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Background: Medial elbow injury is common in baseball pitchers, with evidence of elbow valgus instability after only 60 consecutive pitches. However, the tissue-specific effects of repetitive pitching on medial elbow stabilizers are largely unknown. Purpose/Hypothesis: This study aimed to investigate changes in the ulnar collateral ligament (UCL) and forearm flexor-pronator muscles (FPMs) during repetitive pitching and factors that relate to identified change. We hypothesized that repetitive pitching would increase elasticity of the medial elbow stabilizers and therefore induce laxity. Study Design: Descriptive laboratory study. Methods: A total of 30 high school baseball pitchers participated (mean ± SD age, 16.6 ± 0.5 years). Each participant pitched 100 times (5 blocks of 20 pitches). The strain ratio, indicating elasticity in the UCL and FPMs, was measured using ultrasound before pitching and after every 20-pitch block. Data for each pitch block were compared using analysis of variance. Multiple regression analysis was used to investigate factors related to the change rate of the strain ratio. Results: The strain ratio of the UCL after 100 pitches was significantly less than that before pitching (before pitching, 4.83 ± 1.70; after 100 pitches, 3.59 ± 1.35; P = .013), but this was not the case for the FPMs (before pitching, 0.57 ± 0.24; after 100 pitches, 0.43 ± 0.18; P = .07). The ratio of the strain ratio in the UCL and FPMs (UCL/FPMs) before pitching (β = −0.385; P = .031) and the elbow flexion range of motion before pitching (β = −0.352; P = .046) were significantly and independently correlated with the change rate of the UCL. Conclusion: Elasticity significantly increased for the UCL, indicating laxity, but not for the FPMs after 100 pitches. Furthermore, the ratio of elasticity (UCL/FPMs) and the elbow flexion range of motion before pitching were significantly related to the change rate of UCL elasticity. Clinical Relevance: To reduce laxity of the UCL, pitchers should be limited to

Haptic robotic-arm-assisted total knee arthroplasty (RATKA) seeks to leverage three-dimensional planning, intraoperative assessment of ligament laxity, and guided bone preparation to establish and achieve patient-specific targets for implant position. We sought to compare (1) operative details, (2) knee alignment, (3) recovery of knee function, and (4) complications during adoption of this technique to our experience with manual TKA. We compared 120 RATKAs performed between December 2016 and July 2018 to 120 consecutive manual TKAs performed between May 2015 and January 2017. Operative details, lengths of stay (LOS), and discharge dispositions were collected. Tibiofemoral angles, Knee Society Scores (KSS), and ranges of motion were assessed until 3 months postoperatively. Manipulations under anesthesia, complications, and reoperations were tabulated. Mean operative times were 22 minutes longer in RATKA (p

Background Many people suffer from ligamentous laxity even in the absence of other diseases. This is called the benign generalized ligamentous laxity. It can be a predisposing factor for musculoskeletal and joint injuries. We did this research to determine the prevalence of generalized ligamentous laxity in different ethnic groups of Hamadan province as a pilot study for a future national investigation. Materials and methods In this descriptive-analytical study, 378 people were selected by simple sampling in 2017 from a province in northwest of Iran. We looked for the ligamentous laxity in them with clinical examination according to Beighton's score criteria using goniometer for measuring the joint movement's angle. The population included people between 17 and 40 years old. They were from various Iranian ethnic backgrounds who were living in this province. Results Eighty-six participants (22.8%) had generalized ligamentous laxity. Generalized ligamentous laxity was more prevalent in women (31.5% compared to 14.7% in men). The most common ligament laxity was on the fingers. Most participants with generalized ligamentous laxity (78 of 86 participants) had no knowledge of their problem and its importance in choosing the appropriate sports activities; 12 of 86 participants (14%) had a history of sports-related injuries, and 31 of 86 participants (36.5%) had a musculoskeletal disease. Conclusion The prevalence of generalized ligamentous laxity is considerably higher in women regardless of their ethnicity. Most people are unaware of their problem. Also, the history of musculoskeletal diseases is significantly higher in people with this problem compared to those without it.

ResumoLuxação intra-articular da patela é uma afecção incomum, podendo ocorrer deslocamento no plano horizontal ou vertical; pode se associar com lesão/ruptura do tendão do quadríceps, total ou parcial, com lesão osteocondral ou dos ligamentos colaterais. Fatores de risco são: frouxidão ligamentar, hipermobilidade patelar, patela alta e displasia troclear, e é mais comum em jovens, podendo necessitar de redução cruenta. Casos de luxação intra-articular da patela são eventos raros, sendo necessários uma suspeição diagnóstica e um manejo diferenciado. O objetivo deste trabalho é relatar um caso raro de luxação intra-articular da patela, assim como seu quadro clínico, diagnóstico, conduta e revisão da literatura.

International audience; OBJECTIVE:Pregnancy-related changes in ligament laxity have been shown to be associated with various disorders such as back pain or pelvic floor disorders. The purpose of this study was to assess laxity changes during pregnancy by confronting different methods in order to suggest a simple clinical tool helping to prevent the aforementioned problems.DESIGN:Seventeen pregnant women were evaluated at the first, second and third trimesters as cases and 16 non-pregnant women participated as controls. Ligamentous laxity was measured using an extensometer for the metacarpophalangeal joint of the index, a fingertip to floor test and a sit and reach test to assess hip and lumbar flexibility and the Beighton score. Statistical analysis included independent samples t-tests, analysis of variance and Pearson correlation coefficients.RESULTS:Laxity of the metacarpophalangeal joint increased by 11% from the first to the second trimester of pregnancy and stabilized until delivery. The Beighton score was significantly higher in the second trimester of pregnancy (p

Symptomatic osteoarthritis (OA) secondary to tibial plateau fractures is a relatively rare entity encountered in everyday’s practice. Risk factors are high-energy accidents, high degree of bony injuries, persistent ligament laxity or varus/valgus deformity, and specific patient factors such as age. The majority of tibia plateau fractures are treated operatively, and the surgical indication is based on fracture morphology.

During pregnancy, physiological and hormonal changes lead to increase in ligament laxity and postural changes. Damage to the ligaments of knee joint, and other knee problems which results in increase in the risk of fall in pregnant women. Objective: The study was done to determine the prevalence of knee joint dysfunction in multiparous pregnant women. Method: The study involved 66 multiparous women at KIMSDU. Each of them was assessed for right and left Q angle and also knee joint proprioception was recorded by using goniometer. Signs and symptoms of knee joint dysfunction were graded based on lysholm knee scoring scale. Result: On the basis of this study 29% of women showed signs and symptoms of knee joint dysfunction. 47 subjects had excellent and 19 subjects had poor joint condition. 44 had normal Q angle and 21 had altered Q angle. There are significant changes in knee joint proprioception. Conclusion: The study concluded that there is prevalence of knee joint dysfunction in multiparous pregnant women.

Hallux valgus is a common foot problem affecting nearly one in every four adults. Generalized ligament laxity was proposed as the intrinsic cause or risk factor toward the development of the deformity which was difficult to be investigated by cohort clinical trials. Herein, we aimed to evaluate the isolated influence of generalized ligament laxity on the deterioration using computer simulation (finite element analysis). We reconstructed a computational foot model from a mild hallux valgus participant and conducted a gait analysis to drive the simulation of walking. Through parametric analysis, the stiffness of the ligaments was impoverished at different degrees to resemble different levels of generalized ligament laxity. Our simulation study reported that generalized ligament laxity deteriorated hallux valgus by impairing the load-bearing capacity of the first metatarsal, inducing higher deforming force, moment and malalignment at the first metatarsophalangeal joint. Besides, the deforming moment formed a deteriorating vicious cycle between hallux valgus and forefoot abduction and may result in secondary foot problems, such as flatfoot. However, the metatarsocuneiform joint did not show a worsening trend possibly due to the overriding forefoot abduction. Controlling the deforming load shall be prioritized over the correction of angles to mitigate deterioration or recurrence after surgery.

Open surgical reconstruction for chronic lateral ankle instability is a proven and effective means of providing renewed stability. Ankle arthroscopy is recommended before reconstruction to address intra-articular pathology. The open procedure discussed is well researched and proven to restore stability and the ability to return to sport and daily activity. Anatomic shortening with reattachment into a bony trough allows return to full motion, reliable stability, and return to an active lifestyle without sacrificing any tendons or requiring a tenodesis. The authors' aggressive rehabilitation protocol is provided; the approach to athletes/patients with ligament laxity or cavovarus alignment is also addressed.

Pure ankle dislocation is a rare event that primarily results from high-energy trauma. Predisposing anatomical factors such as talar hypoplasia, ligament laxity, and previous sprains may play a key role. This report presents the case of a 55-year-old man with fatal anterior and posterior tibial artery tears following a pure anterolateral dislocation of the right ankle. To the best of our knowledge, no such cases have previously been reported in the English-language literature.

The pathogenesis of Adolescent Idiopathic Scoliosis (AIS) remains unclear. Previous research proposed that ligament laxity is a clinical feature that can be easily overlooked in patients with AIS. We speculated a new hypothesis which is an improvement of our three-dimensional spring model hypothesis of AIS pathogenesis. The tethered string in the spring model stimulates the spinal ligament instead of spinal cord. Spinal overgrowth in the adolescent age leads to higher tension of posterior spinal ligament. And the ligament laxity leads to lower tension of anterior spinal ligament. This uncoupled anterior and posterior spinal ligament tension maybe the key cause of AIS.

WOS: 000396413400008, Aim: In surgeries on patients with advanced ligament instabilities or severe bone defects rotating hinged knee prostheses are one of a limited number of appropriate options. The objective of our study is to evaluate the mid-term functional results and complications of several surgeries using this form of prothesis. Material and Method: The rotating hinged knee prosthesis (RHKP) was applied to 23 knees of 19 patients in primary or revision surgeries at our instution between February 2009 and December 2011. Following their operations, patients underwent several retrospective evaluations to assess surgical success. The average follow-up period for the patients was 54 months. The average age of the patients at their last follow-up was 75. Results: The average Special Surgery Knee Scores, Knee Society Knee Scores, and Knee Society Functional Scores were 44, 27, and 18, respectively, before the surgery; and 83, 92, and 70 in the final post-surgery follow-ups. In addition, the average range of motion increased from the pre-operative level of 76 to 101 degrees at the final evaluation. Two patients had per-operative rupture of the patellar tendon, and four patients had various complications after the surgery, including periprosthetic fracture, deep infection, aseptic loosening, and patellofemoral instability. Discussion: Primary or revision knee arthroplasty using RKHP can be successful in cases with advanced ligament instability or severe bone defects; however, increased complication rates should be kept in mind.

Background: The anterior cruciate ligament (ACL) reconstruction is conducted to improve the stability and function of the knee. Bone-patellar tendon-bone (BPTB) graft is still considered as one of the best grafts for ACL reconstruction. The purpose of this paper was to assess outcomes of BPTB ACL reconstruction at 7 years of follow-up. Materials and Methods: This was a retrospective study in which records of 26 patients, who had ACL reconstruction using BPTB graft from 2013 to 2015, were done and the outcomes of results were analyzed by clinical Tegner activity levels and Lysholm score at 6–8 years of follow-up. Results: The follow-up study has revealed excellent long-term results. Approximately 87% of 26 patients had negative pivot shift examination with the remaining 13% having grade 1 ligament laxity. Tegner activity levels were similar to preinjury levels and Lysholm score was 91. All patients were satisfied with the procedure. Conclusion: BPTB ACL reconstruction using transtibial tunnel provides a satisfactory mid-term follow-up outcome.

Acupuncture has been widely accepted as valuable treatment for many pain and sport injuries in the United States and abroad. Medical literature reports varying rates of success for acupuncture treatment that is often as good or better than recovery seen with conventional biomedical therapeutics. However, all acupuncturists recognize that not all of their patients' pain and sport injuries are resolved through acupuncture. Acupuncture-related techniques may often eliminate pain and restore health and function when acupuncture alone has not succeeded. Techniques that have been generally recognized include moxibustion, cupping, scraping (Gwa Sha), various acupuncture microsystems (auricular, hand, scalp, etc.) and neural therapy. In addition, the current author proposes that prolotherapy is an invaluable acupuncture-related technique that leads to tissue regeneration and functional restoration, and should often be considered as a viable therapeutic modality when acupuncture has failed. The physiologi...

To evaluate the clinical outcome of this modified physeal-sparing technique for MPFL reconstruction in skeletally immature patients with ligament laxity. This study was conducted on 16 patients (11 females and 5 males) with an average age of 11.5 years (8–15). They all had recurrent patellar dislocation with generalized ligament laxity (mean Beighton’s score of 7) and no patellar tilt on X-ray. We modified the Frank Noyes’ non-anatomic technique for MPFL reconstruction to become anatomic without hardware fixation for the graft. The mean follow-up period was 29.25 months (SD 4.3) ranged from 24 to 34 months. Preoperative Kujala score had ranged from 49 to 61 points (mean of 56, SD 4.72), improved to be ranged from 90 to 99 points (mean 94, SD 2.73), which is considered highly significant (p value

The growing skeleton has distinct structural features that distinguish it from the adults, and few places is this more true than in the cervical spine, where characteristics such as increased ligament laxity, developing bony anatomy, and the presence of growth centers create a unique biomechanical environment. As an example, radiographic findings that are abnormal in an adult—such as pseudosubluxation—may be normal in children, and differentiating age-dependent normal from pathologic states can be difficult for the inexperienced or uninformed physician. An understanding of clinically relevant biomechanical principles of the immature cervical spine is, therefore, essential for any physician treating spine pathology in children.

Prolotherapy, or fibroproliferative therapy, is a regenerative injection therapy, first popularized in the 1940s and 1950s. Unfortunately, the combination of “better” surgical techniques and a series of high-profile medical catastrophes by poorly trained providers relegated the technique into the “fringe” arena. However, recent recognition of the failure of surgical interventions, combined with better technology and a burgeoning interest in the continuum of regenerative injection options, has renewed the interest and research into this “old” technique.

Study Design Case-control. Objective To examine the difference in inversion-eversion (IE) ankle ligament laxity between those with and without previous lower extremity injuries. Background Individuals with previous ankle sprains have increased ankle ligament laxity. However, with the body as a kinetic chain, mechanical ankle instability could increase injury risk at more proximal joints of the lower extremity. Methods and Measures 72 Division-I collegiate athletes (40 females, 32 males; age=20.1±1.37 years; height=179.3±12.3 cm; mass=75.2±14.0 kg) that did not suffer an ankle sprain 6 months prior to data collection were recruited for this study. After signing the informed consent, IE ankle ligament laxity was taken using an instrumented ankle arthrometer (Blue Bay Research Inc., Milton, FL). Previous ankle sprains and additional lower extremity injuries were documented from the participants’ medical records. Two one-way ANOVAs analysed the differences in IE measurements between a previously sprained group and a healthy group and between a previous lower extremity injury group and a healthy group. Results The previously sprained group had a significantly greater IE laxity (n=75 ankles, 36.08o ± 11.07o) than the healthy group (n=69 ankles, 31.86o ± 9.48o) at p=0.022. However, no differences were found in IE laxity between the previous lower extremity injury group (n=89 ankles, 36.03o ± 11.48o) and the healthy group (n=55 ankles, 32.87o ± 11.48o) at p=0.101. Conclusion As expected, those with a history of an ankle sprain presented with an increase of ligament laxity. However, there were no differences in IE laxity between groups with and without lower extremity injuries. Lower extremity injuries documented include knee ligamentous and meniscal injuries, patellar tendonitis, and fractured ankles. With the foot and ankle as the base of the body’s kinetic chain, it does not seem that mechanical ankle instability has an affect on injuries at more proximal joints.

Background Context Predicting physiological range of motion (ROM) using a finite element (FE) model of the upper cervical spine requires the incorporation of ligament laxity. The effect of ligament laxity can be observed only on a macro level of joint motion and is lost once ligaments have been dissected and preconditioned for experimental testing. As a result, although ligament laxity values are recognized to exist, specific values are not directly available in the literature for use in FE models. Purpose The purpose of the current study is to propose an optimization process that can be used to determine a set of ligament laxity values for upper cervical spine FE models. Furthermore, an FE model that includes ligament laxity is applied, and the resulting ROM values are compared with experimental data for physiological ROM, as well as experimental data for the increase in ROM when a Type II odontoid fracture is introduced. Design/Setting The upper cervical spine FE model was adapted from a 50th percentile male full-body model developed with the Global Human Body Models Consortium (GHBMC). FE modeling was performed in LS-DYNA and LS-OPT (Livermore Software Technology Group) was used for ligament laxity optimization. Methods Ordinate-based curve matching was used to minimize the mean squared error (MSE) between computed load-rotation curves and experimental load-rotation curves under flexion, extension, and axial rotation with pure moment loads from 0 to 3.5 Nm. Lateral bending was excluded from the optimization because the upper cervical spine was considered to be primarily responsible for flexion, extension, and axial rotation. Based on recommendations from the literature, four varying inputs representing laxity in select ligaments were optimized to minimize the MSE. Funding was provided by the Natural Sciences and Engineering Research Council of Canada as well as GHMBC. The present study was funded by the Natural Sciences and Engineering Research Council of Canada to support the work of one graduate student. There are no conflicts of interest to be reported. Results The MSE was reduced to 0.28 in the FE model with optimized ligament laxity compared with an MSE 0f 4.16 in the FE model without laxity. In all load cases, incorporating ligament laxity improved the agreement between the ROM of the FE model and the ROM of the experimental data. The ROM for axial rotation and extension was within one standard deviation of the experimental data. The ROM for flexion and lateral bending was outside one standard deviation of the experimental data, but a compromise was required to use one set of ligament laxity values to achieve a best fit to all load cases. Atlanto-occipital motion was compared as a ratio to overall ROM, and only in extension did the inclusion of ligament laxity not improve the agreement. After a Type II odontoid fracture was incorporated into the model, the increase in ROM was consistent with experimental data from the literature. Conclusions The optimization approach used in this study provided values for ligament laxities that, when incorporated into the FE model, generally improved the ROM response when compared with experimental data. Successfully modeling a Type II odontoid fracture showcased the robustness of the FE model, which can now be used in future biomechanics studies.

Background: The contribution of mechanical laxity and ligament stiffness to chronic ankle instability is unclear, particularly when using the inversion laxity test, and may have implications for diagnosis, prognosis, and treatment. Our purpose was to determine if individuals with chronic ankle instability demonstrate greater mechanical ligament laxity and altered stiffness compared to controls and copers (those with a healed sprain) during an instrumented arthrometer inversion stress test. Methods: Recreationally active individuals were classified as those with chronic ankle instability (n = 16), copers (n = 16), or controls (n = 16) based on injury history and self-reported score on the Cumberland Ankle Instability Tool (CAIT). Three trials of an inversion stress test were applied with an instrumented arthrometer utilizing a reliable tester. Talocrural inversion (degrees) and stiffness values were extracted. One-way ANOVAs were calculated, and Tukey post hoc testing was applied (α ≤ .05). Results: Groups were not different in age, height, or weight. The chronic ankle instability group (19 ± 6) had significantly lower CAIT scores than the control (30 ± 1) and coper (29 ± 1) groups ( P < .001). The chronic ankle instability group (23 ± 12 degrees) demonstrated significantly greater inversion than the controls (13 ± 9 degrees) ( P = .04) but was not significantly different than the copers (17 ± 10 degrees). No significant differences were detected in stiffness between the groups. Conclusion: The chronic ankle instability group demonstrated decreased self-reported ankle function and increased mechanical laxity utilizing an instrumented arthrometer for inversion compared to the control group but not the coper group. Laxity, but not stiffness, may be a factor affecting chronic ankle instability and self-reported function. Level of Evidence: Level III, comparative study.

We report the case of an 18-years-old patient with thumb carpometacarpal ligament laxity due to Ehlers-Danlos syndrome who was treated with trapezial opening wedge osteotomy combined with volar ligaments reconstruction. Two years postoperatively she is pain free and the thumb carpometacarpal joint is stable.

These authors describe an orthosis they have successfully used in their clinic to treat patients with distal radioulnar joint instability. In addition to describing how they fabricate the orthosis, these authors also describe how they determine if the patient needs volar or dorsal support, and how they then incorporate this support into the orthosis - Victoria Priganc, PhD, OTR, CHT, CLT, Practice Forum Editor.

Knowledge of physiological and anatomical changes during pregnancy is important for optimal prevention and care. Epidemiological and clinical observational studies have focused on bothersome patient symptoms and changes related to the pelvic floor during pregnancy.

Introduction Morphological variations of articular facets of calcaneum may predispose people to joint instability, ligamentous laxity and development of arthritic changes in the subtalar joint. Knowledge of such variations is essential for treatment and diagnostic procedures in orthopaedic surgeries. Aim The aim of this study was to determine patterns of articular facets of calcanei and to establish its correlation with calcaneal spurs. Materials and methods The study was conducted on 580 adult calcanei of Indian origin at Maulana Azad Medical College and pattern of articular facets were observed and classified according to five patterns described in literature. A digital vernier calliper was used to measure separation between anterior and middle facet. Degree of intersecting angle between anterior and medial facets was calculated using UTHSCSA Image Tool software. The calcaneal spurs were observed by visual inspection. Results Out of 580 calcanei, 66.55% had fused anterior and middle facets (Pattern I), 27.59% had all three facets separate (Pattern II), 5.52% had absence of anterior facet (Pattern III), 0.17% had all three facets fused (Pattern IV) and 0.17% had fused middle and posterior facets (Pattern V). A significant side variation was present in Pattern III with predominance on left side. Mean angle of intersection was 147.700 in Pattern I and 133.340 in Pattern II calcaneum. Calcaneal spurs were found in 61.38% out of which it was associated with Pattern I in 43.62%, Pattern II in 14.66% and Pattern III in 2.76%. Conclusion Individuals with Pattern I and III calcaneum were found to be at a greater risk of subtalar joint instability than individuals with Pattern II. Angle of intersection was obtuse in Pattern I which resulted in ligament laxity and unstable joint. Pattern I was more common in Indian population and this fact necessitates modifications of the western surgical techniques to suit the Indian scenario. An association between the presence of spur and facet configuration was found to be significant.

Ehlers-Danlos syndrome is a heterogeneous connective tissue condition characterized by varying degrees of skin hyperextensibility, joint hypermobility, and vascular fragility. Joint dislocations, musculoskeletal pain, atrophic scars, easy bleeding, vessel/viscera rupture, severe scoliosis, and obstetric complications may occur. These manifestations are secondary to abnormal collagen, with specific molecular defects in types I, III, and V collagen; they may also be related to tenascin-X, which has been identified in some patients. Ehlers-Danlos syndrome has been classified into 6 types, with variable degrees of joint instability, skin hyperextensibility, wound healing difficulty, and vascular fragility. Diagnosis begins with recognition of the signs and symptoms of global hypermobility and referring appropriate patients for genetic consultation. It is important to accurately identify patients with Ehlers-Danlos syndrome to initiate appropriate musculoskeletal treatment, optimize anesthetic and postoperative management, perform appropriate vascular screening, and help families address their concerns with other families and advocacy groups.

Introduction Recurrent habitual patellar dislocation can be treated by soft tissue reconstruction or osteotomy or combination of both. However, no single surgical procedure can address the complex issue. We have successfully treated three patients (four knees) with trochlea hypoplasia and generalized ligament laxity with different surgical techniques. Patients and Methods From January 2001 to November 2008, four knees of three female patients were presented with recurrent habitual dislocation of the patella and generalized ligament laxity. Different surgical procedures were performed, including Insall proximal realignment in two knees, Roux-Goldthwait procedure in one knee, and combined trochleoplasty and tibial tubercle transfer in one knee. This article reports the functional and radiographic assessments at a mean follow-up of 3.4 years. Results The modified Cincinnati score increased from 74 ± 9 preoperatively to 88 ± 6 at latest follow-up; and the Kujala patellofemoral disorder score increased from 75 ± 10 to 86 ± 11. No recurrent dislocation occurred on all knees. Radiographic parameters improved, including congruence angle and axial linear patellar displacement. The sulcus angle improved in patient who underwent combined trochleoplasty and tibial tubercle transfer. Conclusions Surgical treatment for recurrent habitual dislocation of the patella varied according to the severity of the anatomical abnormality and the patellar stability assessed intraoperatively. In severe cases, combined trochleoplasty and tibia tubercle transfer is indicated to correct the recurrent dislocation of the patella. Proper patient selection and good surgical technique are the keys to success.

A 37-year-old woman was diagnosed with an isolated proximal tibiofibular joint dislocation (PTJD) after an accident during gymnastic exercise. The dislocation has a low incidence rate and is often missed in the emergency department as physical and radiology signs are subtle. Treatment consists of closed or open reduction and immobilisation. When it is not recognised it is associated with significant peroneal nerve injury.

Background: Although isolated posterior cruciate ligament reconstruction (PCLR) has become a more frequently performed procedure, reports of functional outcomes and return-to-sport (RTS) rates to support its use are still limited. Purpose: To systematically review the literature to determine the rates of RTS and the functional outcomes of patients after isolated PCLR. Study Design: Systematic review: Level of evidence, 4. Methods: Two reviewers independently searched 5 databases for patient-based clinical studies with a minimum 2-year follow-up that analyzed functional outcome and RTS following isolated PCLR. Studies with multiligament knee reconstruction were excluded. Risk of bias was performed with a modified Downs and Black checklist. The primary outcomes were Tegner and Lysholm scores, rates of RTS, and International Knee Documentation Committee (IKDC) subjective scores. Secondary outcomes were IKDC objective scores, instrumented knee laxity assessment, and Telos radiographic analysis. Where feasible, these data were pooled via a random effects meta-analysis model. Results: Of the 240 titles identified, 14 studies were included. The median time from injury to surgery was 10.6 months (range, 6 weeks–21 years). The pooled mean postoperative Tegner and Lysholm scores were 5.7 (95% CI, 5.4-6.0) and 87.8 (95% CI, 85.6-90.0), respectively, following isolated PCLR; the pooled effect size between pre- and postoperative values was 2.8 (95% CI, 1.6-4.0) and 3.7 (95% CI, 2.6-4.9), respectively. An RTS rate of 44% (95% CI, 23%-66%) was identified. IKDC subjective scores improved to a pooled mean of 73.5 (95% CI, 62.8-84.1), with an effect size of 3.0 (95% CI, 0.4-5.6). The proportion of patients with postoperative IKDC objective scores of grade A/B was 82%. The pooled postoperative KT-1000/KT-2000 side-to-side difference was 3.4 mm (95% CI, 2.5-4.3 mm), with an effect size of 2.8 (95% CI, 1.1-4.5). The pooled postoperative Telos side-to-side difference measurement was 3.5 mm (95% CI, 2.8-4.3 mm), with an effect size of 3.9 (95% CI, 3.3-4.5). Conclusion: The results of this review demonstrate that while isolated PCLR results in a significant improvement in functional outcome scores and improved knee laxity, there is a low rate of return to preinjury level of sport. The prolonged period from injury to surgery might reduce functional improvement and RTS following reconstruction. Therefore, comparison of the outcomes of isolated PCLR and nonoperative treatment is impracticable owing to the potential for selection bias.

The dynamic anterior ankle tester (DAAT) has shown a good reliability in testing anterior talar translation in earlier studies. The goal of the present study was first to evaluate the reliability of the DAAT in a clinical setting and second to analyze its ability to detect increased ligament laxity. In 39 patients with unilateral chronic lateral ankle instability, the anterior talar translation of the affected and non-affected side was measured pre and postoperatively using the DAAT, Telos stress radiographs, and the manual anterior drawer test. In contrast to both other tests, the DAAT was not able to accurately detect increased ligament laxity preoperatively or decreased laxity of the affected ankle postoperatively. The DAAT showed a low sensitivity to change (the difference between the mean pre and postoperative value) and a low reliability compared to both other tests. There were no correlations between the three tests. In conclusion, the DAAT showed a low reliability in effectively testing lateral ankle ligament laxity in a clinical setting. This is in contrast to earlier evaluations.

Exercise is an important component of a healthy lifestyle and, as such, is recommended during pregnancy. However, the response to exercise of both the expectant mother and fetus varies depending on the fitness level of the woman. The response to exercise is also affected by the known musculoskeletal and physiologic changes associated with pregnancy, such as increased ligament laxity, weight gain, change in the center of gravity, and carpal tunnel syndrome. Although the physiologic responses of the pregnant woman and fetus have been well studied, the literature contains comparatively few studies investigating response to exercise. When performed properly, activities such as aerobics, impact and nonimpact activities, resistance training, and swimming may be beneficial during pregnancy.

Injuries to the collateral ligaments of the knee are very common. Recognition of collateral ligament laxity is extremely important, especially when associated with a cruciate ligament injury. Reconstruction of the collaterals are necessary when addressing these combined instabilities.

The initial clinical assessment of spinal pain consists of diagnostic triage into: (i) serious spinal pathology; (ii) other pathological entities; and (iii) non-specific symptoms. The non-specific group comprises the major burden of spinal illness. There are two broad approaches to the diagnostic challenge of non-specific spinal pain. One approach is to split the group into sub-groups explained by separate pathophysiological abnormalities. The focus of this work is to describe these proposed abnormalities in greater detail and to discover which clinical features distinguish them. The other approach is to 'lump' all of those with non-specific features into one group, and consider the common psychosocial factors that are relevant to the whole group. A variety of pathological and non-pathological models have been proposed. Pathological models include ligament laxity, facet syndrome, discogenic pain, spondylosis and instability; non-pathological models include a pain–spasm–pain cycle, muscle inhibiti...

Studies were performed in order to obtain information on the pathogenesis of patellar tip syndrome (PTS). Using a finger hyperextensiometer, ligamental laxity tests were performed on athletes, non-athletes and controls. Ninety-eight PTS patients who did not indulge regularly in sports, 39 patients from the German federal volleyball league, and 400 healthy controls were examined. No difference in the extensibility of ligaments was found between the patients from the group of competitive athletes and the controls. However, a significantly increased extensibility of the finger joints was found in all age and sex groups with "spontaneous" PTS. The authors conclude that 1) constitutional laxity of the ligaments is a key predisposing factor for PTS, and 2) PTS is triggered by physical stress. Susceptibility to microtrauma at the insertion of the patellar ligament is a function of the constitutional strength of the ligaments.

This paper reports about the check-up of 33 juvenile and 28 adult patients who were operated on because of osteochondrosis dissecans of the knee. The average period of observation was 4.7 years. According to the aspects of age and the stage of the disease the results were compared to each other. The age of the patient at the moment of operation has doubtless the greatest influence on the prognosis. Juveniles operated in stage 2 or 3 have a particularly good prognosis. From stage 4 on it does not seem reasonable to try to preserve the dissecate. In the case of juveniles metabolic or endocrinological diseases do not appear to be of any relevance whereas mechanical factors like overstress at sports, hereditary ligament laxity or deviations of axis of whatever origin seem to be of larger import.

Background: Not all patients develop chronic ankle instability (CAI) after one or more lateral ankle sprains; some seem to heal or adjust to the ankle laxity after injury. Why do some patients develop CAI and others are able to cope and return to normal function? The purpose of this study was to examine ligament laxity between subjects with and without CAI. Materials and Methods: Sixteen subjects with unilateral CAI and 16 subjects without participated in the study. Ligament laxity was measured with an instrumented ankle arthrometer. The arthrometer measured ankle joint motion for anterior/posterior displacement (mm) during loading at 125 N and inversion/eversion rotation (degrees of ROM) during loading at 4000 N/mm. For each dependent variable a 2 × 2 mixed model ANOVA was run with the between factor being group (CAI, No CAI) and the within factor with repeated measures being side (involved, uninvolved). Results: A significant group by side interaction for anterior displacement (F1,30 = 370.085, p < 0.001), and inversion rotation (F1,30 = 7.455, p = 0.010) was found. There was significantly more anterior displacement and inversion rotation for the involved ankles of the CAI group than the involved ankles of the stable group and the uninvolved ankles of the CAI group. Conclusion: Based on the results of this study it appears that the increased anterior displacement and inversion rotation compared to patients without instability may be why subjects develop CAI. Although the patients without instability have a history of more than one lateral ankle sprain, they did not demonstrate increased laxity, which may be the reason why they do not complain of the functional impairment demonstrated in subjects with CAI.

WOS: 000446917800017, PubMed: 27656635, Ligament laxity measurement is clinically valuable to diagnose the injury and also to compare the laxity before and after surgical procedure. The aim of the study was to compare the accuracy of the Lachman and Anterior Drawer Tests to evaluate the knee examination with the KT1000 arthrometer after the anterior cruciate ligament (ACL) surgery in early follow-up period. Fourty ACL reconstructed knees were examined with the Lachman and Anterior Drawer Tests, and KT1000 arthrometer with compariable intact knee of the same patients. Physical emanination findings were compared with the KT1000 arthrometer with each power. Spearman correlation and receiver operating characteristic (ROC) analysis were used for the evaluation of relations between parameters. Significance was evaluated in P

Background there is need to ascertain clinical and imaging outcomes after posterior cruciate ligament (PCL) augmentation. Methods we performed a retrospective analysis of clinical, imaging and functional data on 21 physically active males who underwent arthroscopic trans-tibial augmentation of the PCL for symptomatic grade III PCL insufficiency. The average follow-up time was 50 months (24-60 months). The Lysholm knee score was administered to all the patients, ligament laxity was evaluated with the posterior drawer test, the KT-1000 arthrometer, and the anteromedial tibial step-off. Standing antero-posterior, lateral and Merchant's view radiographs were taken preoperatively and at annual follow-up. Results post-operatively, ligament laxity and Lysholm knee scores were significantly improved than at baseline. Sixteen patients (73%) returned to pre-injury sport activity level, 3 patients (14%) returned to a lower level, 2 had to stop. We found radiographic degenerative changes in 5 of 22 affected knees (23%), with evidence of a statistically significant association between the occurrence of degenerative changes and the interval time from injury to surgery and duration of the follow up. Conclusions arthroscopic transtibial single bundle autograft hamstring augmentation significantly improves the function of the knee, with an overall satisfactory outcome of 82% at 2-5 years from surgery.

Capsular plication or thermal shrinkage can be used to enhance surgical joint stabilization. We compared mechanical or morphologic properties of the medial collateral ligament of the rabbit knee treated by either bipolar radiofrequency electrothermal shrinkage or surgical plication. After 12 weeks, the medial collateral ligaments were procured from treated and contralateral knees to undergo viscoelastic (creep) testing, quantitative transmission electron microscopy, and immunohistochemistry. Creep strain in thermal (1.85% +/- 0.32%) and plicated (1.92% +/- 0.36%) ligaments was almost twice that of the control group (1.04% +/- 0.15%), although there was no difference between treatment modalities. The morphologic parameters of all 3 groups were significantly different (P.001). The thermal ligaments demonstrated predominantly small fibrils, whereas the plicated group displayed an intermediate distribution of heterogeneous fibrils, suggesting a different pattern of remodeling. Viscoelastic properties are similar after thermal shrinkage or plication, though inferior to those of intact ligaments.

Alignment of normal, arthritic, and replaced human knees is a much debated subject as is the collateral ligamentous laxity. Traditional quantitative values have been challenged. Methods used to measure these are also not without flaws. Authors review the recent literature and a novel method of measurement of these values has been included. This method includes use of computer navigation technique in clinic setting for assessment of the normal or affected knee before the surgery. Computer navigation has been known for achievement of alignment accuracy during knee surgery. Now its use in clinic setting has added to the inventory of measurement methods. Authors dispel the common myth of straight mechanical axis in normal knees and also look at quantification of amount of collateral knee laxity. Based on the scientific studies, it has been shown that the mean alignment is in varus in normal knees. It changes from lying non-weight-bearing position to standing weight-bearing position in both coronal and the sagittal planes. It also varies with gender and race. The collateral laxity is also different for males and females. Further studies are needed to define the ideal alignment and collateral laxity which the surgeon should aim for individual knees.

Mechanical alignment has been overlooked as an important contributor to knee stability with respect to collateral ligament laxity. The detrimental effects of varus or valgus limb malalignment become more obvious when the restraining force is lost because of ligamentous injury especially on the medial or the lateral/posterolateral side. Even with repair or reconstruction of these injuries, with repetitive load, the ligament will eventually fail to restore its structure and strength, resulting in failure and secondary restraint laxity. We have found that realignment of the limb is the most important factor in restoring a functional limb. After realignment, joint laxity, if persistent, can be addressed successfully with ligamentous reconstruction. Diagnosis and treatment of limb malalignment cannot be ignored in the management of chronic ligamentous instabilities, especially those with prior failed reconstruction. Our approach to these difficult problems and the preferred techniques of osteotomies on both tibial and femoral sides are described.

Proximal tibiofibular dislocations are a rare orthopaedic injury. It is one that is easily missed if one does not have high clinical suspicion for such an injury. This report discusses two cases of proximal tibiofibular dislocations that presented to the emergency department. In both cases, the patients fulfilled the criteria for having generalized ligamentous laxity—including passive apposition of thumb to extensor aspect of forearm, passive hyperextension of the fingers so that they lie parallel to the forearm, hyperextension of the elbow and knee, and excessive range of passive dorsiflexion of the ankle and eversion of the foot. Both cases also highlighted the difficulty in diagnosing the injury with single X-ray films, requiring additional comparison films to confirm the diagnosis.

BACKGROUND: Fear of iatrogenic growth disturbance has prevented the routine use, in children, of anatomic methods of anterior cruciate ligament replacement that have proven successful in adults. To minimize the risk of growth disturbance, extra-articular or modified physeal sparing procedures have been performed to stabilize the knee, but these procedures do not provide isometry. This study was performed to evaluate the results of a transepiphyseal replacement of the anterior cruciate ligament in skeletally immature athletes. METHODS: From 1993 to 1999, twelve patients with a mean age (and standard deviation) of 13.3 ± 1.4 years underwent replacement of the anterior cruciate ligament with a quadruple hamstring tendon graft performed with an arthroscopic technique and intraoperative fluoroscopic imaging for precise tunnel placement. The femoral and tibial tunnels went through the epiphyses but avoided the physes. Eight of the twelve patients also had a meniscal repair. All patients returned for follow-up, at a mean of 4.1 ± 1.9 years (range, two to 8.2 years) after surgery. RESULTS: The mean amount of growth from the time of surgery to the time of follow-up was 16.5 ± 10.0 cm (range, 8 to 38 cm). The difference between the lengths of the lower limbs, as measured on orthoradiographs, was not clinically relevant. The mean score on the International Knee Documentation Committee (IKDC) subjective knee form was 96.5 ± 4.4 points (range, 86 to 100 points). Ligament laxity testing with a KT-1000 arthrometer revealed a mean side-to-side difference of 1.5 ± 1.1 mm. The rating according to the criteria of the objective 2001 IKDC knee form was normal for seven patients and nearly normal for five. CONCLUSIONS: Transepiphyseal replacement of the anterior cruciate ligament, a technically demanding procedure with a small margin of error, should be attempted only by accomplished knee surgeons. The preliminary results in this small series, however, demonstrate that this surgical technique can be performed in prepubescent patients with efficacy and relative safety.

Proper alignment and balancing of soft tissues of the knee are important goals for TKA. Despite standardized techniques, there is no consensus regarding the optimum amount of collateral ligament laxity one should leave at the end of the TKA.I asked (1) what is the collateral laxity in young healthy volunteers, and (2) is there a difference in collateral laxity between males and females.The femorotibial mechanical angle (FTMA) was measured in 314 knees in healthy volunteers aged 19 to 35 years. Subjects with a history of pain, malalignment, dysplasia, or trauma were excluded. Twenty-five knees were excluded because the hip center could not be acquired, and 22 were excluded because of a history of pain and trauma, leaving 267 knees for inclusion in the study. Of these, 155 were from men and 112 were from women. A validated method using a computer navigation system was used to obtain the measurements. A 10-Nm torque was used to stress the knee in varus and valgus at 0° extension and 15° flexion. An independent t-test and ANOVA were applied to the data to calculate any significant difference between groups (p0.05).The mean (SD) unstressed supine FTMA was varus of 1.2° (SD, 4°) in 0° extension and varus of 1.2° (SD, 4.4°) in 15° flexion (p=0.88). On varus torque of 10 Nm, the supine FTMA changed by a mean of 3.1° (SD, 2°) (95% CI, 2.4°-3.8°; p0.001) in 0° extension and 6.9° (SD, 2.6°) (95% CI, 6.2°-7.7°; p0.001) in 15° flexion. On valgus torque of 10 Nm, the FTMA changed by a mean of 4.6° (SD, 2.2°) (95% CI, 3.9°-5.3°; p0.001) in 0° extension and 7.9° (SD, 3.4°) (95% CI, 7.1°-8.7°; p0.001) in 15° flexion. The mean unstressed FTMA in 0° extension was varus of 1.7° (SD, 4°) in men and 0.4° (SD, 3.9°) in women (p=0.01). Differences in collateral ligament laxity were seen between men and women (p0.001 for valgus torque and 0.035 for varus torque in 15° flexion). With valgus torque at 0° flexion, the supine FTMA change was valgus of 4.2° (SD, 2.0°) for men and 5.0° (SD, 2.4°) for women, while at 15° flexion the FTMA change was valgus 7.6° (SD, 3.6°) for men and 8.3° (SD, 3.2°) for women With varus torque at 0° flexion, additional varus was -3.0° (SD, 1.8°) for men and -3.3° (SD, 2.2°) for women, while at 15° flexion, varus was -7.0° SD, (2.5°) for men and -6.9° (SD, 2.8°) for women.The collateral laxity in young healthy volunteers was quantified in this study. The collateral ligament laxity is variable in different persons. In addition, ligaments in women are more lax than in men in valgus stress.This study was conducted on young, healthy knees. Whether the findings are applicable to arthritic knees and replaced knees needs additional evaluation. However the findings provide a baseline from which to work in the evaluation of arthritic knees and in the case of TKA.

The aim of this study was to evaluate laxity in knees with pre-operative (preop) valgus alignment compared to knees with pre-operative varus alignment after total knee arthroplasty (TKA).This was a retrospective study including 81 patients, with six years follow-up, for pre-operative valgus- or varus alignment of the leg. All patients had been supplied with the same cruciate retaining (CR) TKA with rotating platform. Clinical findings were assessed by KSS, OKS and IKDC 2000 score. Rotational knee laxity was evaluated by a validated instrument (Laxitester®) with 2 Nm torque in 30° flexion. Collateral ligament laxity was tested manually in 30° flexion with a bending moment of approximately 5 Nm. Biomechanical results were compared to the contralateral side.Thirty-one patients had a preop valgus alignment of 8.96° and 50 patients a varus leg axis of 4.99° in the mean. In the preop valgus knees rotational analysis showed an increased laxity of 10.7° compared to preop varus knees (p = 0.001). There was no significant difference in medial (valgus 2.6 mm, varus 2.5 mm) and lateral (valgus 2.8 mm, varus 2.7 mm) laxity. KSS and OKS showed no significant differences in the follow-up results. In the IKDC 2000 objective score 50 % of the preop varus knees and 25.8 % of the preop valgus knees were classified as nearly normal. The difference in the IKDC objective was highly significant (p0.001).Preop valgus knees show a significantly increased rotational laxity but no increased collateral ligament laxity compared to pre-operative varus knees six years after TKA with rotating platform. There is a significant difference in IKDC objective.

The more than 80 procedures described for chronic lateral ligamentous instability generally are divided intoanatomic and nonanatomic procedures or augmented and nonaugmented procedures. Of the anatomic repairs, the modified Brostrom is currently the most commonly used. It is indicated for most chronically unstable ankles. Relative contraindications include generalized ligamentous laxity, previous reconstructive procedures, and lengthy time from the original injury. The Chrisman-Snook and Watson-Jones procedures are nonanatomic, augmented reconstructions in which a portion of the peroneus brevis is used to reconstruct the ATFL (Watson-Jones) or the ATFL and CFL (Chrisman-Snook). Indications for these procedures have included patients with combined ankle and subtalar instability, obese patients, athletes at high risk for repetitive rotation and varus ankle stresses (such as football linemen), patients with connective tissue disease (such as Ehlers-Danlos syndrome), and patients with failed direct (anatomic) repair.

Summary Female athletes are more likely to suffer certain sports-related injuries than their male counterparts. The knee joint in particular is a troublesome site and the anterior cruciate ligament is a structure especially susceptible to injury. Many explanations regarding possible contributing factors to this increased prevalence have been put forward, including sex-related skeletal variation such as pelvic width, femoral anteversion, femoral intercondylar notch dimensions, and increased Q-angle. Some of these explanations appear to be dubious. However, recent research into pronation control, ligament laxity, neuromuscular characteristics and the effect of menstrual hormones on the ACL has produced some enlightening data. Awareness of the possible causes of increased ACL injury rates in women and girls provides a basis for strategies to help to prevent this potentially devastating injury. It seems that co-ordination and agility work combined with proprioceptive exercises could play a large part in reducing injury rates.