Knee trauma, diagnosis and treatment.
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Biomechanical Phenomena↗
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Comparison of CT and MRI in patients with tibial plateau fracture: can CT findings predict ligament tear or meniscal injury?
OBJECTIVE: (1) To determine the accuracy of computed tomography (CT) in the evaluation of ligament tear and avulsion in patients with tibial plateau fracture. (2) To evaluate whether the presence or severity of fracture gap and articular depression can predict meniscal injury. DESIGN AND PATIENTS: A fellowship-trained musculoskeletal radiologist retrospectively reviewed knee CT and MRI examinations of 41 consecutive patients presenting to a level 1 trauma center with tibial plateau fractures. Fracture gap, articular depression, ligament tear and footprint avulsions were assessed on CT examinations. The MRI studies were examined for osseous and soft tissue injuries, including meniscal tear, meniscal displacement, ligament tear, and ligament avulsion. RESULTS: CT demonstrated torn ligaments with 80% sensitivity and 98% specificity. Only 2% of ligaments deemed intact on careful CT evaluation had partial or complete tears on MRI. Although the degree of fracture gap and articular depression was significantly greater in patients with meniscal injury compared with those without meniscal injury, ROC analysis demonstrated no clear threshold for gap or depression that yielded a combination of high sensitivity and specificity. CONCLUSIONS: In the acute setting, CT offers high sensitivity and specificity for depicting osseous avulsions, as well as high negative predictive value for excluding ligament injury. However, MRI remains necessary for the preoperative detection of meniscal injury.
Adolescent↗
An anatomic study of the ligamentous structure of the triangular fibrocartilage complex.
An anatomic study of the ligamentous structures of the triangular fibrocartilage complex and their attachments on the ulnar styloid was performed using 27 embalmed cadaver wrists. The dorsal and palmar distal radioulnar ligaments of the triangular fibrocartilage complex in each specimen contained a superficial and a deep portion. The deep portion of both ligaments inserted on the fovea of the ulna. The superficial portion of both ligaments surrounded the articular disc uniting at the ulnar-most portion of the articular disc. The tissue that is between the ulnar aspect of the superficial ligament (and integrated on its periphery) and the ulnar capsule is defined as the meniscus homologue. Anatomic variations in the meniscus homologue and the prestyloid recess (the cavity adjacent to the ulnar styloid) were seen in 1 of 3 ways; the narrow opening type in 74% of specimens, the wide opening type in 11%, and the no opening type in 15%. The ulnotriquetral ligament inserted on the palmar-radial aspect of the base of the ulnar styloid and the ulnolunate ligament inserted on the palmar border of the articular disc.
Cadaver↗
Lateral ligament injury of the ankle and associated articular cartilage degeneration in the talocrural joint: anatomic study using elderly cadavers.
We investigated degenerative changes (DCs) of the articular cartilage using 33 cadaveric talocrural joints with anterior talofibular ligament injuries. The control group (93 normal ankles) were age- and sex-matched with the injury group. The injured ligament carried unusual wavy collagen bundles with hyalinization (or elongation) or rupture with scar. In both groups, we found talar-side dominance of DCs, multifocus occurrence, and a high incidence of mirror-image DCs in the medial parts of the joint. However, the mirror-image lesion was multiple or large (or both) in the injury group in contrast to its restricted nature in the control. Thus, the averaged numbers of affected areas or sectors in the injury group were almost twice as large as in the controls. A significantly high incidence of DCs, especially of the mirror-image lesion, was found in the lateral malleolar facet in the injury group. Although initial DC lesions might be at a medial site in the joint, as hypothesized in the control group, the lateral ligament injury seemed to increase the dominance of DCs on the lateral site. Consequently, early evaluation and treatment for lateral ligament insufficiency is more necessary in elderly patients than in younger patients to avoid widespread development of osteoarthritis.
Aged↗
MR imaging of the sternoclavicular joint following trauma.
The purpose of this study is to describe the magnetic resonance imaging (MRI) findings of the sternoclavicular (SC) joint seen in patients who presented to our department with joint pain related to trauma. Clinical history and MRI findings on 41 patients were reviewed retrospectively to establish types and frequencies of soft tissue injuries and subluxations. Because both SC joints were imaged, the asymptomatic joints were used as a control group. Articular disk injuries were seen in 80% of patients. Injuries of the anterior, posterior, interclavicular and costoclavicular ligaments were seen in 73%, 39%, 29% and 14% of patients, respectively. Most clavicular subluxations were in the superior and posterior directions. Posterior impingement of mediastinal structures was seen in cases of posterior clavicular subluxation as well as in cases of retrosternal inflammatory or fibrotic tissue without clavicular subluxation. Biomechanical models of the SC joint are discussed to explain how different ligamentous injuries typically result in different types of subluxations.
Adult↗
[Intra-articular knee stabilization with synthetic material. A practice-oriented stabilization technic].
An intra-articular method designed to stabilise the knee joint using synthetic material after rupture of the anterior cruciate ligament is described. The results obtained in forty dogs and two cats treated by this method during the period from 1980 to 1985, are reported. The morbid-anatomical findings within fourteen months after surgery are referred to in one case. Rejection of the ligament was not observed in a single case. When habitual or stationary medial dislocation of the patella was present in addition to a lesion of the anterior cruciate ligament, the patella was no longer found to be subject to dislocation following stabilisation of the knee joint. Clinical results ranged from moderate to satisfactory, varying with the degree of arthrosis and the lesions of the meniscus which were present. This technique does not take up much time and consequently saves expenses.
Animals↗
Arthroscopic diagnosis and treatment of intra-articular insertional injuries of the suspensory ligament branches in 18 horses.
REASONS FOR PERFORMING STUDY: Clinical association between the branches of insertion of the suspensory ligament (SL) and metacarpophalangeal (MCP) and metatarsophalangeal (MTP) joints has been reported. However, there has been no assessment of the lengths of the SL branches which are subsynovial with respect to the joints or reports of involvement of the MCP/MTP joints in injuries of the SL branches. OBJECTIVES: To establish proportions of SL branches subsynovial with respect to the MCP/MTP joints and report clinical and arthroscopic findings in horses with desmitis of SL branches identified as having an articular component to the lesion. HYPOTHESIS: Arthroscopic surgery enables identification and potential treatment of intra-articular injuries of SL branches. METHODS: Twelve forelimbs and 13 hindlimbs were dissected and the total and subsynovial lengths of the SL branches recorded. Case records of horses with intra-articular injuries of the SL branches were reviewed and 18 animals identified. Diagnostic information and arthroscopic findings were recorded and results of treatment determined by telephone follow-up. RESULTS: Of SL branches, 28.45% in the forelimb and 29.56% in the hindlimb were subsynovial to the MCP and MTP joints. All animals with intra-articular lesions of the SL branch were lame and had distension of the affected MCP/MTP joint. In 16 horses (17/22 branches), there was palpable thickening of the affected SL branch. Disrupted infrastructure was evident ultrasonographically in 15/17 branches and involvement of the dorsal articular surface of the ligament was predicted in 12/17 branches. Following arthroscopic intervention, 13 horses returned to work at a level equal to or greater than that achieved prior to injury and 2 returned to work at a lower level. Three horses incurred separate injuries and were retired or subjected to euthanasia. CONCLUSIONS: Articular involvement should be considered in animals with injuries of an SL branch and concurrent distension of the MCP/MTP joint. Arthroscopy is necessary to identify such lesions confidently and to direct case management. POTENTIAL RELEVANCE: Arthroscopy of the MCP/MTP joints can make a positive contribution to the assessment and management of some SL branch injuries.
Animals↗
Concentrations of chondroitin sulfate epitopes 3B3 and 7D4 in synovial fluid after intra-articular and extracapsular reconstruction of the cranial cruciate ligament in dogs.
OBJECTIVE: To evaluate effects of intra-articular and extracapsular reconstruction of the cranial cruciate ligament (CCL) on metabolism of articular cartilage as reflected by concentrations of chondroitin sulfate epitopes 3B3 and 7D4 in synovial fluid. ANIMALS: 13 adult dogs. PROCEDURE: Each dog underwent unilateral CCL transection (CCLT). One month after CCLT, sham CCL reconstruction (3 dogs), intra-articular CCL reconstruction (5), or extracapsular CCL reconstruction (5) was performed. Synovial fluid was collected by direct arthrocentesis from CCLT and contralateral stifle joints immediately before (time 0) and 1, 3, and 5 months after CCLT. Fluid was examined for concentrations of 3B3 and 7D4 epitopes and total sulfated glycosaminoglycan (GAG) content. RESULTS: Concentrations of 3B3, 7D4, and GAG, 3B3:GAG, or 7D4:GAG in CCLT joints did not differ significantly among treatment groups nor in the ratios of these variables in CCLT joints to contralateral joints at 3 months. In a longitudinal analysis, concentrations of 3B3 and 7D4, 3B3:GAG, and 7D4:GAG in CCLT joints in all groups changed significantly with time, but we did not detect time X group interactions. CONCLUSIONS AND CLINICAL RELEVANCE: Transection of CCL resulted in significant perturbation in articular cartilage metabolism as reflected by alterations in concentrations of 3B3 and 7D4 in synovial fluid. These changes over time were not significantly influenced by method of CCL reconstruction. We did not find evidence that surgical stabilization of CCL-deficient joints by intra-articular or extracapsular techniques had any effect on preventing alterations in composition of synovial fluid that have been associated with secondary osteoarthritis.
Animals↗
The "enthesis organ" concept: why enthesopathies may not present as focal insertional disorders.
OBJECTIVE: The Achilles tendon insertion is associated with a complex of adjacent fibrocartilages, a bursa, and a fat-pad, and is functionally much more than a focal insertion. This has important implications for a better understanding of the spondylarthropathies (SpA). However, the degree to which other insertions form comparable "enthesis organs" has not been established. The aim of this study was to demonstrate the applicability of the enthesis organ concept to other insertion sites. METHODS: Both joint-related (articular) and extraarticular entheses were removed from 28 sites in the limbs of formalin-fixed cadavers (age at death 70-101 years) that had been donated for anatomic study. The samples were prepared for paraffin histologic analysis and sectioned longitudinally. The presence and extent of enthesis organs was evaluated at each site in serial sections stained with Masson's trichrome and toluidine blue. RESULTS: Articular enthesis organs were found at 14 entheses, including the attachments of the digital extensor tendons and collateral ligaments, the cruciate ligaments, tibialis anterior, the lateral collateral ligament of the knee, and the popliteal tendon. Extraarticular enthesis organs were seen at 2 sites, the biceps brachii and patellar tendon insertions. In all enthesis organs, sesamoid and/or periosteal fibrocartilage was present in close association with synovium. CONCLUSION: The concept of an enthesis organ is of general significance in understanding attachment sites and may explain the diverse pathologic changes, including synovitis, bursitis, and extracapsular changes, seen adjacent to tendon/ligament entheses in SpA. These findings may provide insight into the reason the target tissues in SpA are apparently so diverse.
Aged↗
Variations in meniscofemoral ligaments at anatomical study and MR imaging.
PURPOSE: To demonstrate variations in the meniscofemoral ligaments (ligaments of Wrisberg and Humphrey) at anatomical study and magnetic resonance (MR) imaging. DESIGN: Twenty-eight cadaveric knees were partially dissected for the examination of the meniscofemoral ligaments. One hundred knee MR examinations were reviewed by two experienced musculoskeletal radiologists. Proximal variations in the meniscofemoral ligaments at MR imaging were classified into three types according to the attachment site: type I, medial femoral condyle; type II, proximal half of the posterior cruciate ligament (PCL); type III, distal half of the PCL. Distal variations were classified into vertical or oblique types according to the orientation of the intermediate signal at the interface of the ligament and lateral meniscus. RESULTS: At anatomical study, six cases showed variations in the proximal insertion site of the meniscofemoral ligaments. At MR imaging 93 cases had one or more meniscofemoral ligaments, giving a total of 107 ligaments: 90 ligaments of Wrisberg and 17 ligaments of Humphrey. Forty-one ligaments of Wrisberg were type I, 28 type II, 19 type III, and with two indeterminate type, while 6 ligaments of Humphrey were type I and the remaining 11 were indeterminate. Seven cases showed no meniscofemoral ligament. Of the 107 meniscofemoral ligaments, the distal insertion orientation was of vertical type in 10 ligaments, oblique type in 70 and unidentified in 27. CONCLUSION: An understanding of the high incidence of meniscofemoral ligament variations may help in the interpretation of knee MR studies.
Adolescent↗
Reconstruction of the posterolateral corner of the knee.
PURPOSE: To describe a technique for reconstruction of the posterolateral corner (PLC) of the knee and report the results of a prospective series of patients. TYPE OF STUDY: Case series. METHODS: Twenty-two patients with PLC injuries underwent reconstruction; 15 patients had multiligamentous knee injuries and 7 had isolated PLC injuries. We used the modified 2-tailed technique that reconstructs the popliteofibular ligament and fibulocollateral ligament. The technique includes use of an allograft tendon placed through transtibial and transfibular bone tunnels and around a screw on the lateral femoral condyle. All patients have been followed-up prospectively with clinical examinations, Lysholm knee scores, KT-2000 ligament arthrometer examinations, and evaluation of work and recreational functional status. RESULTS: There were 15 male and 7 female patients (mean age, 32 years; range, 17 to 55 years). Follow-up was a minimum of 24 months (mean, 29.5 months; range, 24 to 38 months). Mean range of motion is extension of 0.2 degrees (range, 0 degrees to 5 degrees) and flexion of 133.4 degrees (80 degrees to 144 degrees). The range of motion for the multiligamentous knees was 0.3 degrees to 129 degrees compared with 0 degrees to 143 degrees for knees with isolated corner injuries. Mean Lysholm knee scores were 90 for the entire group with a score of 92 for the multiligamentous knees and 88 for the isolated corners. Stability was clinically graded on a scale of 0 to 3 for both varus stress and external rotation, with a score of 2 or 3 indicating a failed PLC reconstruction. The mean score for varus stress was 0.2 for the whole group, with 0.3 in the multiligamentous knee and 0.1 for the isolated injuries. Similarly, the mean score for external rotation was 0.4, with a 0.5 for multiligamentous knee and 0.3 for isolated PLC injuries. There were 2 failures in the multiligamentous knee injury group (13%), compared with no failures in the isolated PLC group. The failure rate for the whole study was 9%. CONCLUSIONS: Reconstruction of the PLC using an allograft reconstruction of the popliteus, popliteofibular, and fibulocollateral ligaments yielded a stable reconstruction with excellent functional results. Predictably, range of motion and incidence of failure were both better for patients with isolated PLC injuries than for those with multiligamentous knees. Both groups, however, showed excellent overall functional results. LEVEL OF EVIDENCE: Level IV, case series.
Adolescent↗
Ultrasound in acute and chronic knee injury.
This article presents a clinical approach to the role of ultrasound in the assessment of intra-articular and extra-articular knee pathology, including a comprehensive review of both acute and chronic conditions that may affect the tendons, ligaments, and bursae related to the knee joint. A brief review of the ultrasound findings in degenerative and inflammatory arthropathies and some of the more common tumors and masses that may be encountered around the symptomatic knee also has been included. Finally, the limited role of ultrasound in the assessment of the knee menisci and the symptomatic postarthroscopic patient is discussed.
Acute Disease↗
Normal joint tissues and their reaction to injury.
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Animals↗
Diagnostic arthroscopy and longitudinal open lateral release: a safe and effective treatment for "chondromalacia patella".
Lateral release is a reliable component of any surgical treatment of patellofemoral dysfunction or "chondromalacia patella," good to excellent results in approximately 80% of cases having been reported by numerous investigators. This study confirms the efficacy of the procedure and highlights the features of the open technique as compared with the arthroscopic method. We advocate diagnostic arthroscopy for complete evaluation of the joint. Particular attention is drawn to the anatomic structures that must be divided and the care taken to secure hemostasis to optimize results. Since no correlation was found between the severity of chondromalacia and the final results, this study casts doubt on the value of shaving the rough articular surface.
Adolescent↗
[Concomitant injuries after upper ankle joint dislocations].
Functional treatment with the Air Stirrup Ankle Brace recommended by C. N. Stover in 1979 can reduce pathological inversion of the ankle joint. In our retrospective study of 109 patients treated by this kind of ankle brace we found 96 patients (88%) with excellent results. Only 13 patients (12%) reported moderate to good results. To detect and characterize their painful conditions of ankles we did a clinical, radiological and MRI-Investigation. In only 2 cases we found a moderate instability after clinical investigation, anterior stress roentgenogram and talar tilt. By using the MRI-investigation 1.0 Tesla with a 512 x 360 Matrix we could find 10 cases with osteochondral lesions of the ankle. In 7 cases there was separated ossicle in the fibulotalar joint, in 1 case we detected a fracture of the processus anterior tali, in another case we could see a posttraumatic lesion of the talus and calcaneus with bone bruise and at least one osteochondral fracture of the distal tibia. The capability of the MRI to detect particularly osteo-chondral lesions of the talus and the tibiofibular joint was shown in 10 of 13 cases. Therefore we recommend to do an MRI-investigation on all patients after ankle sprain if there are painful conditions within the ankle after conservative treatment.
Adult↗
Review of pathogenesis and treatment of degenerative joint disease.
Treatment of degenerative joint disease (osteoarthritis) is discussed in relationship to pathogenesis of five clinical entities, defined to facilitate discussion:-1) occurring in high motion joints and associated with synovitis; 2) associated with low motion joints; 3) "non-progressive" articular cartilage erosion; 4) secondary to other identified problems (intra-articular fractures, ligamentous damage, wounds, septic arthritis, osteochondrosis); and 5) chondromalacia of the patella. In addition to direct damage to articular cartilage, synovitis and capsulitis and depletion of matrical glycosaminoglycans and proteoglycans play important roles. The natural healing response in damaged articular cartilage is inadequate. The principles of treatment are divided into: 1) prevention or treatment of primary causes. These include the effects of track surface, shoeing, and the appropriate resolution of intra-articular fractures, septic arthritis and osteochondritis dissecans. 2) treatment of active soft tissue disease contributing to articular cartilage degeneration, including rest, physical therapy, synovectomy and administration of anti-inflammatory drugs, sodium hyaluronate and polysulfated glycosaminoglycans. 3) attempts at treatment of articular cartilage loss or degeneration, including articular cartilage curettage, subchondral bone drilling, osteophyte removal, articular cartilage grafting and arthrodesis.
Animals↗
Volar plate fractures.
Rupture of the volar plate of the proximal interphalangeal joint, usually secondary to hyper-extension injury, may be accompanied by a radiographically evident avulsion fracture at the base of the middle phalanx. Findings were reviewed in 55 patients with 58 cases of volar plate fracture. This fracture should be specifically looked for in a patient with the typical history, since it may be the only radiographic evidence of a potentially disabling injury.
Adolescent↗
Subluxation of the distal radio-ulnar joint by hyperpronation.
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Adolescent↗