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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

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

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.

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.

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

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.

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.

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.

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.

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.

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.

We assessed proprioception in the knee using the angle reproduction test in 20 healthy volunteers, ten patients with acute anterior instability and 20 patients with chronic anterior instability after reconstruction of the anterior cruciate ligament (ACL). In addition, the Lysholm-knee score, ligament laxity and patient satisfaction were determined. Acute trauma causes extensive damage to proprioception which is not restored by rehabilitation alone. Three months after operation, there remained a slight decrease in proprioception compared with the preoperative recordings, but six months after reconstruction, restoration of proprioception was seen near full extension and full flexion. In the mid-range position, proprioception was not restored. At follow-up, 3.7 ± 0.3 years after reconstruction, there was further improvement of proprioception in the mid-range position. There was no difference between open and arthroscopic techniques. The highest correlation was found between proprioception and patient satisfaction. After reconstruction of the ACL reduced proprioception may explain the poor functional outcome in some patients, despite restoration of mechanical stability.

Thumb motion and stability were examined after sequential division of support ligaments of the trapeziometacarpal (TMC) to simulate the pathologic condition of ligament laxity. The motion obtained with passive circumduction was measured with a magnetic tracking system. The lengths of the TMC joint ligaments were approximated by measuring the distance between origin and insertion of each ligament. The change in this apparent interorigin distance of the ligaments was measured before and after ligament sectioning. The anterior oblique ligament (AOL) and the ulnar collateral ligament (UCL) had the greatest effect on TMC joint stability during circumduction of the thumb. Division of the first intermetacarpal ligament (IML) did not produce a change in apparent length of other ligaments. We conclude that small changes in ligament length affect thumb stability and alter the path of circumduction. Neither the IML or posterior oblique ligaments were major stabilizers of the TMC joint during circumduction, prehensile grasp, or tip pinch. Reconstruction of the AOL and UCL ligaments should be considered for treatment of the initial stages of TMC instability.

Purpose To assess the normal degree of laxity of the collateral ligaments (CLs) of the finger metacarpophalangeal (MCP) joints and to compare side-to-side differences in CL laxity. Methods One hundred subjects had measurements of the degree of laxity in the radial (RCL) and ulnar (UCL) collateral ligaments of the MCP joints of each digit on both hands with the joints at neutral and at 30° and 90° of flexion using a custom-made measuring device. Statistical analysis was performed to assess both the difference in laxity for each ligament at each position of flexion and between sides for analogous ligaments (eg, the right index RCL at neutral compared to the left index RCL at neutral). Results There was a significant decrease in laxity for all ligaments between neutral (mean, 24° laxity) and 90° of flexion (mean, 15° laxity). There was a side-to-side difference between the RCL of all digits in extension (mean, 3°) and the index RCL in flexion (2°). These differences were statistically significant but clinically minimal. There were no side-to-side differences between any of the other ligaments at any position. Conclusions Finger MCP joint CL stability increases with increasing flexion of the joint. There is little to no difference between analogous ligaments on either hand of the subject when tested in the same position of MCP joint flexion. Knowledge of the average degree of MCP joint CL laxity can be helpful in assessing a potentially injured joint. A patient's contralateral, uninjured side can be used to determine that individual's normal laxity and a substantial increase from this on an injured digit can indicate CL rupture. Type of study/level of evidence Diagnostic II.

OBJECTIVE:: Ankle sprains are the most common injury in the active population. With high reinjury rates and complaints of the ankle "giving way," it has been suggested that laxity of ankle ligaments increases with repeated sprains. The objective of this study was to determine if a relationship exists between ligament laxity and the number of ankle sprains. DESIGN:: Cross-sectional study. SETTING:: Biomechanics laboratory. PARTICIPANTS:: A total of 203 Division I collegiate athletes (84 women; 119 men; age, 18.5 ± 1.1 years; height, 178.5 ± 10.8 cm; mass, 79.8 ± 18.7 kg) participated in the study. INTERVENTION:: Each participant reported the number of previous sprains on each ankle. Ligament laxity was measured using an instrumented ankle arthrometer. MAIN OUTCOME MEASURES:: Measurements for anterior displacement (AD), inversion (IV), and eversion (EV) rotation of the ankle were obtained using an instrumented ankle arthrometer. RESULTS:: There was no relationship between ligament laxity and the number of ankle sprains in either direction (AD, P = 0.86; IV, P = 0.64; EV, P = 0.81). In addition, comparing ligament laxity between previously sprained ankles and ankles that have never been sprained resulted in no differences in the direction of movement (AD, P = 0.98; IV, P = 0.96; EV, P = 0.67). CONCLUSIONS:: Despite anecdotal evidence suggesting repeated ankle sprains increase ligament laxity, this report involving a large data set and a reliable measurement analysis found no relationship between the two. The results of this study make it necessary to rethink the causes of ligament laxity. Therefore, further research is necessary to understand the causes of "giving way" of the ankle and their role in repeated ankle sprains. Language: en

We studied the healing response of a devitalized anterior cruciate ligament to a treatment of initial anterior-posterior joint translation in goats. Devitalization and devascularization were achieved by five successive freeze-thaw cycles. Anterior-posterior translation was surgically altered by an osteotomy of the tibial attachment of the devitalized ligament and its reattachment either in the anatomical position or in a position 5 mm posterior. Six weeks after the first surgery, the same procedure was performed on the contralateral limb, except that the ligament was reattached in the alternate position. Six months after the initial surgery, femur-anterior cruciate ligament-tibia specimens were tested to determine their structural and mechanical material properties. Anatomic ligament placement resulted in reduced anterior-posterior translation (p < 0.05) and greater anterior joint stiffness (p < 0.05). Maximum load (p < 0.05) and ligament stiffness (p < 0.01) also were greater for the anatomically placed anterior cruciate ligaments. The maximum load for anatomically placed ligaments averaged 1.625 +/- 211 N (SEM). The strength of the posteriorly placed anterior cruciate ligament, 895 +/- 164 N was similar to results of historical anterior cruciate autograft reconstructions. Ligament failure occurred near the tibial insertion in the posteriorly placed ligaments more often than in the anatomically placed ligaments (four of five times compared with one of five times). Ligament failure near the tibial insertion occurred with lower mean maximum load than failure at the midsubstance or by bone avulsion (796 compared with 1.592 N: p < 0.05). These data support the hypothesis that ligament laxity is important to the healing and remodeling of anterior cruciate ligament grafts.

We prospectively enrolled 160 consecutive patients with inversion trauma of the ankle in a diagnostic protocol that included physical examination within 2 days and at 5 days after trauma, arthrography, stress radiography, and ultrasonography. 135 patients had pathological lateral ligament laxity on the later physical examination or lateral ligament rupture diagnosed on arthrography and they were operated on 122 of these patients had ligament ruptures. At clinical follow-up after a minimum of half a year, all of the patients who were not operated on had stable joints without signs of previous ligament ruptures. Delayed physical examination at 5 days after the injury led to the highest overall sensitivity (96%) and specificity (84%) for the detection of a ligament rupture. Additional diagnostic procedures, at a considerable cost, yielded little additional information.

Made available in DSpace on 2019-09-12T16:25:53Z (GMT). No. of bitstreams: 0 Previous issue date: 2012 INTRODUÇÃO: A entorse de tornozelo é uma das lesões mais comuns em atletas. Uma forma de avaliar a frouxidão ligamentar pode ser através da medida da amplitude passiva dos movimentos de inversão e eversão do pé para estimar a resistência passiva das estruturas capsuloligamentares do tornozelo, o qual pode ser chamado de torque de resistência passiva. Existem poucos estudos que utilizam a avaliação do torque passivo do tornozelo para avaliar a resistência da cápsula e dos ligamentos. OBJETIVO: O objetivo deste estudo foi comparar o torque passivo dos movimentos de inversão e eversão do pé em atletas com e sem história de entorse de tornozelo. MÉTODO: Participaram do estudo 32 atletas de basquetebol e voleibol feminino (16,06 ± 0,8 anos, 67,63 ± 8,17kg, 177,8 ± 6,47cm). Seus tornozelos foram divididos em dois grupos: grupo controle (29), composto por tornozelos sem sintomas, e grupo entorse de tornozelo, composto por tornozelos que sofreram lesão (29). O torque dos movimentos passivos do tornozelo foi registrado por um dinamômetro isocinético, e a atividade dos músculos fibular longo e tibial anterior foi medida por um eletromiógrafo. As atletas realizaram duas repetições do movimento de inversão e eversão, nas velocidades de 5, 10 e 20°/s e, em seguida, o mesmo protocolo foi repetido apenas para o movimento de inversão máxima do pé. RESULTADOS: O torque de resistência passiva durante os movimentos de inversão e eversão do pé foi menor no grupo com entorse do tornozelo. Este grupo também mostrou menor torque durante o movimento de inversão máxima do pé. Não foram observadas diferenças entre o movimento de inversão e eversão. CONCLUSÕES: A entorse de tornozelo leva a um menor torque de resistência passiva, indicando redução da resistência dos ligamentos colaterais do tornozelo e uma frouxidão articular mecânica. INTRODUCTION: The ankle sprain is one of the most common injuries in athletes. Direct evaluation of the ligament laxity can be obtained through the objective measurement of extreme passive inversion and eversion movements, but there are few studies on the use of the evaluation of the passive resistive torque of the ankle to assess the capsule and ligaments resistance. OBJECTIVE: The aim of this study was to compare the inversion and eversion passive torque in athletes with and without ankle sprains history. METHOD: 32 female basketball and volleyball athletes (16.06 ± 0.8 years old; 67.63 ± 8.17 kg; 177.8 ± 6.47 cm) participated in this study. Their ankles were divided into two groups: control group (29), composed by symptom-free ankles, and ankle sprain group, composed by ankles which have suffered injury (29). The resistive torque at maximum passive ankle movement was measured by the isokinetic dynamometer and the muscular activity by electromyography system. The athletes performed 2 repetitions of inversion and eversion movement at 5, 10 and 20°/s and the same protocol only at maximum inversion movement. RESULTS: The resistive passive torque during the inversion and eversion was lower in the ankle sprain group. This group also showed lower torques at the maximum inversion movement. No differences were observed between inversion and eversion movement. CONCLUSIONS: Ankle sprain leads to lower passive torque, indicating reduction of the resistance of the lateral ankle ligaments and mechanical laxity. [Araujo, Rubens Correa] Universidade de Taubaté, Brazil Fernandes, Tulio Diniz; Hernandez, Arnaldo Jose] Universidade de São Paulo, Brazil Barbanera, Márcia] Universidade São Judas Tadeu, Brazil

The Integral Theory (1993) stated: “Stress, urge, and abnormal emptying are mainly caused by connective tissue laxity in the suspensory ligaments of vagina, a result of altered connective tissue”. More recently, the theory has been amended to include pelvic pain, fecal incontinence, and defecation difficulties. According to the theory, therefore, accurate diagnosis and reconstruction of the suspensory ligaments will cure such symptoms. Essential to understanding the theory are the following concepts: the organs are suspended by ligaments; the organs are opened or closed by neurologically coordinated muscle forces contracting against these ligaments; lax ligaments may invalidate the muscle forces causing organ prolapse, and dysfunctions in closure (incontinence) or opening (evacuation symptoms); a symptom-based diagnostic algorithm helps to locate ligament laxity; these are confirmed by a three-zone structured examination system; and organ prolapse and abnormal symptoms are both addressed by using tapes to reinforce damaged suspensory ligaments.

Anterior tibial tunnel placement contributed to the failure of two previous anterior cruciate ligament reconstructions. An allograft patellar bone-tendon-bone nonunion within the tibial tunnel caused dysfunctional ligament laxity. This is the first report of this type of reconstructive cruciate ligament failure.

Aging population continuously grows up and being active in their lifestyle, they are more likely important to determine outcomes of Anterior Cruciate Ligament (ACL) reconstruction that can be achieve in older adults. The aim of this study was to compare with the knee functional scores and ligament laxity in 30’s and 50‘s years old patients following ACL reconstruction after 1 year. Fifteen subjects, greater than 50 years, had been operated for ACL reconstruction that selected for this retrospect study, and the results were compared with patients in 30 age groups. At follow up, patients were evaluated ligament instability used KT-2000 arthrometer and observed knee functional outcome used Lysholm score International Knee Documentation Committee (IKDC) score. Anterior knee translations (side-toside difference) measure by KT-2000 was 2.3±2.0㎜ for 50’s and 2.8±2.5㎜ for patient 30’s. Mean Lysholm score was 90.7±8.5 for 50’s and 93.6±6.5 for 30’s. In IKDC score was 85.7±14.2 for 50’s and 90.3±8.9 for 30’s However, no statistically significant difference between 30’s and 50’s age groups in the knee functional outcome and ligament laxity. This study showed that ACL reconstruction is a safe and valid option for patients over the age of 50 years with restoration of knee function and stability.

Heat has been used as a therapeutic form of treatment in the field of medicine since ancient times. Electrothermal energy delivered by radiofrequency has the advantages of being able to be used by even the casual arthroscopist and being relatively inexpensive. One of the expanded uses is treating ligament laxity, including the anterior cruciate.

Because the knee has no significant abduction or adduc-tion movement, joint contracture or compensatory joint movement in the frontal plane need not be considered. Considerations of ligament laxity and intraarticular deficiency, which cause some knee motion in the frontal plane, are discussed in Chaps. 14 and Chaps. 15. Frontal plane osteotomy considerations regarding the knee are discussed in Chap 5. Deformity considerations associated with monocompartmental arthritis of the knee are discussed in Chap. 16.

This study was performed to assess the incidence of generalized ligament laxity (GLL) in patients undergoing hip arthroscopy for intraarticular hip pathology diagnosed by clinical examination and confirmed with magnetic resonance arthrography. Prospective data were collected for 27 patients between Feb and May 2013 under the care of a specialist hip surgeon including demographic details; mechanism of injury, operative diagnosis, surgical treatments performed and GLL by using the Beighton score. The mean age was 32 years (range 18–56). There were 14 male (52%) and 13 (48%) female patients. 81% patients were involved in sports and football was the most common sports in 55%. The mean duration of symptoms was 4 years (range 1–16). The mean Non-arthritic hip score was 30 (range 20–46). 80% patients denied hip injury, 8% had significant hip injury, 8% were involved in road traffic accidents and 4% had a trivial injury. 21% patients had bilateral, 67% had right and 12% had left sided symptoms. 54% patients had Femoroacetabular Impingement (FAI) and an associated labral tear, 31% had an isolated labral tear and 15% had only impingement. 42% patients had labral debridement and osteochondroplasty of the femoral neck, 19% had labral debridement, 15% had osteochondroplasty, 15% had labral repair and osteochondroplasty and 8% had only labral repair. The mean Beighton score for these patients was 2.7 (range 0–9). 10 patients (37%) in this group had a Beighton score of 4 or more indicating GLL. We found that there was a high incidence (37%) of GLL in patients undergoing hip arthroscopy. 54% patients had FAI and associated labral tear, 80% denied hip injury and 21% had bilateral symptoms. Further research to study the effect of GLL on intraarticular hip pathology in young athletic population is required for appropriate advice about the risk of injuries.

Collateral ligament laxity has recently been recognized as an important component of frontal plane malalignment. The authors have developed new surgical techniques to re-tension lax collateral ligaments. Twenty-three collateral ligament re-tensioning with bony alignment were carried out in 17 patients, with 19 knees being graded excellent, 2 fair, and 2 poor. Recurrence of significant laxity was noted in one patient.

A 24-year-old professional football player sustained an isolated rupture of the popliteus tendon. The injury was confirmed by arthroscopic examination. No clinical instability was present initially or during the recovery period. The injury was managed nonoperatively with the patient able to return to full sports participation. No residual ligament laxity or weakness on isokinetic testing resulted.

Purpose: To analyze the findings of midcarpal and radiocarpal arthroscopic examinations in the diagnosis of wrist trauma and pathology focusing on interosseous ligament laxity. Materials and Methods: Forty-one midcarpal arthroscopic examinations were performed in conjunction with radiocarpal arthroscopic examinations. Thirty-one wrists with distal radius fracture and ten wrists with triangular fibrocartilage complex tear were included. Scapholunate and lunotriquetral ligament laxity was graded by using the Geissler classification and radiocarpal and midcarpal arthroscopic findings were compared. Results: For scapholunate findings midcarpal arthroscopy confirmed radiocarpal findings in 14 cases and provided a diagnosis in 6 cases. For lunotriquetral findings midcarpal arthroscopy confirmed radiocarpal findings in 13 cases and provided a diagnosis in 6 cases. Conclusion: Midcarpal arthroscopy added more statistically significant information to the results of radiocarpal examination than wrist arthroscopy performed without a midcarpal examination.

Background: Prolotherapy is an effective treatment for pain due to ligament or tendon laxity. The purpose of this study was to determine the effects of prolotherapy on the relief of knee joint pain. Methods: Forty patients who complained of knee joint pain, considered ligament originated pain were investigated using a pain score system. Prolotherapy was performed using 15% dextrose to regions according to Hemwall's pattern. We recorded visual analog scale (VAS) pain scores just before prolotherapy and 1, 2, 4 and 8 weeks later. Results: For the 40 patients, prolotherapy proved to be effective and satisfactory in 82% (VAS; after prolotherapy). Conclusions: Prolotherapy with 15% dextrose resulted in a clinically significant improvement of knee joint pain due to ligamentopathy.

Asymptomatic spontaneous subluxation of C1 on C2 is common in Down's syndrome and can result in compression of the upper cervical cord. Symptomatic atlantoaxial dislocations developed in two such patients. The causes of the atlantoaxial dislocations were possibly due to the ligament laxity in one case and due to the osseous malformation in the other. Conditions in both patients were relieved by surgical stabilization of the first and second cervical vertebrae.

Measurements have been made on knee radiographs exposed during stress displacement by controlled hydraulic forces using a specially designed apparatus. This accurately records the amount of anterior and posterior tibial displacement (drawer sign) and the degree of medial and lateral collateral ligament laxity on radiographs. The findings in 25 patients have been analysed following the Jones' procedure for the repair of the anterior cruciate ligaments. The operative results were judged to be completely successful in 72 per cent of patients and the value of stress radiographic measurements is discussed.

Linscheid and Dobyns (1972), in a classical article on post-traumatic instability of the wrist described two major types of instability, dorsal and volar. The dorsal intercalated segment instability (D.I.S.I.) was the more common and occurred with scapholunate dissociation and displaced scaphoid fractures. The instability occurred in these conditions as a result of the scaphoid losing its ability to support the carpus. They presented five cases of volar intercalated segment instability (V.I.S.I.) of which four were related to congenital ligament laxity and not to traumatic ligament disruption. In the one case of traumatic origin they felt that the capitolunate ligament was ruptured. However, more recent publications by Taleisnik, Prietto (1982) and Reagan, (1984) have proposed that for V.I.S.I. to occur the lunate triquetral interosseous ligament must be disrupted. We report this case as it demonstrates which ligamentous structures are torn for V.I.S.I. to occur. In addition, these ligament disruptions were pathological and occurred spontaneously as a result of longterm systemic steroid medication.

Of 45 consecutive knees undergoing Macintosh fascia lata anterior cruciate substitution, only five had accompanying collateral ligament laxity. Over a third of cases (16) had more than ten episodes of major instability causing falls to the ground pre-operatively. The initial injury caused haemarthrosis, usually without external trauma (36), was often accompanied by a sensation of knee disruption (18), and was always associated with immediate disability. The results of 26 lateral substitution operations with minimum 12 month follow-up show abolition of pivot shift jerk in all patients. Incomplete control of objective and functional instability postoperatively in four patients may have been related to soft tissue stretching associated with early mobilization in a cast-brace or generalized ligamentous laxity.

1. Recurrent dislocation of the elbow is caused primarily by collateral ligament laxity with secondary damage to the capitulum and head of radius. 2. The pathological changes resemble those of recurrent dislocation of the shoulder. 3. Subluxation or instability of the radial head is often associated with capsular ossification and deserves wider recognition because it may be confused with osteochondritis dissecans. 4. A simple method of soft-tissue repair has successfully prevented redislocation of eight elbows.