Thumb metacarpophalangeal joint collateral ligament injury management

The thumb collateral ligaments at the metacarpophalangeal joint are important to the elite athlete for precision grip and pinch. Injuries to these ligaments can result in pain and instability and are seen at a higher frequency at the elite level. Whereas the collateral ligament tears used to be associated primarily with recreational skier's injury, these injuries have been reported with increasing frequency in major professional sports. The ulnar collateral and radial collateral ligament injuries of the thumb occur through different mechanisms and are described in separate sections given the differences in their anatomy.     

Thumb metacarpophalangeal ulnar collateral ligament injuries: a biomechanical simulation study of four static reconstructions

PURPOSE: To determine the optimal tunnel placement positions for tendon graft reconstruction of chronic thumb metacarpophalangeal (MCP) ulnar collateral ligament injuries that would stabilize the joint while maintaining motion. METHODS: Four commonly used tunnel placement methods were simulated on a cadaveric model using fresh-frozen thumbs and a suture/screw construct. The methods were as follows: (1) triangular configuration with apex proximal, (2) triangular configuration with apex distal, (3) cruciate configuration, and (4) parallel configuration. Stability was tested by valgus loading at 0 degrees and 30 degrees , and range of motion was tested by loading the thumb tendons. Statistical analysis was performed by 1-way analysis of variance testing. RESULTS: Valgus load stability testing at 0 degrees and 30 degrees showed that all 4 reconstruction methods stabilized the MCP joint compared with the fully sectioned state. The amount of stability achieved was not significantly different between the 4 methods. Only the reconstruction method, however, with a triangular configuration with the apex proximal restored flexion/extension range of motion not significantly different from the intact state. The other 3 methods resulted in significantly decreased range of motion. CONCLUSIONS: The reconstruction tunnel positioning of triangular configuration with apex proximal stabilizes the thumb MCP joint while maintaining flexion/extension range of motion. We recommend this configuration for chronic MCP joint injuries in which the native ulnar collateral ligament is inadequate and tendon graft reconstruction is performed.     

Radial collateral ligament injuries of the thumb

Radial collateral ligament (RCL) injuries of the thumb are relatively common although they are less common than ulnar collateral ligament injuries, which make up 10% to 42% of collateral ligament injuries of the thumb. The RCL is especially important for pinch movements and for movements of depression. Complete disruption of the RCL can result in both static and dynamic instability, which can lead to a predictable sequence of a painful deformity resulting in articular degeneration. Most authors agree that both acute and chronic grade 3 RCL tears should be surgically treated. There are various methods of repair or reconstruction of the RCL that yield satisfactory results, providing radial stability and intending to preclude the appearance of degenerative disease of the metacarpophalangeal joint. This article reviews the anatomy, physiology, diagnosis, and treatment, including surgical technique, for RCL injuries of the thumb.     

Lateral collateral ligament ankle injuries in young athletic individuals.

1. Eleven cases of surgical repair of acute tears of the capsule, anterior talo-fibular, and calcaneo-fibular ligaments of the ankle in young athletic individuals are reported. 2. Diagnosis was made by clinical examination and stress X-rays and confirmed by arthrography in selected cases. All of the ligament ruptures were visualized at surgery. 3. Post-surgery, all of the patients had a stable ankle and were able to return to vigorous athletic endeavors without disability. 4. This study lends support to the impression that surgical repair of severe lateral collateral ankle ligament injuries in young athletic individuals leads to a functionally and mechanically stable ankle able to withstand severe stress without disability.     

Thumb metacarpophalangeal joint ulnar collateral ligament reconstruction using a tendon graft

Chronic instability of the ulnar collateral ligament of the metacarpophalangeal joint of the thumb can cause significant functional disability due to pain and weakness of pinch and grasp. In the absence of adequate ligament to repair, stability of the joint can be restored by reconstruction using a free tendon graft. The technique described here routes the tendon graft through two holes in the proximal phalangeal base and one hole in the metacarpal neck in a triangular configuration, which recapitulates the normal anatomy of the ulnar collateral ligament. The results of reconstruction are good. Stability and strength are restored without sacrificing significant range of motion and with minimal donor site morbidity.     

An anatomic basis for revision rhinoplasty

As the popularity of rhinoplasty has increased, so have the expectations of both patients and surgeons alike. Revision rhinoplasty has become an evolving field with unique challenges. One must first address the patient's specific concerns and emotional issues. To properly repair the inadequacies of a failed rhinoplasty, the surgeon must thoroughly analyze and understand the anatomic causes leading to why the patient needs revision surgery.     

第三腓骨肌动力解剖重建外侧副韧带

[目的]介绍第三腓骨肌腱解剖重建外侧副韧带治疗踝关节慢性外侧不稳定的技术与临床疗效。[方法]回顾分析2015年12月～2018年01月采用第三腓骨肌动力解剖重建外侧副韧带治疗慢性踝关节外侧不稳63例。在第三腓骨肌肌腱远端止点处切断,向近端游离至远侧伸肌支持带近端,向下牵拉肌腱,于距骨颈距腓前韧带附着点放置锚钉,缝合固定第三腓骨肌腱。于外踝距腓前韧带及跟腓韧带附着点分别建立骨道并相通,将移植腱游离端穿过骨隧道,拉紧肌腱,Swivelock锚钉固定肌腱,重建距腓前韧带,再在跟骨止点建立骨道,将移植腱游离端导入,Swivelock锚钉固定,重建跟腓前韧带。[结果]随访时间为8～28个月。术后6个月,患者的AOFAS评分,应力下影像距骨倾斜角、距骨前移距离均较术前显著改善,差异均具有统计学意义(P0.05)。末次随访时,临床结果评定为优11例,良49例,可3例,优良率为95.24%。[结论]应用第三腓骨肌解剖重建外侧副韧带,创伤小,操作简单,临床疗效满意。     

Combined anterior cruciate ligament and medial collateral ligament injuries in adolescents

Although literature supports bracing of most medial collateral ligament (MCL) injuries followed by arthroscopic repair of anterior cruciate ligament (ACL) tears in adults with combined ACL-MCL injuries, little is published regarding the treatment of these injuries in the pediatric population. The purpose of this study was to present our outcomes after treatment of combined ACL-MCL injuries in a series of adolescents. All 180 patients who underwent ACL reconstruction at our children's hospital from January 1997 to January 2003 were reviewed to identify those patients with concomitant grade II or III MCL injuries. Clinical data were obtained from chart review. All patients were treated with a hinged brace for their MCL injury followed by delayed arthroscopic reconstruction of their ACL using a transphyseal technique with Achilles tendon soft tissue allograft. Patients were contacted by phone to complete Lysholm knee questionnaires and assess return to athletic competition. Data were compared with a control cohort of patients who underwent isolated ACL reconstruction using the same technique. Twelve (6.7%) of 180 patients had combined ACL-MCL injuries. There were 6 boys and 6 girls; the mean age was 15.6 years (range, 14-17 years). Follow-up averaged 5.3 years (range, 2.6-8.2 years), and no patients were lost to follow-up. At last examination, all patients had a stable knee on both Lachman and valgus stress tests; the mean Lysholm knee score was 96 (range, 94-100). All patients were able to return to their preinjury level of athletics. One patient required manipulation for arthrofibrosis. When compared with the control group of 19 isolated ACL reconstructions, there was no significant difference with regards to Lysholm scores or return to athletics.Bracing of grade 2 or 3 MCL injuries followed by ACL reconstruction was an effective means of treating combined ACL-MCL injuries in this small series of adolescent patients.     

内侧副韧带合并前交叉韧带损伤的临床治疗策略

膝关节内侧副韧带Hughston Ⅲ级损伤常合并有前交叉韧带损伤,韧带重建术是目前该类损伤主要的治疗方式。其中,前交叉韧带重建术已经从传统的等长重建发展到解剖重建,使膝关节术后的前后稳定性和患者的运动水平得到了更满意的临床效果;目前内侧副韧带的重建方式较多,但是大多不能很好的恢复膝关节的旋转稳定性,内侧副韧带三角矢量重建在恢复膝关节外翻稳定性的同时,能够有效的恢复旋转稳定性。对于合并有内侧副韧带和前交叉韧带的损伤,二者造成旋转稳定性的叠加损失,内侧副韧带三角矢量重建发挥的作用就显得更加重要。作者提出了一种治疗内侧副韧带和前交叉韧带合并损伤的临床治疗策略,旨在更好地指导、应用于临床。     

Total elbow allografts with collateral ligament reconstruction for posttraumatic elbow injuries

Background  

The use of total osteoarticular elbow allografts as a salvage procedure for reconstruction of posttraumatic elbow periarticular defects and bone loss has been previously described. Although the procedure restores bone stock and provides a painless functional joint, it is associated with multiple complications, including infection, nonunion, and instability.     

Combined injuries of the medial collateral ligament and the anterior cruciate ligament

Aim of this retrospective study is to evaluate the effect of acute and late anterior cruciate ligament (ACL) reconstruction in patients with a combined injury of the ACL and the medial collateral ligament (MCL). All MCL injuries were treated non-operatively. In 27 patients (group I) we performed early ACL reconstruction (within the first 3 weeks after injury). The postoperative rehabilitation protocol included brace treatment for all patients over a period of 6 weeks. In 37 patients we performed late ACL reconstruction (after a minimum of 10 weeks). In this group initial non-operative MCL treatment (6 weeks brace treatment) was followed by a period of accelerated rehabilitation. Patients with late ACL reconstruction had a lower rate of loss of motion after finishing the postoperative rehabilitation programme and a lower rate of re-arthroscopies for a loss of extension (group I: 4 patients, group II: 1 patient). The difference in the mean quadriceps muscle strength (group I: 83.3%, group II: 86.3%) was not statistically significant. After a mean interval of 22 months, we saw no difference in the frequency of anterior or medial instabilities or in the loss of motion. The Lysholm score was significantly better in the group with late ACL reconstruction (group I: 85.3, group II: 89.9). The position on the Tegner activity scale decreased in both groups, to 5.5 in group I (preoperatively: 6.0) and to 5.6 in group II (preoperatively: 5.9). With regard to the lower rate of motion complications in the early postoperative period, the lower rate of re-arthroscopies, and the significantly better results in the Lysholm score, we prefer late ACL reconstruction in the treatment of combined injuries of the ACL and the MCL.     

Medial collateral knee ligament healing: Combined medial collateral and anterior cruciate ligament injuries studied in rabbits

We examined the histological appearance and biochemical properties of the healing medial collateral ligament (MCL) of a rabbit knee after combined MCL and anterior cruciate ligament (ACL) injury treated with ACL reconstruction and with or without MCL repair. By so doing, we hoped to understand better our previous biomechanical observations (Ohno et al. 1995) and possibly learn where to focus future investigation into improving the quality of the healing MCL.

Ligaments were examined at 6 and 12 weeks of healing. We found healing of all ligaments with hypercellularity and fibroblast elongation along the axis of loading, as expected. Unexpected, however, was the finding of multiple osteophytes in both the repaired and nonrepaired specimens at the medial borders of the joint and at the MCL insertions. These were felt to affect possibly the biomechanics of the MCL by causing stress risers at the point where they undermine the ligament. Biochemically, we demonstrated a correlation between collagen content and hydroxypyridinium crosslinks and modulus of elasticity. While this implies that the modulus is dependent on collagen content and hydroxypyridinium crosslink density, modulus is also probably dependent on other factors such as collagen organization, type and internal structure. Overall, the detailed characterization and correlation between the histological, biochemical, and biomechanical properties of the healing MCL in the severe knee injury model provide insight into the functional behavior of the healing MCL.     

Treatment of "Gamekeeper's Thumb" by reconstruction of the ulnar collateral ligament

This study examines the treatment of 22 thumbs with symptomatic laxity of the ulnar collateral ligament of the metacarpophalangeal joint by ligament reconstruction 1 week to 10 years after injury. The existing ligament remnants were repaired in 13 thumbs and were re-attached to bone, using a bone anchor, in seven cases. Two ligaments were reconstructed using the extensor pollicis brevis tendon. Patients were reviewed at a mean of 16 months. Functional stability was regained in all patients, but two thumbs had ongoing pain in the metacarpophalangeal joint. All but one patient returned to their original work and recreational pastimes. This study suggests that ligament reconstruction for chronic laxity of the ulnar collateral ligament is likely to achieve painless stability of the metacarpophalangeal joint even when reconstruction is delayed. This makes joint fusion unnecessary in most instances.     

The role of the musculature in injuries to the medial collateral ligament.

With a knee-testing device we measured the valgus stiffness of the medial musculoligamentous complex of the knee in five volunteers. Tests were done with the muscles quiescent and with contraction of the sartorius and vastus medialis. Contraction of those muscles substantially increased the valgus stiffness. In eight subjects the voluntary reaction times were measured. With either a visual or a tactile impulse for prophylactic muscle contraction, the muscles acted too slowly to augment the stiffness of the knee so as to prevent injury. In fifty-one volunteers we applied the maximum torque to the leg, just short of eliciting pain, and showed that even then the muscle contraction would occur too late to protect the knee in typical sports situations.     

Initial repair strengths of two methods for acute medial collateral ligament injuries of the elbow.

The purposes of this study were to compare the initial repair strength of the medial collateral ligament (MCL) of the elbow using trans-osseous sutures and suture anchor methods and to determine the effect of repair pretensioning. Twelve, fresh-frozen upper extremities (66 +/- 5 years) were mounted in a valgus-loading system. MCL repairs were performed using trans-osseous suture and suture anchor methods with 20 N or 40 N pretensioning. A cyclic (0.5 Hz), valgus 40 N load was applied 12 cm distal to the elbow axis of flexion. The load was increased by 10 N every 200 cycles until a length increase of 5 mm or catastrophic failure of the repair occurred. Repairs pretensioned with 40 N endured a significantly higher number of cycles and failed at higher loads than those pretensioned with 20 N (p < 0.05). No difference was found in the cycles or load to failure between trans-osseous sutures and suture anchors (p > 0.05). A higher magnitude of pretensioning of MCL repairs was found to increase initial repair strength suggesting that pretensioning should be performed clinically. Despite the comparable failure loads of the trans-osseous suture and suture anchor methods, the failure mechanism differed between the two techniques. The suture anchors usually failed catastrophically when the sutures broke as they passed through the anchor eyelet, while the trans-osseous sutures gradually elongated to the defined failure length by stretching and sliding through the ligament. The use of different suture anchors, suture sizes, or suture materials would likely influence the findings of this study and should be considered when applying these findings clinically.     

An anatomic study of the popliteofibular ligament

Our study was prompted by the varied reports in literature about the existence of the popliteofibular ligament as an integral part of the posterolateral corner of the knee. We performed 25 formalinised cadaveric knee dissections and identified the popliteofibular ligament. It was on an average 11.06 (5-16) mm in width and 11.8 (6-16) mm in length. Our study did not include a functional evaluation. We found the ligament to be a constant structure of the posterolateral knee complex, and recommend its repair in acute injuries as well as reconstruction in chronic injuries of the posterolateral corner of the knee.