcome assessment. RESULT: There were no significant differences in clinical outcomes. However, the surgical time was significantly shorter in cannulated screw group (85.45±4.156) compared to the buttress plate group (93.81±8.863, P=0.008), and the surgical time was associated with internal fixation (P=0.008). CONCLUSION: Although there was selection of cases in that small fragments were treated with buttress plate and large fragments with cannulated screw, the buttress plate and cannulated screw have comparable functional outcomes on fixation of the anteromedial coronoid fracture with elbow PMRI. The fixation of the anteromedial coronoid fracture with large fragments using the cannulated screw has a shorter operation time.

Anatomic repair and ligament bracing as an alternative treatment option for acute combined PCL injuries involving the posteromedial or posterolateral corner-results of a multicentre study.

INTRODUCTION: Combined PCL injuries involving the posteromedial/-lateral corner (PMC/PLC) usually require surgical management. Literature shows controversy regarding the standards of treatment. Suture-augmented repair leads to excellent results in acute knee dislocations but has not been investigated clinically in combined PCL injuries. The purpose of this multicentre study was to evaluate the clinical outcome of this technique in acute combined PCL injuries. MATERIALS & METHODS: N = 33 patients with acute combined PCL injuries involving the PMC/PLC were treated by one-stage suture repair with ligament bracing of the PCL and suture repair of the accompanying PMC/PLC injuries with/without ligament bracing or primary augmentation by semitendinosus autograft. Outcome was assessed by IKDC questionnaire, Lysholm Score, Tegner Activity Scale and KOOS. Additional PCL stress-radiography was performed. RESULTS: N = 31 patients with combined PCL injuries (female: male = 7:24; age 39.1 ± 13.8 years) with a follow-up of 16.8 ± 9.6 months were finally evaluated. 18 had PMC injuries, 13 PLC injuries. 32.2% presented with accompanying meniscal tears (70% medial meniscus). 19.4% showed cartilage injuries grade III-IV. Complications included one infection and four knee stiffnesses. Three had symptomatic postoperative instability, all affiliated to the PLC group. The IKDC was 69.8 ± 16.5, Lysholm score 85 ± 14.4 and KOOS 89.7 ± 8.1. Median loss of activity (Tegner) was 0.89 ± 1.31. Comparing PMC and PLC, all scores showed a tendency towards more favourable outcomes in the PMC group (n.s.). Stress-radiography showed an overall side-to-side difference of 3.7 ± 3.8 mm. Subgroup evaluation showed statistically significant better results (p = 0.035) of PMC (2.5 ± 1.5 mm) versus PLC (5.8 ± 5.6 mm). CONCLUSIONS: One-stage suture repair with ligament bracing is a viable technique for acute combined PCL injuries and predominantly leads to good and excellent clinical outcomes. Patients with PLC injuries show a tendency towards inferior outcomes and higher instability rates compared to PMC injuries. These results may help in therapy planning and counselling patients with these rare injury pattern. LEVEL OF EVIDENCE: Level II.

Less soft tissue release in total knee arthroplasty for anteromedial compared to posteromedial knee osteoarthritis.

In total knee arthroplasty (TKA), the aim of achieving a mechanically straight leg axis as well as symmetrical and equally wide gaps has become established as the gold standard in terms of surgical technique. In contrast to TKA unicompartmental knee arthroplasty (UKA) is performed in anteromedial osteoarthritis (AMOA) and does not normally require releases. This raises the hypothesis whether the type of osteoarthritis (AMOA vs. posteromedial osteoarthritis (PMOA)) determines the requirement for soft tissue releases in TKA.In this retrospective study, 114 patients with medial osteoarthritis of the knee who had been treated with a navigated total knee replacement were consecutively included. On the basis of the preoperative lateral radiographs, the patients were divided into two groups: AMOA and PMOA. The incidence and the extent of releases performed were recorded using the navigation records.Patient-specific data (gender, age) did not differ between the groups (NS). Knees with AMOA presented an overall varus alignment of 5.3 ± 3.5°, knees with PMOA 8.0 ± 4.0° (p < 0.001). 30 cases (44%) had to be released in the AMOA group, compared with 33 cases (72%) in the PMOA group (p = 0.004). In the case of medial release, the extension gap increased 3.3 ± 2.4 mm in the AMOA compared to 5.3 ± 3.7 mm in the PMOA group (p = 0.006). The medial flexion gap was released 2.2 ± 2.6 mm in the AMOA and 2.9 ± 3.0 mm in the PMOA group (p = 0.008).To achieve a neutral mechanical alignment, a release has to be performed due to asymmetry of the extension gap more often if PMOA is present than in AMOA. Surgeons should be prepared to perform more frequent and extensive medial releases in PMOA. Higher constrained implants should be available in case of unintended over release in PMOA.

Morphological study of CT image of posterior pilon variant fracture and its possible clinical significance.

OBJECTIVE: The incidence of posterior pilon variant fractures has been underestimated. The purpose was to study the characteristics of posteromedial (PM) and posterolateral (PL) fragments in CT imaging of posterior pilon variant fractures, and to provide help for clinical diagnosis and treatment. METHODS: CT imaging data of 109 cases of posterior pilon variant fractures in our hospital from January 2013 to December 2020 were retrospectively analyzed. According to Mason and Molloy classification, PM fragments were further divided into pilon subtypes and avulsed subtypes. The largest actual area of fragments in axial and sagittal were selected as the study plane, and the maximum axial lengths of X, Y and Z, α angle, ß angle, fragment area (S1-7) and fragment area ratio (FAR1-4), interfragmentary (IF) angle, and back of tibia (BT) angle were measured. RESULTS: A total of 109 cases were included in this study, 61 of whom were pilon subtypes [90.16% were supination-external rotation (SER) injuries]. 48 cases were avulsed subtypes [81.25% were pronation-external rotation (PER) injuries]. Pilon subtypes were larger than avulsed subtypes in X, Y, Z, α2 Angle, ß2 Angle, fragment area and ratio, and IF and BT angle (P < 0.05). There was no difference between α1 and ß1 angle (P > 0.05). CONCLUSION: The morphology of pilon subtype was larger than that of avulsion subtype. According to fragment size, morphology, and injury mechanism, two fragments of pilon subtype should be anatomic reduction and fixation. However, the PL fragment of avulsion subtype should to be fixed, while PM fragment may only need conservative treatment.

Conservative versus surgical management of isolated O'Driscoll II coronoid fracture: A systematic review.

PURPOSE: The purpose of this systematic review is to summarize the current literature on conservative and surgical management of isolated O'Driscoll II coronoid fracture. STUDY DESIGN: Systematic review. METHODS: We systematically searched Medline, Embase, Google Scholar, and Web of Science databases for published studies by complying with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and using the keywords "isolated coronoid fracture," "O'Driscoll type 2 coronoid fracture," "anteromedial coronoid fracture," "anteromedial facet coronoid fracture," "posteromedial rotatory instability," and "varus posteromedial rotatory instability." Patients were divided into conservative treatment and surgical treatment groups. Oxford Centre for Evidence-Based Medicine and Methodological Index for Non-Randomized Studies were assessed to determine each article's quality. The primary outcomes of the present reviews were the Mayo elbow performance score (MEPS) and the disabilities of the arm, shoulder, and hand (DASH) score, and the secondary outcomes were associated with complications and reoperations. Eligible trials were independently chosen by two review authors, and a third reviewer resolved all disagreements. RESULTS: The search yielded 458 records, among which 446 articles were of relevance, and 12 were included. In the final review, 138 patients were evaluated-98 (71%) who received surgical treatment and 40 (29%) who received conservative treatment. The mean MEPS score and the DASH score of surgical treatment were 91 and 8, respectively; 69.8% of patients had excellent scores, and 27.0% had good scores. The mean MEPS score and the DASH score of conservative treatment were 92 and 12, respectively; 70.6% of patients had excellent scores, and 23.5% had good scores. CONCLUSIONS: In select cases, conservative treatment can achieve good results in the treatment of isolated O'Driscoll II coronoid fracture when a stricter indication is followed. However, there is insufficient evidence to recommend the appropriate treatment for a particular fracture subtype, and there is a need for more high-quality randomized controlled trials to determine which treatment is superior.