Isolated Polyethylene Insert Exchange for Instability after Total Knee Arthroplasty: Comparable Survival Rates and Range of Motion and Improved Clinical Scores Regardless of Hyperextension.

Background: Isolated polyethylene insert exchange (IPIE) has not been established as a treatment option for hyperextension instability after primary total knee arthroplasty (TKA). The purpose of the study was to evaluate the survival rate and clinical outcomes of IPIE for the treatment of instability with or without hyperextension after TKA. Methods: This study retrospectively reviewed 46 patients who underwent IPIE for symptomatic prosthetic knee instability by dividing them into 2 groups based on the presence of hyperextension (without for group I and with for group IH). Patient demographics, clinical scores, radiographic data, range of motion (ROM), and surgical information were collected. Clinical failure was defined as a subsequent surgery following IPIE for any reason. The survival rate of IPIE and differences in demographics, clinical scores, and ROM were compared. Results: There were 46 patients (91% were women) with an average age of 70.1 years and a mean follow-up of 44.8 months. The average time between primary TKA and IPIE surgery was 6.5 ± 4.2 years, and during IPIE, 2 out of the 8 cruciate-retaining inserts were converted to "deep-dish" ultracongruent inserts while the insert thickness increased from 11.9 ± 1.8 mm to 17.1 ± 3.1 mm. After IPIE surgery, a significantly thicker tibial insert was used in the group with hyperextension (15.39 ± 2.4 mm for group I, 18.3 ± 2.9 mm for group IH; p < 0.001 by independent t-test), and no significant differences were observed in the ROM and clinical scores before and after IPIE between the 2 groups. The overall survival rate for IPIE was 83% at 5 years and 57% at 10 years, and there were no statistically significant differences between the groups using the Cox proportional hazards regression model. Conclusions: IPIE demonstrated an overall survival rate of 83% at 5 years with no difference in the recurrence of instability regardless of hyperextension. This study highlighted the effectiveness of using thicker inserts to resolve instability without significant differences in the ROM or clinical scores between the groups, suggesting its potential as a decision-making reference for surgeons.

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.

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.

Proximal humerus fracture and acromioclavicular joint dislocation.

Proximal humerus fractures and injuries to the acromioclavicular joint are among the most common traumatic diseases of the upper extremity. Fractures of the proximal humerus occur most frequently in older people and are an indicator fracture of osteoporosis. While a large proportion of only slightly displaced fractures can be treated non-operatively, more complex fractures require surgical treatment. The choice of optimal treatment and the decision between joint-preserving surgery by means of osteosynthesis or endoprosthetic treatment is often a difficult decision in which both fracture morphology factors and individual factors should be taken into account. If endoprosthetic treatment is indicated, satisfactory long-term functional and clinical results have been achieved with a reverse shoulder arthroplasty. Injuries to the acromioclavicular joint occur primarily in young, athletic individuals. The common classification according to Rockwood divides the injury into 6 degrees of severity depending on the dislocation. This classification forms the basis for the decision on non-operative or surgical treatment. The indication for surgical treatment for higher-grade injuries is the subject of controversial debate in the latest literature. In chronic injuries, an autologous tendon transplant is also performed. Whereas in the past, treatment was often carried out using a hook plate, which was associated with complications, the gold standard today is minimally invasive treatment using Endobutton systems. This review provides an overview of the two injury patterns and discusses the various treatment options.

[Current treatment concepts of the lateral clavicle and the acromioclavicular joint]. / Aktuelle Versorgungskonzepte der lateralen Klavikula und des Akromioklavikulargelenks.

Injurie to the lateral clavicle and acromioclavicular joint (ACJ) are frequent events which are relevant to everyday life and particularly affect active adults at the age of 20-40 years. The Rockwood classification has been established for the classification of ACJ injuries. Lateral clavicle fractures are classified according to the Neer classification or the Jäger and Breitner classification. A newly established classification is the Cho classification. Depending on the injury pattern and in particular the presence of instability, various conservative and surgical care strategies are used. This article provides an overview of the various treatment concepts.

Arthroscopic-Assisted Repair of the Triangular Fibrocartilage Complex.

Triangular fibrocartilage complex (TFCC) injuries are a common cause of ulnar-side wrist pain and may progress to persistent pain, instability of the distal radioulnar joint, and arthritis if left untreated. Diagnosis and management of these injuries requires a nuanced understanding of features pertinent to the clinical presentation, imaging, and arthroscopic findings for accurate management. Arthroscopic-assisted repair techniques have revolutionized surgical management, providing detailed visualization and facilitating the repair of TFCC injuries and associated pathologies with minimally invasive techniques. In this review, we discuss the anatomy of the TFCC, history and examination of ulnar-sided pathology, imaging findings, and classification schemes and review surgical techniques for the treatment of TFCC injuries. We also touch on pearls and pitfalls of the techniques, complications, and results of treatment.

[Reconstruction of the medial collateral ligament complex with a flat semitendinosus auto- or allograft]. / Rekonstruktion des medialen Kollateralbandkomplexes mit einem flachen autologen oder allogenen Semitendinosussehnentransplantat.

OBJECTIVE: Replacement of superficial medial collateral ligament (sMCL) and posterior oblique ligament (POL) with an allograft. INDICATIONS: Chronic 3° isolated medial instability and combined anteromedial or posteromedial instability. CONTRAINDICATIONS: Infection, open growth plates, restricted range of motion (less than E/F 0-0-90°). SURGICAL TECHNIQUE: Longitudinal incision from medial epicondyle to superficial pes anserinus and exposure of the medial collateral ligament complex. Thawing of the allogeneic semitendinosus tendon graft at room temperature, reinforcement of the tendon ends with sutures and preparation of a two-stranded graft. Placement of guidewires in the sMCL and POL insertions and control with image intensifier. Tunnel drilling. Pulling the graft loop into the femoral bone tunnel and fixation with a flip button. Pulling the two graft ends into the tibial tunnels. Tibial fixation by knotting the suture ends in a 20° flexion on the lateral cortex. Suture the tendon bundles to the remaining remnants of the medial collateral ligament complex to adopt the flat structure of the natural medial collateral ligament complex. POSTOPERATIVE MANAGEMENT: Six weeks partial weight-bearing, immediately postoperatively splint in the extended position, after 2 weeks movable knee brace for another 4-6 weeks. Mobility: 4 weeks 0-0-60, 5th and 6th weeks 0-0-90. RESULTS: From 2015-2021, this surgical procedure was performed in 19 patients (5 women, 14 men, age 34 years). Mean Lysholm score at follow-up after at least 2 years was 89 (76-99) points. In 6 patients, there was restricted range of motion 3 months postoperatively, which resulted in further therapy (3 נsystemic cortisone therapy, 3 נarthroscopically supported manipulations under anesthesia).

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.

A Unique "Galeazzi-Like" Fracture through a Vacated External-Fixator Pin Track: A Case Report.

Introduction: Galeazzi fractures are fractures of the radial shaft accompanied by distal radioulnar joint (DRUJ) instability. They usually occur due to a mechanical fall or direct trauma to the wrist or forearm. Management of this serious injury varies from non-operative treatment with closed reduction and splinting to operative fixation using an external fixator (ex-fix) or open reduction internal fixation with plate and screws. Case Report: We present a 76-year-old female who presented with a right distal radius fracture after a ground-level fall. Due to fracture displacement after initial conservative management, she was placed in an external fixator for stabilization. After removal of the ex-fix, she sustained a midshaft radius fracture with DRUJ malalignment, consistent with a "Galeazzi-like" fracture. Conclusion: "Galeazzi-like" fractures with associated DRUJ malalignment can occur from previous external fixator pin sites and are adequately treated with standard operative fixation.

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.

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.

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.

Risk Factors Associated with First Time and Recurrent Shoulder Instability: A Systematic Review.

Background: Shoulder instabilities constitute a large proportion of shoulder injuries and have a wide range of presentations. While evidence regarding glenohumeral dislocations and associated risk factors has been reported, less is known regarding the full spectrum of instabilities and their risk factors. Purpose: The purpose of this systematic review was to identify modifiable risk factors to guide patient management decisions with regards to implementation of interventions to prevent or reduce the risk of shoulder instability. Study Design: Systematic Review. Methods: A systematic, computerized search of electronic databases (CINAHL, Cochrane, Embase, PubMed, SportDiscus, and Web of Science) was performed. Inclusion criteria were: (1) a diagnosis of shoulder instability (2) the statistical association of at least one risk factor was reported, (3) study designs appropriate for risk factors, (4) written in English, and (5) used an acceptable reference standard for diagnosed shoulder instability. Titles and abstracts were independently screened by at least two reviewers. All reviewers examined the quality studies using the Newcastle-Ottawa Scale (NOS). At least two reviewers independently extracted information and data regarding author, year, study population, study design, criterion standard, and strength of association statistics with risk factors. Results: Male sex, participation in sport, hypermobility in males, and glenoid index demonstrated moderate to large risk associated with first time shoulder instability. Male sex, age \<30 years, and history of glenohumeral instability with concomitant injury demonstrated moderate to large risk associated with recurrent shoulder instability. Conclusion: There may be an opportunity for patient education in particular populations as to their increased risk for suffering shoulder instability, particularly in young males who appear to be at increased risk for recurrent shoulder instability. Level of Evidence: Level III.

COMPARISON BETWEEN PORTALS FOR PLACEMENT OF ANCHORS IN SHOULDER INSTABILITY.

Objective: to radiographically compare the effects of anchor positioning in the arthroscopic treatment of shoulder instability, in the 3- and 5-o'clock portals. Methods: retrospective study of 36 patients, operated by two shoulder surgeons at the Unimed BH hospital, between January 2013 and January 2018. Each surgeon used only one of either the 3- or the 5-o'clock portal. After postoperative radiographs we performed angle comparisons between the greatest glenoidal axis, the angle of anchor insertion and distance from the inferior pole. Results: the 5-o'clock portal provided better placement than its 3-o'clock counterpart, which allowed for greater orthogonality in relation to the glenoid rim (p < 0.05). Conclusion: the 5-o'clock portal allowed for better anchor placement than the 3 o'clock one. Level of Evidence II, Clinical Trial.

Objetivo: Comparar radiograficamente o posicionamento das âncoras utilizadas no tratamento artroscópico da instabilidade do ombro, através dos portais de 3 ou 5 horas. Métodos: Avaliação retrospectivae de 36 pacientes, operados por dois cirurgiões de ombro do Hospital Unimed BH, entre janeiro de 2013 e janeiro de 2018. Cada cirurgião utilizou apenas uma das técnicas ­ portal de 3 ou 5 horas. As radiografias pós-operatórias foram avaliadas e comparadas a angulações entre o maior eixo da glenoide, o ângulo de inserção da âncora e a distância em relação ao polo inferior. Resultados: A utilização do portal de 5 horas propiciou a colocação mais adequada das âncoras em relação ao portal de 3 horas, permitindo o posicionamento mais ortogonal em relação à borda da glenoide (p < 0,05). Conclusão: A utilização do portal de 5 horas apresenta melhor posicionamento das âncoras quando comparado ao portal de 3 horas. Nível de evidência II, Ensaio Clínico.

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.

Effect of whole-body vibration on postural stability in young adults with generalized joint hypermobility: A comparative study.

BACKGROUND: Whole-body vibration (WBV) is being used in rehabilitation and sport. Studies confirm its positive impact on muscle strength and power or regulating muscle hypertension. However, there are some uncertainties regarding its influence on postural stability. This issue seems particularly interesting in the case of individuals with generalized joint hypermobility (GJH), for whom proprioceptive training and muscle strengthening exercises are recommended while techniques that decrease muscle tension are not advised. OBJECTIVE: The aim of the study was to evaluate the acute effect of WBV on postural stability in adults with GJH. METHODS: 60 participants were categorized into the groups: 1) hypermobility with vibration (GJH+WBV), 2) hypermobility without vibration (GJH-WBV), 3) control group with vibration (CTRL+WBV), 4) control group without vibration (CTRL-WBV). The first and the third group completed WBV (frequency: 15 Hz and 30 Hz, amplitude 3 mm, 3 × 3 min). The second and fourth groups participated only in measurement sessions. GJH was assessed using the Beighton test. Postural stability was measured as the overall stability index (OSI) on the Biodex Balance System on the stable and unstable platform with open and closed eyes. Measurements were taken before and after WBV for two weeks. RESULTS: At a frequency of 15 Hz, a significant time effect was observed for measurements Before and After in CTRL-WBV on the stable platform with open eyes (p= 0.012) and on the unstable platform with closed eyes (p= 0.000) for the GJH+WBV and CTRL+WBV groups. There were no significant interactions (p> 0.05) between factors. At a frequency of 30 Hz, there was a significant time effect Before and After (p= 0.047) on the stable platform with open eyes, but no interaction was found between factors (p= 0.835). CONCLUSION: There is no positive acute effect of WBV on postural stability in adults with and without GJH.

Combined Anterior Cruciate Ligament Reconstruction (ACLR) and Lateral Extra-articular Tenodesis through the Modified Lemaire Technique versus Isolated ACLR: A Meta-analysis of Clinical Outcomes.

Objective Lateral extra-articular tenodesis (LET) has been proposed to resolve rotatory instability following anterior cruciate ligament reconstruction (ACLR). The present meta-analysis aimed to compare the clinical outcomes of ACLR and ACLR with LET using the modified Lemaire technique. Materials and Methods We performed a meta-analysis following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) staement. The literature search was performed on the PubMed, EBSCOHost, Scopus, ScienceDirect, and WileyOnline databases. The data extracted from the studies included were the study characteristics, the failure rate (graft or clinical failure) as the primary outcome, and the functional score as the secondary outcome. Comparisons were made between the patients who underwent isolated ACLR (ACLR group) and those submitted to ACLR and LET through the modified Lemaire technique (ACLR + LET group). Results A total of 5 studies including 797 patients were evaluated. The ACLR + LET group presented a lower risk of failure and lower rate of rerupture than the ACLR group (risk ratio [RR] = 0.44; 95% confidence interval [95%CI]: 0.26 to 0.75; I 2 = 9%; p = 0.003). The ACLR + LET group presented higher scores on the Knee Injury and Osteoarthritis Outcome Score (KOOS) regarding the following outcomes: pain, activities of daily living (ADL), sports, and quality of life (QOL), with mean differences of 0.20 (95%CI: 0.10 to 0.30; I 2 = 0%; p < 0.0001), -0.20 (95%CI: -0.26 to -0.13; I 2 = 0%; p < 0.00001), 0.20 (95%CI: 0.02 to 0.38; I 2 = 0%; p = 0.03), and 0.50 (95%CI: 0.29 to 0.71; I 2 = 0%; p < 0.00001) respectively when compared with the ACLR group. Conclusion Adding LET through the modified Lemaire technique to ACLR may improve knee stability because of the lower rate of graft rerupture and the superiority in terms of clinical outcomes. Level of Evidence I.

A Novel Fixation Method of the Graft to the Fibular Head in Knee Lateral Collateral Ligament Reconstruction: Technical Note.

The lateral collateral ligament (LCL) is the strongest lateral stabilizer of the knee. It provides support against varus stress and posterolateral rotation of the knee. Lateral collateral ligament injuries mostly occur together with anterior and/or posterior cruciate ligament injuries. While grades 1 and 2 injuries are treated conservatively since they are partial injuries, total ruptures, as in grade 3, require surgical treatment. In conventional LCL reconstruction methods, hamstring grafts are used, and bioscrews are used in bone-tendon fixation. Lateral collateral ligament reconstruction is usually performed as a component of multiple ligament surgery. Therefore, there is a need for a contralateral hamstring tendon or allograft. The present article aims to define a technique that does not require tendon grafts and bioscrews in fibular fixation.

Homeopathic Ankle Dislocation for Treatment of Unstable Trimalleolar Fractures Involving Posterior Die-Punch Fragment: A Retrospective Cohort Study.

OBJECTIVES: Unstable trimalleolar fractures are relatively complex and more difficult to manage if die-punch fracture is present. We aimed to evaluate the curative effect of homeopathic ankle dislocation on the unstable trimalleolar fractures involving posterior die-punch fragments. METHODS: A total of 124 patients diagnosed with unstable trimalleolar fractures combined with post-die punch fragment between June 2008 and June 2020 were retrospectively included. Patients who received homeopathic ankle dislocation were named as the experimental group, and patients who accepted conventional treatment were control group. The fracture healing time, wound healing, American Orthopedic Foot and Ankle Society ankle-hindfoot scale (AOFAS), visual analogue scale (VAS), the Kellgren-Lawrence arthritis grading scale (KLAGS) and short-form 36 score (SF-36) scores were collected. Student t-test was used for fracture healing time. Wound healing and SF-36 were compared using the Mann-Whitney test. Repeated measurement analysis of variance (ANOVA) was used for AOFAS and VAS. χ2-test was used for KLAGS. RESULTS: AOFAS showed statistically significant differences between the two groups (p = 0.001). In non-weight-bearing and weight-bearing conditions, VAS scores were significant different between the two groups, and there was an interaction between group and time point (p < 0.001). The experimental group was superior to the control group in terms of physical function (p = 0.022), role-physical (p = 0.018), general health (p = 0.001) and social function (p = 0.042).The operation time of experimental group was shorter than that of control group (p < 0.001). CONCLUSION: Homeopathic ankle dislocation is used for the unstable trimalleolar fractures involving posterior die-punch fragment, which can provide better functional outcomes while shortening the operation time and recovery period.

Must a Knee with Anterior Cruciate Ligament Deficiency and High-grade Pivot Shift Test Present an Increase in Internal Rotation?

Objective: Rupture of the anterior cruciate ligament (ACL) is one of the most common injuries in athletes and is often associated with damage to anterolateral structures. This combination of injuries presents itself clinically as a high-grade pivot shift test. The hypothesis of this study is that patients with ACL deficiency and high-grade pivot shift test should have an increased internal knee rotation. Methods: Twenty-two patients were tested. After effective spinal anesthesia, two tests were performed with the patient in supine position. First, the bilateral pivot shift test was performed manually, and its grade was recorded. Then, with the knee flexed to 90 degrees, the examiner drew the projection of the foot in a neutral position and in maximum internal rotation, and the angle of internal rotation was measured from the axes built between the central point of the heel and the hallux. Results: In the ACL-deficient knee, it was observed that there is a statistically significant average internal rotation (IR) delta of 10.5 degrees between the groups when not adjusted for age, and 10.6 degrees when adjusted for age. Conclusions: Knees with ACL deficiency and with pivot shift test grade I do not show increased internal rotation in relation to knees with intact ACL. Knees with ACL deficiency and with pivot shift test grades II and III show increased internal rotation in comparison to healthy knees.