Prevalence of Ulnar Collateral Ligament Surgery in Professional Baseball Players.

PubMed

Conte, Stan A; Fleisig, Glenn S; Dines, Joshua S; Wilk, Kevin E; Aune, Kyle T; Patterson-Flynn, Nancy; ElAttrache, Neal

2015-07-01

While the high rate of ulnar collateral ligament (UCL) injuries in professional baseball is widely discussed in the media and medical literature, the actual prevalence of UCL reconstruction has not been documented. The prevalence of UCL reconstruction will be higher among pitchers than nonpitchers, and Major League Baseball (MLB) pitchers will have a higher prevalence than will minor league pitchers. Descriptive epidemiology study. An online questionnaire was distributed to all 30 MLB organizations. Certified athletic trainers from each team administered the questionnaire to all players in the organization, including major league players and 6 levels of minor league players. Demographic data were compared between major and minor league players. Continuous variables (age, years of professional baseball, country of origin, etc) were compared with Student t tests (P < .05). Categorical variables (level, position, etc) were compared using chi-square analysis (P < .05). A total of 5088 professional baseball players (722 major league and 4366 minor league) participated in the survey. Pitchers represented 53% of all players, and 497 players reported at least 1 UCL reconstruction, demonstrating a prevalence rate of 10% (497 of 5088). Pitchers reported a significantly higher prevalence of UCL reconstruction (16%; 437 of 2706) than nonpitchers (3%; 60 of 2382; P < .001). Among major league pitchers, 25% (96 of 382) had a history of UCL reconstruction, while minor league pitchers showed a 15% (341 of 2324) prevalence (P < .001). Major league pitchers were also significantly older (28.8 ± 3.9 years) than minor league pitchers (22.8 ± 3.0; P < .001). The majority of major leaguers (86%) had their UCL reconstruction as professional pitchers, whereas the majority of minor league pitchers (61%) underwent their UCL reconstruction during high school and college (P < .001). The rates of UCL revision, prior elbow surgery, prior shoulder surgery, and types of UCL graft were similar

The effects of medial ulnar collateral ligament reconstruction on Major League pitching performance.

PubMed

Keller, Robert A; Steffes, Matthew J; Zhuo, David; Bey, Michael J; Moutzouros, Vasilios

2014-11-01

Medial ulnar collateral ligament (MUCL) reconstruction is commonly performed on Major League Baseball (MLB) pitchers. Previous studies have reported that most pitchers return to presurgical statistical performance levels after MUCL reconstruction. Pitching performance data--specifically, earned run average (ERA), walks and hits per inning pitched (WHIP), winning percentage, and innings pitched--were acquired for 168 MLB pitchers who had undergone MUCL reconstruction. These data were averaged over the 3 years before surgery and the 3 years after surgery and also acquired from 178 age-matched, uninjured MLB pitchers. Of the pitchers who had MUCL reconstruction surgery, 87% returned to MLB pitching. However, compared with presurgical data, pitching performance declined in terms of ERA (P = .001), WHIP (P = .011), and innings pitched (P = .026). Pitching performance also declined in the season before the surgery compared with previous years (ERA, P = .014; WHIP, P = .036; innings pitched, P < .001; winning percentage, P = .004). Compared with age-matched control pitchers, the MUCL reconstruction pitchers had significantly more major league experience at the same age (P < .001). MUCL reconstruction allows most players to return to pitching at the major league level. However, after MUCL reconstruction, there is a statistically significant decline in pitching performance. There appears to be a statistically significant decline in pitching performance the year before reconstructive surgery, and this decline is also a risk factor for requiring surgery. In addition, there is an increased risk of MUCL reconstruction for pitchers who enter the major leagues at a younger age. Copyright © 2014 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.

Outcomes and Return to Sport After Ulnar Collateral Ligament Reconstruction in Adolescent Baseball Players.

PubMed

Saper, Michael; Shung, Joseph; Pearce, Stephanie; Bompadre, Viviana; Andrews, James R

2018-04-01

The number of ulnar collateral ligament (UCL) reconstructions in adolescent athletes has increased over the past 2 decades. Clinical results in this population have not been well studied. The purpose of this study was to evaluate the outcomes and return to sport after UCL reconstruction in a large group of adolescent baseball players. We hypothesized that excellent clinical outcomes and high rates of return to sport would be observed in this population at a minimum 2-year follow-up. Case series; Level of evidence, 4. We reviewed 140 adolescent (aged ≤19 years) baseball players who underwent UCL reconstruction with the American Sports Medicine Institute (ASMI) technique by a single surgeon. Medical records were reviewed for patient demographics, injury characteristics, operative details, and surgical complications. Patient-reported outcomes were assessed using the Conway scale, the Andrews-Timmerman (A-T) score, the Kerlan-Jobe Orthopaedic Clinic (KJOC) score, and a 0- to 100-point subjective scale for elbow function and satisfaction. Return to sporting activity was assessed using a custom-designed questionnaire. The mean age at the time of surgery was 18.0 years (range, 13-19 years), and the mean follow-up was 57.9 months (range, 32.4-115.4 months). Over half (60%) of patients were high school athletes. The mean duration of symptoms before surgery was 6.9 months (range, 0.5-60.0 months). Partial tears were identified in 57.9% of patients, and 41.3% of patients had preoperative ulnar nerve symptoms. Graft type included the ipsilateral palmaris in 77.1% of patients. Concomitant procedures were performed in 25% of patients. Outcomes on the Conway scale were "excellent" in 86.4% of patients. The mean A-T and KJOC scores were 97.3 ± 6.1 and 85.2 ± 14.6, respectively. Mean patient satisfaction was 94.4. Overall, 97.8% of patients reported returning to sport at a mean of 11.6 months (range, 5-24 months), and 89.9% of patients returned to sport at the same level of

Outcomes and Return to Sport After Ulnar Collateral Ligament Reconstruction in Adolescent Baseball Players

PubMed Central

Saper, Michael; Shung, Joseph; Pearce, Stephanie; Bompadre, Viviana; Andrews, James R.

2018-01-01

Background: The number of ulnar collateral ligament (UCL) reconstructions in adolescent athletes has increased over the past 2 decades. Clinical results in this population have not been well studied. Purpose/Hypothesis: The purpose of this study was to evaluate the outcomes and return to sport after UCL reconstruction in a large group of adolescent baseball players. We hypothesized that excellent clinical outcomes and high rates of return to sport would be observed in this population at a minimum 2-year follow-up. Study Design: Case series; Level of evidence, 4. Methods: We reviewed 140 adolescent (aged ≤19 years) baseball players who underwent UCL reconstruction with the American Sports Medicine Institute (ASMI) technique by a single surgeon. Medical records were reviewed for patient demographics, injury characteristics, operative details, and surgical complications. Patient-reported outcomes were assessed using the Conway scale, the Andrews-Timmerman (A-T) score, the Kerlan-Jobe Orthopaedic Clinic (KJOC) score, and a 0- to 100-point subjective scale for elbow function and satisfaction. Return to sporting activity was assessed using a custom-designed questionnaire. Results: The mean age at the time of surgery was 18.0 years (range, 13-19 years), and the mean follow-up was 57.9 months (range, 32.4-115.4 months). Over half (60%) of patients were high school athletes. The mean duration of symptoms before surgery was 6.9 months (range, 0.5-60.0 months). Partial tears were identified in 57.9% of patients, and 41.3% of patients had preoperative ulnar nerve symptoms. Graft type included the ipsilateral palmaris in 77.1% of patients. Concomitant procedures were performed in 25% of patients. Outcomes on the Conway scale were “excellent” in 86.4% of patients. The mean A-T and KJOC scores were 97.3 ± 6.1 and 85.2 ± 14.6, respectively. Mean patient satisfaction was 94.4. Overall, 97.8% of patients reported returning to sport at a mean of 11.6 months (range, 5

Effect of distal ulnar collateral ligament tear pattern on contact forces and valgus stability in the posteromedial compartment of the elbow.

PubMed

Hassan, Sheref E; Parks, Brent G; Douoguih, Wiemi A; Osbahr, Daryl C

2015-02-01

It is not known whether the pattern of ulnar collateral ligament (UCL) tear affects elbow biomechanics. There will be a significant change in elbow biomechanics with 50% proximal but not 50% distal simulated rupture of the UCL. Controlled laboratory study. Pressure sensors in the posteromedial elbow joint of 25 male cadaveric elbows (average age, 54.9 years; range, 26-66 years) were used to measure contact area, pressure, and valgus torque at 90° and 30° of elbow flexion. Thirteen specimens were tested with the UCL intact, then with proximal-to-distal detachment of 50%, and then with proximal-to-distal detachment of 100% of the anterior band of the UCL from the ulnar attachment. This method was repeated in the remaining 12 specimens in a distal-to-proximal direction. With 50% proximal-to-distal detachment, contact area decreased significantly versus intact at 90° (91.3 ± 23.6 vs 112.2 ± 26.0 mm(2); P < .001) and 30° (69.3 ± 14.8 vs 83.1 ± 21.6 mm(2); P < .001) of elbow flexion; the center of pressure (COP) moved significantly proximally versus intact at 90° (3.8 ± 2.5 vs 5.4 ± 2.3 mm; P < .001) and 30° (5.9 ± 2.8 vs 7.4±1.9 mm; P < .001). With 50% distal-to-proximal UCL detachment versus intact, no significant change was observed in contact area, movement of the COP, or valgus laxity at either flexion position. With 100% proximal-to-distal and distal-to-proximal detachment, significant change in contact area, movement of the COP, and valgus laxity versus intact was found at 90° and 30° of elbow flexion (P < .05). No significant difference in contact pressure was observed in any test conditions. Significant change in contact area and proximal movement of the COP with 50% proximal UCL detachment and the lack of significant change with 50% distal UCL detachment suggest that the proximal half of the UCL ulnar footprint has a primary role in maintaining posteromedial elbow biomechanics. The findings suggest that surgical reconstruction should aim to

Effects of flexor-pronator muscle loading on valgus stability of the elbow with an intact, stretched, and resected medial ulnar collateral ligament.

PubMed

Udall, John H; Fitzpatrick, Michael J; McGarry, Michelle H; Leba, Thu-Ba; Lee, Thay Q

2009-01-01

The medial ulnar collateral ligament (MUCL) is an important passive stabilizer to the valgus stresses that athletes experience during overhead throwing motion. However, the role of the flexor-pronator muscles as active stabilizers to valgus stress is not well defined in the literature. The objectives of this study were to quantify the relative contribution of the individual flexor-pronator muscles to valgus stability of the elbow and how this relationship was affected by ligament status. A custom elbow testing system and Microscribe 3DLX were used for biomechanical testing. Flexor-pronator muscles were loaded to simulate contraction, and the valgus angle of the elbow was measured in eight cadaveric specimens at 30 degrees , 60 degrees , and 90 degrees of elbow flexion with 3 different valgus torques applied to the forearm. Loads based on muscle cross-sectional area were applied to the flexor carpi ulnaris (FCU), flexor digitorum superficialis (FDS), and pronator teres (PT). The effect of each muscle was evaluated by unloading the individual muscle while the other 2 remained loaded, resulting in 5 loading conditions: no muscles loaded, all muscles loaded, unloaded FCU, unloaded FDS, and unloaded PT. Valgus angle was measured for 3 MUCL ligament conditions: intact, stretched, and cut. The effect of muscle loading on valgus angle was similar for each ligament condition. Loading the flexor-pronator muscles significantly decreased valgus angle of the elbow in all testing conditions (P < .01). Unloading the FDS significantly increased valgus angle compared to all muscles loaded in all testing conditions (P < .016). Unloading the FCU and PT significantly increased valgus angle in less than half of the testing conditions. The FDS, PT, and FCU are all active stabilizers of the elbow to valgus stress. The FDS is the biggest contributor amongst the flexor-pronator muscles.

Incidence of Elbow Ulnar Collateral Ligament Surgery in Collegiate Baseball Players

PubMed Central

Rothermich, Marcus A.; Conte, Stan A.; Aune, Kyle T.; Fleisig, Glenn S.; Cain, E. Lyle; Dugas, Jeffrey R.

2018-01-01

Background: Recent reports have highlighted the progressive increase in the incidence of ulnar collateral ligament (UCL) injuries to the elbow in baseball players of all levels. However, knowledge of the incidence and other epidemiological factors regarding UCL injuries, specifically in college baseball players, is currently lacking. Purpose: To evaluate, over a period of 1 year, the incidence of UCL injuries requiring surgery in National Collegiate Athletic Association (NCAA) Division I baseball programs. Study Design: Descriptive epidemiology study. Methods: A total of 155 Division I collegiate baseball programs agreed to participate in the study. Demographics (position, year, background [location of high school]) for all players on these rosters were obtained from public websites. At the conclusion of the 2017 collegiate baseball season, the athletic trainer for each program entered anonymous, detailed information on injured players through an electronic survey into a secured database. Results: All 155 teams enrolled in the study completed the electronic survey. Of the 5295 collegiate baseball players on these rosters, 134 underwent surgery for an injured UCL (2.5% of all eligible athletes), resulting in a team surgery rate of 0.86 per program for 1 year. These 134 players came from 88 teams, thus 56.8% of the study teams underwent at least 1 surgery during the year. The surgery rate was 2.5 per 100 player-seasons for all players and was significantly higher among pitchers (4.4/100 player-seasons) than nonpitchers (0.7/100 player-seasons). The surgery rate was also significantly higher in underclassmen (3.1/100 player-seasons among freshmen and sophomores) than upperclassmen (1.9/100 player-seasons among juniors and seniors) (incidence rate ratio, 1.7; 95% CI, 1.1-2.4). Players from traditionally warm-weather states did not undergo UCL surgery at a significantly different rate from players from traditionally cold-weather states (2.7/100 player-seasons vs 2

Incidence of Elbow Ulnar Collateral Ligament Surgery in Collegiate Baseball Players.

PubMed

Rothermich, Marcus A; Conte, Stan A; Aune, Kyle T; Fleisig, Glenn S; Cain, E Lyle; Dugas, Jeffrey R

2018-04-01

Recent reports have highlighted the progressive increase in the incidence of ulnar collateral ligament (UCL) injuries to the elbow in baseball players of all levels. However, knowledge of the incidence and other epidemiological factors regarding UCL injuries, specifically in college baseball players, is currently lacking. To evaluate, over a period of 1 year, the incidence of UCL injuries requiring surgery in National Collegiate Athletic Association (NCAA) Division I baseball programs. Descriptive epidemiology study. A total of 155 Division I collegiate baseball programs agreed to participate in the study. Demographics (position, year, background [location of high school]) for all players on these rosters were obtained from public websites. At the conclusion of the 2017 collegiate baseball season, the athletic trainer for each program entered anonymous, detailed information on injured players through an electronic survey into a secured database. All 155 teams enrolled in the study completed the electronic survey. Of the 5295 collegiate baseball players on these rosters, 134 underwent surgery for an injured UCL (2.5% of all eligible athletes), resulting in a team surgery rate of 0.86 per program for 1 year. These 134 players came from 88 teams, thus 56.8% of the study teams underwent at least 1 surgery during the year. The surgery rate was 2.5 per 100 player-seasons for all players and was significantly higher among pitchers (4.4/100 player-seasons) than nonpitchers (0.7/100 player-seasons). The surgery rate was also significantly higher in underclassmen (3.1/100 player-seasons among freshmen and sophomores) than upperclassmen (1.9/100 player-seasons among juniors and seniors) (incidence rate ratio, 1.7; 95% CI, 1.1-2.4). Players from traditionally warm-weather states did not undergo UCL surgery at a significantly different rate from players from traditionally cold-weather states (2.7/100 player-seasons vs 2.1/100 player-seasons, respectively). Nearly half of

Do Clinical Results and Return-to-Sport Rates After Ulnar Collateral Ligament Reconstruction Differ Based on Graft Choice and Surgical Technique?

PubMed Central

Erickson, Brandon J.; Cvetanovich, Gregory L.; Frank, Rachel M.; Bach, Bernard R.; Cohen, Mark S.; Bush-Joseph, Charles A.; Cole, Brian J.; Romeo, Anthony A.

2016-01-01

Background: Ulnar collateral ligament reconstruction (UCLR) has become a common procedure performed in overhead-throwing athletes of many athletic levels. Purpose/Hypothesis: The purpose of this study was to determine whether clinical outcomes and return-to-sport (RTS) rates differ among patients undergoing UCLR based on graft choice, surgical technique, athletic competition level, handedness, and treatment of the ulnar nerve. We hypothesized that no differences would exist in clinical outcomes or RTS rates between technique, graft choice, or other variables. Study Design: Cohort study; Level of evidence, 3. Methods: All patients who underwent UCLR from January 1, 2004 through December 31, 2014 at a single institution were identified. Charts were reviewed to determine patient age, sex, date of surgery, sport played, handedness, athletic level, surgical technique, graft type, and complications. Patients were contacted via telephone to obtain the RTS rate, Conway-Jobe score, Timmerman-Andrews score, and Kerlan-Jobe Orthopaedic Clinic (KJOC) Shoulder and Elbow score. Results: Eighty-five patients (mean age at surgery, 19.3 ± 4.7 years; 92% male; 78% right hand–dominant) underwent UCLR between 2004 and 2014 and were available for follow-up. Overall, 87% were baseball pitchers, 49.4% were college athletes, and 41.2% were high school athletes. No significant difference existed between the docking and double-docking techniques, graft choice, handedness, sex, activity level, and treatment of the ulnar nerve with regard to clinical outcomes, RTS, or subsequent surgeries (all P > .05). More complications were seen in the docking technique compared with the double-docking technique (P = .036). Hamstring autograft was used more commonly with the docking technique (P = .023) while allograft was used more commonly with the double-docking technique (P = .0006). Conclusion: Both the docking and double-docking techniques produce excellent clinical outcomes in patients undergoing

Do Clinical Results and Return-to-Sport Rates After Ulnar Collateral Ligament Reconstruction Differ Based on Graft Choice and Surgical Technique?

PubMed

Erickson, Brandon J; Cvetanovich, Gregory L; Frank, Rachel M; Bach, Bernard R; Cohen, Mark S; Bush-Joseph, Charles A; Cole, Brian J; Romeo, Anthony A

2016-11-01

Ulnar collateral ligament reconstruction (UCLR) has become a common procedure performed in overhead-throwing athletes of many athletic levels. The purpose of this study was to determine whether clinical outcomes and return-to-sport (RTS) rates differ among patients undergoing UCLR based on graft choice, surgical technique, athletic competition level, handedness, and treatment of the ulnar nerve. We hypothesized that no differences would exist in clinical outcomes or RTS rates between technique, graft choice, or other variables. Cohort study; Level of evidence, 3. All patients who underwent UCLR from January 1, 2004 through December 31, 2014 at a single institution were identified. Charts were reviewed to determine patient age, sex, date of surgery, sport played, handedness, athletic level, surgical technique, graft type, and complications. Patients were contacted via telephone to obtain the RTS rate, Conway-Jobe score, Timmerman-Andrews score, and Kerlan-Jobe Orthopaedic Clinic (KJOC) Shoulder and Elbow score. Eighty-five patients (mean age at surgery, 19.3 ± 4.7 years; 92% male; 78% right hand-dominant) underwent UCLR between 2004 and 2014 and were available for follow-up. Overall, 87% were baseball pitchers, 49.4% were college athletes, and 41.2% were high school athletes. No significant difference existed between the docking and double-docking techniques, graft choice, handedness, sex, activity level, and treatment of the ulnar nerve with regard to clinical outcomes, RTS, or subsequent surgeries (all P > .05). More complications were seen in the docking technique compared with the double-docking technique ( P = .036). Hamstring autograft was used more commonly with the docking technique ( P = .023) while allograft was used more commonly with the double-docking technique ( P = .0006). Both the docking and double-docking techniques produce excellent clinical outcomes in patients undergoing UCLR. No difference in outcome scores was seen between surgical technique

Anterior and posterior bands of the anterior bundle in the elbow ulnar collateral ligament: ultrasound anatomy.

PubMed

Yoshida, Masahito; Goto, Hideyuki; Takenaga, Tetsuya; Tsuchiya, Atsushi; Sugimoto, Katsumasa; Musahl, Volker; Fu, Freddie; Otsuka, Takanobu

2017-10-01

The anterior oblique bundle (AOL) of the ulnar collateral ligament (UCL) is composed of anterior and posterior bands. This study evaluated the anatomy of the anterior and posterior bands in the AOL of the UCL for their separate visualization with ultrasound (US). We dissected 18 cadaveric elbow joints and recorded the direction of each band from the lateral view to determine the proper position for the US transducer. To determine the proper inclination of the transducer, we measured the inclinations of each band at the proximal and distal insertions from the transverse view. A paired t test was used for comparisons between both bands. Values of P < .05 were considered statistically significant. The mean angles of the directions in the anterior and posterior bands were 10° ± 4° and 24° ± 9°, respectively. At the medial epicondyle, the mean inclination angles of both bands were 61° ± 5° and 67° ± 5°, respectively. At the sublime tubercle, the mean inclination angles of both bands were 14° ± 7° and 44° ± 9°, respectively. The inclination angles at the proximal ulna and the directions in both bands were significantly different (P < .001). This study shows that the directions of both bands and inclination angles of the bony attachments in both bands can assist with correct placement of the US transducer and allow for separate visualization of each band. Copyright © 2017 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.

[Internal fixation with one-hole microplate for the treatment of collateral ligament injuries of the metacarpophalangeal joint of the thumb combined with fracture].

PubMed

Wang, Xi-Xun; Sun, De-Tao; Chen, Xu-Hui; Li, Jun; Cui, Yan; Hu, Ji-Chao; Shu, Zheng-Hua; He, Jian; Ding, Chao-Qi; Chen, Bo

2015-03-01

To study clinical effects of one-hole microplate internal fixation for the treatment of collateral ligament injuries of the metacarpophalangeal joint of the thumb combined with fracture. Twenty-two patients (16 males, 6 females) with collateral ligament injuries of the metacarpophalangeal joint of the thumb combined fracture were treated with one-hole microplate internal fixation. The age of the patients ranged from 18 to 53 years old with a mean age of 28.5 years old. The duration from injury to surgery ranged from 2 hours to 2 months, and the mean time was 6 days. All the patients had collateral ligament injuries combined with fracture of the metacarpophalangeal joint of the thumb. Thirteen patients had injuries in the right hand and 9 patients had injuries in the left hand. There were 18 cases of closed wound and 4 cases of open wound. Eighteen patients had fresh injuries (< 2 weeks) and 4 had old injuries (> 2 weeks). Sixteen patients had injuries in the ulnar collateral ligament of the thumb combined with fracture, 6 patients had radial collateral ligament injuries of the thumb combined with fracture, 4 cases of which were complicated with injuries of abductor pollicis brevis and the end of the flexor pollicis brevis tender. The size of the avulsed fragment was about 3.0 mm x 4.0 mm to 6.0 mm x 7.0 mm. The incisions of 22 patients healed by first intention. The follow-up periods ranged from 6 months to 5 years old,with an average of 2.5 years old. The thumb function was evaluated by Saetta and other evaluation criteria, and 20 patients got an excellent result and 2 good. The application of one-hole microplate internal fixation in treating collateral ligament injuries with fracture of the metacarpophalangeal joint of the thumb is an effective method.

Treatment of Ulnar Collateral Ligament Tears of the Elbow: Is Repair a Viable Option?

PubMed

Erickson, Brandon J; Bach, Bernard R; Verma, Nikhil N; Bush-Joseph, Charles A; Romeo, Anthony A

2017-01-01

Ulnar collateral ligament (UCL) tears have become common, and UCL reconstruction (UCLR) is currently the preferred surgical treatment method for treating UCL tears. The purpose of this study was to review the literature surrounding UCL repair and determine the viability of new repair techniques for treatment of UCL tears. We hypothesized that UCL repair techniques will provide comparable results to UCLR for treatment of UCL tears. Systematic review and meta-analysis; Level of evidence, 4. A systematic review was registered with PROSPERO and performed with PRISMA guidelines using 3 publicly available free databases. Biomechanical and clinical outcome investigations reporting on UCL repair with levels of evidence 1 through 4 were eligible for inclusion. Descriptive statistics were calculated for each study and parameter/variable analyzed. Of the 46 studies eligible, 4 studies (3 clinical and 1 biomechanical) were included. There were 92 patients (n = 92 elbows; 61 males [62.3%]; mean age, 21.9 ± 4.7 years) included in the clinical studies, with a mean follow-up of 49 ± 14.4 months. Eighty-six percent of repairs performed were on the dominant elbow, and 38% were in college athletes. Most UCL repairs (66.3%) were performed via suture anchors. After UCL repair, 87.0% of patients were able to return to sport. Overall, 94.9% of patients scored excellent/good on the Andrews-Carson score. Patients who were able to return to sport after UCL repair did so within 6 months after surgery. Biomechanically, when UCL repair was compared with the modified Jobe technique, the repair group showed significantly less gap formation than the reconstruction group. In patients for whom repair is properly indicated, UCL repair provides similar return-to-sport rates and clinical outcomes with shorter return-to-sport timing after repair compared with UCL reconstruction. Future outcome studies evaluating UCL repair with internal bracing are necessary before recommending this technique.

Pitching performance and longevity after revision ulnar collateral ligament reconstruction in Major League Baseball pitchers.

PubMed

Marshall, Nathan E; Keller, Robert A; Lynch, Jonathan R; Bey, Michael J; Moutzouros, Vasilios

2015-05-01

Medial ulnar collateral ligament (UCL) reconstruction is a common procedure performed on professional pitchers in Major League Baseball (MLB). Although a great deal is known about primary reconstruction, much less is known about revision reconstruction. The purpose of this study was to evaluate statistical performance, return to play, and career longevity in MLB pitchers after revision UCL surgery, with the hypothesis that pitching performance and career longevity will decline after revision surgery. Cohort study; Level of evidence, 3. A total of 33 MLB pitchers who underwent revision UCL reconstruction surgery (UCL-R group) were identified and compared with 33 age- and position-matched controls (CTL group). Return to play, total years played, and statistical performance were evaluated and compared with controls. After revision surgery, 65.5% of UCL-R pitchers returned to the MLB level. On average, the UCL-R pitchers played 0.8 years less in the majors (P<.01) than did the control pitchers. The UCL-R pitchers who returned to the MLB level had a similar earned run average (UCL-R: 4.88, CTL: 4.76, P=.82) and walks/hits per innings pitched (UCL-R: 1.58, CTL: 1.44, P=.22) compared with the control pitchers. There were significant declines, however, in terms of innings pitched (UCL-R: 36.95, CTL: 75.00, P<.01), walks per 9 innings (UCL-R: 4.75, CTL: 3.49, P<.01), and wins (UCL-R: 1.88, CTL: 4.10, P<.01) as well as nonsignificant declines in wins above replacement (UCL-R: 0.25, CTL: 0.62, P=.06) and runs above replacement (UCL-R: 3.26, CTL: 6.91, P=.07). MLB pitchers who undergo UCL-R have a low rate of return to MLB play and have shortened careers after return. Pitchers who returned to the MLB level maintained performance in several statistics such as earned run average and walks/hits per innings pitched; however, pitchers returned with a significantly decreased workload. © 2015 The Author(s).

Magnetic Resonance Imaging Predictors of Failure in the Nonoperative Management of Ulnar Collateral Ligament Injuries in Professional Baseball Pitchers.

PubMed

Frangiamore, Salvatore J; Lynch, T Sean; Vaughn, Michael D; Soloff, Lonnie; Forney, Michael; Styron, Joseph F; Schickendantz, Mark S

2017-07-01

A medial ulnar collateral ligament (UCL) injury of the elbow is an increasingly common injury in professional baseball pitchers. Predictors of success and failure are not well defined for the nonoperative management of these injuries. To evaluate the efficacy of objective measures to predict failure of the nonoperative management of UCL injuries. Case-control study; Level of evidence, 3. Thirty-two professional pitchers (82%) met inclusion criteria and underwent an initial trial of nonoperative treatment for UCL tears based on clinical and radiological findings. Age, preseason physical examination results, magnetic resonance imaging (MRI) characteristics, and performance metrics were analyzed for these pitchers. Successful nonoperative management was defined as a return to the same level of play or higher for >1 year. Failure was defined as recurrent pain or weakness requiring a surgical intervention after a minimum of 3 months' rest when attempting a return to a throwing rehabilitation program. Thirty-two pitchers (mean age, 22.3 years) who underwent initial nonoperative treatment of UCL injuries were evaluated. Thirty-four percent (11/32) failed and required subsequent ligament reconstruction. Sixty-six percent (21/32) successfully returned to the same level of play for 1 year without a surgical intervention. There was no significant difference seen in physical examination findings or performance metrics between these patients. When comparing MRI findings between the groups, 82% (9/11) ( P < .001) who failed nonoperative management had distal tears, and 81% (17/21) who did not fail had proximal tears ( P < .001). When adjusting for age, location, and evidence of chronic changes on MRI, the likelihood of failing nonoperative management was 12.40 times greater ( P = .020) with a distal tear. No other variable alone or in combination reached significance. When combining the parameters of a high-grade tear and distal location, 88% (7/8) failed nonoperative management

Biomechanical performance of baseball pitchers with a history of ulnar collateral ligament reconstruction.

PubMed

Fleisig, Glenn S; Leddon, Charles E; Laughlin, Walter A; Ciccotti, Michael G; Mandelbaum, Bert R; Aune, Kyle T; Escamilla, Rafael F; MacLeod, Toran D; Andrews, James R

2015-05-01

A relatively high number of active professional baseball pitchers have a history of ulnar collateral ligament reconstruction (UCLr) on their throwing elbow. Controversy exists in the literature about whether professional baseball pitchers regain optimal performance after return from UCLr. It has been suggested that pitchers may have different biomechanics after UCLr, but this has not been previously tested. It was hypothesized that, compared with a control group without a history of UCLr, professional pitchers with a history of UCLr would have (1) significantly different throwing elbow and shoulder biomechanics; (2) a shortened stride, insufficient trunk forward tilt, and excessive shoulder horizontal adduction, characteristics associated with "holding back" or being tentative; (3) late shoulder rotation; and (4) improper shoulder abduction and trunk lateral tilt. Controlled laboratory study. A total of 80 active minor league baseball pitchers (and their 8 Major League Baseball organizations) agreed to participate in this study. Participants included 40 pitchers with a history of UCLr and a matched control group of 40 pitchers with no history of elbow or shoulder surgery. Passive ranges of motion were measured for each pitcher's elbows and shoulders, and then 23 reflective markers were attached to his body. The pitcher took as many warm-up pitches as desired and then threw 10 full-effort fastballs for data collection. Ball speed was recorded with a radar gun. The reflective markers were tracked with a 10-camera, 240-Hz automated motion analysis system. Eleven biomechanical parameters were computed for each pitch and then averaged for each participant. Demographic, range of motion, and biomechanical parameters were compared between the UCLr group and the control group by use of Student t tests (significance set at P<.05). All hypotheses were rejected, as there were no differences in pitching biomechanics between the UCLr group and the control group. There were also

Reasons for Retirement Following Ulnar Collateral Ligament Reconstruction Among Major League Baseball Pitchers

PubMed Central

Erickson, Brandon J.; Ahn, Junyoung; Chalmers, Peter N.; Ahmad, Christopher S.; Bach, Bernard R.; Verma, Nikhil N.; Romeo, Anthony A.

2017-01-01

Background: Ulnar collateral ligament reconstruction (UCLR) has become an increasingly common procedure among Major League Baseball (MLB) pitchers. The long-term effects of this procedure on the career of an MLB pitcher are largely unknown. Purpose/Hypothesis: The purpose of this study was to determine why and when MLB pitchers who underwent UCLR during their careers retired from baseball as compared with controls. We hypothesized that pitchers who underwent UCLR are no more likely than control pitchers to retire from elbow or shoulder problems. Study Design: Cross-sectional study; Level of evidence, 3. Methods: All MLB pitchers who underwent UCLR were identified through publicly available data. A cohort of pitchers who did not undergo UCLR were matched to pitchers with a history of UCLR, based on sex, age, draft year, and draft round. Of those who were no longer pitching in the MLB, the reason for retirement was determined. Reason for retirement and length of career following UCLR (surgical group) and index year (control group) were determined and compared through prior studies via the MLB HITS database, MLB team websites, and publicly available internet-based injury reports. Results: Overall, 153 MLB pitchers who underwent UCLR between 1974 and 2015 are currently retired. Mean ± SD time to retirement was 4.4 ± 4.7 years (range, 0-26 years) after the index year in the control group and 4.4 ± 3.5 years (range, 0-15 years) after surgery in the UCLR group (P = .388). Patients who were status post-UCLR were significantly more likely to be released during the season (34 of 144, 23.6%) than were players who were not status post-UCLR (14 of 144, 9.7%) (P = .002). Shoulder injury as a reason for retirement was more common in the control group than the UCLR group (P = .011). Elbow injury as a reason for retirement was not more common in either group (P = .379). Leg injury as a reason for retirement was more common in the control group (P = .013). Performance as a reason

Medial collateral ligament injuries and subsequent load on the anterior cruciate ligament: a biomechanical evaluation in a cadaveric model.

PubMed

Battaglia, Michael J; Lenhoff, Mark W; Ehteshami, John R; Lyman, Stephen; Provencher, Matthew T; Wickiewicz, Thomas L; Warren, Russell F

2009-02-01

Numerous studies have documented the effect of complete medial collateral ligament injury on anterior cruciate ligament loads; few have addressed how partial medial collateral ligament disruption affects knee kinematics. To determine knee kinematics and subsequent change in anterior cruciate ligament load in a partial and complete medial collateral ligament injury model. Controlled laboratory study. Ten human cadaveric knees were sequentially tested by a robot with the medial collateral ligament intact, in a partial injury model, and in a complete injury model with a universal force-moment sensor measuring system. Tibial translation, rotation, and anterior cruciate ligament load were measured under 3 conditions: anterior load (125 N), valgus load (10 N x m), and internal-external rotation torque (4 N x m; all at 0 degrees and 30 degrees of flexion). Anterior and posterior translation did not statistically increase with a partial or complete medial collateral ligament injury at 0 degrees and 30 degrees of flexion. In response to a 125 N anterior load, at 0 degrees , the anterior cruciate ligament load increased 8.7% (from 99.5 to 108.2 N; P = .006) in the partial injury and 18.3% (117.7 N; P < .001) in the complete injury; at 30 degrees , anterior cruciate ligament load was increased 12.3% (from 101.7 to 114.2 N; P = .001) in the partial injury and 20.6% (122.7 N; P < .001) in the complete injury. In response to valgus torque (10 N x m) at 30 degrees , anterior cruciate ligament load was increased 55.3% (30.4 to 47.2 N; P = .044) in the partial injury model and 185% (86.8 N; P = .001) in the complete injury model. In response to internal rotation torque (4 N.m) at 30 degrees , anterior cruciate ligament load was increased 29.3% (27.6 to 35.7 N; P = .001) in the partial injury model and 65.2% (45.6 N; P < .001) in the complete injury model. The amount of internal rotation at 30 degrees of flexion was significantly increased in the complete injury model (22.8 degrees

Analysis of pitching velocity in major league baseball players before and after ulnar collateral ligament reconstruction.

PubMed

Jiang, Jimmy J; Leland, J Martin

2014-04-01

Ulnar collateral ligament (UCL) reconstructions are relatively common among professional pitchers in Major League Baseball (MLB). To the authors' knowledge, there has not been a study specifically analyzing pitching velocity after UCL surgery. These measurements were examined in a cohort of MLB pitchers before and after UCL reconstruction. There is no significant loss in pitch velocity after UCL reconstruction in MLB pitchers. Cohort study; Level of evidence, 3. Between the years 2008 to 2010, a total of 41 MLB pitchers were identified as players who underwent UCL reconstruction. Inclusion criteria for this study consisted of a minimum of 1 year of preinjury and 2 years of postinjury pitch velocity data. After implementing exclusion criteria, performance data were analyzed from 28 of the 41 pitchers over a minimum of 4 MLB seasons for each player. A pair-matched control group of pitchers who did not have a known UCL injury were analyzed for comparison. Of the initial 41 players, 3 were excluded for revision UCL reconstruction. Eight of the 38 players who underwent primary UCL reconstruction did not return to pitching at the major league level, and 2 players who met the exclusion criteria were omitted, leaving data on 28 players available for final velocity analysis. The mean percentage change in the velocity of pitches thrown by players who underwent UCL reconstruction was not significantly different compared with that of players in the control group. The mean innings pitched was statistically different only for the year of injury and the first postinjury year. There were also no statistically significant differences between the 2 groups with regard to commonly used statistical performance measurements, including earned run average, batting average against, walks per 9 innings, strikeouts per 9 innings, and walks plus hits per inning pitched. There were no significant differences in pitch velocity and common performance measurements between players who returned to

Change in collateral ligament length and tibiofemoral movement following joint line variation in TKA.

PubMed

Lin, Kun-Jhih; Wei, Hung-Wen; Huang, Chang-Hung; Liu, Yu-Liang; Chen, Wen-Chuan; McClean, Colin Joseph; Cheng, Cheng-Kung

2016-08-01

The primary intent of total knee arthroplasty is the restoration of normal knee kinematics, with ligamentous constraint being a key influential factor. Displacement of the joint line may lead to alterations in ligament attachment sites relative to knee flexion axis and variance of ligamentous constraints on tibiofemoral movement. This study aimed to investigate collaterals strains and tibiofemoral kinematics with different joint line levels. A previously validated knee model was employed to analyse the change in length of the collateral ligaments and tibiofemoral motion during knee flexion. The models shifted the joint line by 3 and 5 mm both proximally and distally from the anatomical level. The data were captured from full extension to flexion 135°. The elevated joint line revealed a relative increase in distance between ligament attachments for both collateral ligaments in comparison with the anatomical model. Also, tibiofemoral movement decreased with an elevation in the joint line. Conversely, lowering the joint line led to a significant decrease in distance between ligament attachments, but greater tibiofemoral motion. Elevation of the joint line would strengthen the capacity of collateral ligaments for knee motion constraint, whereas a distally shifted joint line might have the advantage of improving tibiofemoral movement by slackening the collaterals. It implies that surgeons can appropriately change the joint line position in accordance with patient's requirement or collateral tensions. A lowered joint line level may improve knee kinematics, whereas joint line elevation could be useful to maintain knee stability. V.

Effect of Predraft Ulnar Collateral Ligament Reconstruction on Future Performance in Professional Baseball: A Matched Cohort Comparison.

PubMed

Camp, Christopher L; Conte, Stan; D'Angelo, John; Fealy, Stephen A; Ahmad, Christopher S

2018-05-01

In recent years, there has been a dramatic rise in the annual number of ulnar collateral ligament (UCL) reconstructions performed in amateur baseball pitchers. Accordingly, increasing numbers of players are entering professional baseball having already undergone the procedure; however, the effect of prior UCL reconstruction on future success remains unknown. (1) To provide an epidemiologic report on baseball players who undergo UCL reconstruction before being selected in the Major League Baseball (MLB) Draft, (2) to define the outcomes in terms of statistical performance, and (3) to compare these results with those of matched controls (ie, non-UCL reconstruction). Cohort study; Level of evidence, 3. The MLB Amateur Draft Database was queried to identify all drafted pitchers who underwent UCL reconstruction before being drafted. For each pitcher drafted from 2005 to 2014 with prior UCL reconstruction, 3 healthy controls with no history of elbow surgery were randomly identified for matched analysis. A number of demographic and performance comparisons were made between these groups. A total of 345 pitchers met inclusion criteria. The annual number of pitchers undergoing predraft UCL reconstructions rose steadily from 2005 to 2016 ( P < .001). For matched control analysis, 252 pitchers with a UCL reconstruction and a minimum 2-year follow-up (drafted between 2005 and 2014) were matched to 756 controls (non-UCL reconstruction). As compared with the non-UCL reconstruction group, pitchers who underwent predraft UCL reconstruction reached the MLB level with greater frequency (20% vs 12%, P = .003), and their MLB statistical performances were similar for all measures. Compared with all other pitchers drafted during that period, players who had a predraft UCL reconstruction demonstrated an increased likelihood of reaching progressive levels of play (Full Season A, AA, and MLB) within a given time frame ( P < .05 for all). The number of UCL reconstructions performed in

The morphologic change of the ulnar collateral ligament of elbow in high school baseball pitchers, with and without symptoms, by sonography.

PubMed

Tajika, Tsuyoshi; Yamamoto, Atsushi; Oya, Noboru; Ichinose, Tsuyoshi; Shimoyama, Daisuke; Sasaki, Tsuyoshi; Shitara, Hitoshi; Kitagawa, Takanori; Saito, Kenichi; Osawa, Takashi; Takagishi, Kenji

2016-08-01

Few reports in the literature relate morphologic changes of the ulnar collateral ligament (UCL) to prior elbow symptoms. This study used ultrasonography (US) to assess the ulnohumeral joint space width, with and without stress, and elucidate morphologic changes of the UCL of the elbow in high school pitchers with and without a history of elbow symptoms. Each of 122 high school baseball pitchers who underwent US of the medial aspect of both elbows completed a self-administered questionnaire related to the self-satisfaction score (0-100) for pitching performance and throwing-related elbow joint pain sustained during the prior 3 years. We conducted gravity stress US elbow examination with 30° of flexion with and without valgus stress. Comparisons of the UCL thickness and ulnohumeral joint space width, with and without valgus stress, were made among the 122 high school pitchers with and without a history of elbow symptoms. Pitchers with an elbow symptom history exhibited a greater difference between the UCL thickness on the throwing side than those with no elbow symptom history (P = .0013). A negative significant association was found between UCL thickness on the pitching side and the self-evaluation score for pitching performance (r = -0.20, P = .04). US assessment demonstrated that the UCL in the dominant side with elbow symptom history was thicker than that with no elbow symptom history. The UCL thickness might reflect the prior pitching condition of high school baseball pitchers. Copyright © 2016 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.

The success of return to sport after ulnar collateral ligament injury in baseball: a systematic review and meta-analysis.

PubMed

Peters, Scott D; Bullock, Garrett S; Goode, Adam P; Garrigues, Grant E; Ruch, David S; Reiman, Michael P

2018-03-01

Ulnar collateral ligament injury (UCLI) has significantly increased in overhead sports during the past 2 decades. Differences in return to sport (RTS) and RTS at previous level (RTSP) after UCLI have not been differentiated. A computer-assisted literature search of PubMed, CINAHL, Embase, and SportDiscus databases using keywords related to RTS for UCLI was implemented. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were used for study methodology. Quality assessment was conducted using a modified Downs and Black scale. A total of 22 retrospective, level 3b or 4, studies (n = 2289) qualified for analysis. Overall RTS proportion was 90% (95% confidence interval [CI], 86%-94%) and overall RTSP proportion was 79% (95% CI, 75%-84%), both with significant heterogeneity (P < .001, I 2  = 74%-84%). RTS and RTSP proportions were 89% (95% CI, 83%-94%) and 78% (95% CI, 72%-83%) for Major League Baseball players, 91% (95% CI, 77%-99%) and 67% (95% CI, 52%-81%) for Minor League Baseball players, 95% (95% CI, 75%-100%) and 92% (95% CI, 82%-98%) for collegiate players, and 93% (95% CI, 81%-100%) and 83% (95% CI, 77%-89%) for high school players, respectively. Increased earned run average, walks, and hits per inning pitched, decreased innings pitched, and decreased fastball velocity were found after UCLI. Low-level, high-bias evidence demonstrates overall RTS proportion is higher than RTSP, regardless of treatment type for UCLI. Although RTS proportions remained consistent across various levels of play, RTSP proportions were lower in professional players, particularly Minor League Baseball compared with collegiate and high school players. Pitching performance significantly decreased postoperatively in most studies. Copyright © 2017 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.

The "moving valgus stress test" for medial collateral ligament tears of the elbow.

PubMed

O'Driscoll, Shawn W M; Lawton, Richard L; Smith, Adam M

2005-02-01

The diagnosis of a painful partial tear of the medial collateral ligament in overhead-throwing athletes is challenging, even for experienced elbow surgeons and despite the use of sophisticated imaging techniques. The "moving valgus stress test" is an accurate physical examination technique for diagnosis of medial collateral ligament attenuation in the elbow. Cohort study (diagnosis); Level of evidence, 2. Twenty-one patients underwent surgical intervention for medial elbow pain due to medial collateral ligament insufficiency or other abnormality of chronic valgus overload, and they were assessed preoperatively with an examination called the moving valgus stress test. To perform the moving valgus stress test, the examiner applies and maintains a constant moderate valgus torque to the fully flexed elbow and then quickly extends the elbow. The test is positive if the medial elbow pain is reproduced at the medial collateral ligament and is at maximum between 120 degrees and 70 degrees. The moving valgus stress test was highly sensitive (100%, 17 of 17 patients) and specific (75%, 3 of 4 patients) when compared to assessment of the medial collateral ligament by surgical exploration or arthroscopic valgus stress testing. The mean shear range (ie, the arc within which pain was produced with the moving valgus stress test) was 120 degrees to 70 degrees. The mean angle at which pain was at a maximum was 90 degrees of elbow flexion. The moving valgus stress test is an accurate physical examination technique that, when performed and interpreted correctly, is highly sensitive for medial elbow pain arising from the medial collateral ligament.

Anatomy of the collateral ligaments of the feline elbow joint: functional implications.

PubMed

Engelke, E; Pfarrer, C; Waibl, H

2011-04-01

Cats show a higher capability to supinate their forearms than dogs. This suggests a special arrangement of the collateral ligaments of the feline elbow joint. Therefore, the course of the ligaments was examined in 13 adult cats. The size of the ligaments was measured, and effects of passive joint movements were studied. Ligaments of five additional cats were examined histologically. The lateral collateral ligament (LCL) had a superficial and deep part, both originating from the humerus. The free humeral portion of the LCL was short and contained fibrous cartilage. Fibre bundles of the deep part inserted into the annular ligament, while the remaining deep fibres and the superficial part inserted with a long antebrachial portion on the radius. The medial collateral ligament (MCL) originated from the humeral epicondyle and divided into cranial and caudal parts. The caudal part inserted medioproximally on the ulna, while the cranial part attached primarily with a long thin part to the caudal aspect of the radius. During supination, the MCL loosened thus allowing medial widening of the joint space, up to 2 mm. A specific feature of the feline elbow is the long thin part of the MCL. Its course through a special furrow distal to the medial coronoid causes the tightening of the feline MCL during pronation. Apart from that, the feline collateral ligaments combine the features of both human and canine cubital anatomy. This explains the range of supination in cats, which is intermediate between humans and dogs. © 2010 Blackwell Verlag GmbH.

An attachment-based description of the medial collateral and spring ligament complexes.

PubMed

Cromeens, Barrett P; Kirchhoff, Claire A; Patterson, Rita M; Motley, Travis; Stewart, Donald; Fisher, Cara; Reeves, Rustin E

2015-06-01

Anatomy of the medial collateral and spring ligament complexes has been the cause of confusion. The anatomic description is highly dependent on the source studied and little agreement exists between texts. In addition, inconsistent nomenclature has been used to describe the components. This study attempted to clarify confusion through the creation of a 3D ligament map using attachment-based dissection. Nine fresh foot and ankle specimens were observed. The medial collateral ligament and spring ligament complexes were dissected using their attachment sites as a guide to define individual components. Each component's perimeter and thickness was measured and each bony attachment was mapped using a microscribe 3D digitizer. Five components were identified contributing to the ligament complexes of interest: the tibiocalcaneonavicular, superficial posterior tibiotalar, deep posterior tibiotalar, deep anterior tibiotalar, and inferoplantar longitudinal ligaments. The largest component by total attachment area was the tibiocalcaneonavicular ligament followed by the deep posterior tibiotalar ligament. The largest ligament surface area of attachment to the tibia and talus was the deep posterior tibiotalar ligament. The largest attachment to the navicular and calcaneus was the tibiocalcaneonavicular ligament, which appeared to function in holding these bones in proximity while supporting the head of the talus. By defining complex components by their attachment sites, a novel, more functional and reproducible description of the medial collateral and spring ligament complexes was created. The linear measurements and 3D maps may prove useful when attempting more anatomically accurate reconstructions. © The Author(s) 2015.

Does well maintained graft provide consistent return to play after medial ulnar collateral ligament reconstruction of the elbow joint in elite baseball players?

PubMed

Park, Jin-Young; Oh, Kyung-Soo; Bahng, Seung-Chul; Chung, Seok-Won; Choi, Jin-Ho

2014-06-01

Several studies have reported the clinical outcomes of medial ulnar collateral ligament (MUCL) reconstruction of the elbow joint in throwing athletes, including the rate of return to sports. However, little has been known about the imaging outcomes after MUCL reconstruction. The aim of this study is to report the clinical and imaging outcomes after MUCL reconstruction using figure of eight fashion in the elite and professional baseball players. This study included 17 baseball players, who underwent MUCL reconstruction between July 2007 and May 2010. The average follow-up period was 48.6 months. Imaging assessment consisted of preoperative plain and stress radiographs, magnetic resonance imaging, and postoperative serial ultrasonography. The clinical assessments were composed of visual analogue scale (VAS) for pain, range of motion, and the Conway scale. The mean VAS score was 6.4 (range, 3 to 8) preoperatively and 2.2 (range, 0 to 4) postoperatively (p < 0.05). There were nine players (53%) classified as excellent who returned to sports at the same or higher level compared to preinjury. Serial ultrasonography revealed well-maintained grafts at 3 and 12 months in all of the players. Five out of 17 players showed decreased echogenecity in the common flexor tendon at 3 months, which was considered as remaining tissue swelling and resolved completely at 12 months. All grafts are well-maintained until 12-months based on the ultrasonographic findings, although only 53% of the players returned to preinjury level.

Isolated lateral collateral ligament complex injury in rock climbing and Brazilian Jiu-jitsu.

PubMed

Davis, Bryan A; Hiller, Lucas P; Imbesi, Steven G; Chang, Eric Y

2015-08-01

We report two occurrences of high-grade tears of the lateral collateral ligament complex (LCLC), consisting of the anterolateral ligament (ALL) and fibular collateral ligament (FCL). One injury occurred in a rock climber and the other in a martial artist. Increasing awareness of isolated injuries of the LCLC will allow for appropriate diagnosis and management. We review and discuss the anatomy of the LCLC, the unique mechanism of isolated injury, as well as physical and imaging examination findings.

Performance and Injury Characteristics of Pitchers Entering the Major League Baseball Draft After Ulnar Collateral Ligament Reconstruction.

PubMed

Wymore, Lucas; Chin, Paul; Geary, Christopher; Carolan, Gregory; Keefe, Daniel; Hoenecke, Heinz; Fronek, Jan

2016-12-01

Ulnar collateral ligament (UCL) reconstruction (UCLR) has been studied and shown to be a successful procedure for returning overhead athletes to sport. Many studies of Major League Baseball (MLB) players have shown high levels of return to play with successful statistical performance. No study has followed professional advancement of drafted pitchers who underwent UCLR as amateurs when compared with drafted pitchers who did not undergo the procedure before selection in the MLB draft. There would be no difference in professional advancement, statistical performance, or injury rate between the UCLR and control groups. Cohort study; Level of evidence, 3. Thirty-eight pitchers with a UCLR as an amateur and 114 controls were identified in the MLB draft between 2006 and 2010. Highest level of professional baseball achieved was collected from all players, as well as statistical performance metrics including velocity, wins, earned run average (ERA), and walks and hits per inning pitched (WHIP). Additional data on future injuries were analyzed for days on the disabled list (DL), risk of being placed on the DL, and DL assignment for elbow injury. Thirteen of 38 UCLR pitchers reached the major league level (34.2%) compared with 29 of 114 (25.4%) control pitchers, which was not statically significant (P = .295). The UCLR and control groups were similar for average velocity, peak velocity, innings pitched, games, games started, innings per game, ERA, WHIP, wins, losses, saves, batters faced, and innings pitched per year, as well as hits, runs, home runs allowed, strikeouts, batters walked, and batters struck per inning. The UCLR group had a significantly increased rate of DL assignment when compared with controls (86.8% vs 64.0%; P = .008); however, days on DL (152.8 vs 135.6; P = .723) and DL assignment for elbow injury (45.5% vs 43.8%; P = .877) were similar. There was no difference in the rate of professional advancement among pitchers drafted by the MLB who had undergone

Return to football and long-term clinical outcomes after thumb ulnar collateral ligament suture anchor repair in collegiate athletes.

PubMed

Werner, Brian C; Hadeed, Michael M; Lyons, Matthew L; Gluck, Joshua S; Diduch, David R; Chhabra, A Bobby

2014-10-01

To evaluate return to play after complete thumb ulnar collateral ligament (UCL) injury treated with suture anchor repair for both skill position and non-skill position collegiate football athletes and report minimum 2-year clinical outcomes in this population. For this retrospective study, inclusion criteria were complete rupture of the thumb UCL and suture anchor repair in a collegiate football athlete performed by a single surgeon who used an identical technique for all patients. Data collection included chart review, determination of return to play, and Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH) outcomes. A total of 18 collegiate football athletes were identified, all of whom were evaluated for follow-up by telephone, e-mail, or regular mail at an average 6-year follow-up. Nine were skill position players; the remaining 9 played in nonskill positions. All players returned to at least the same level of play. The average QuickDASH score for the entire cohort was 1 out of 100; QuickDASH work score, 0 out of 100; and sport score, 1 out of 100. Average time to surgery for skill position players was 12 days compared with 43 for non-skill position players. Average return to play for skill position players was 7 weeks postoperatively compared with 4 weeks for non-skill position players. There was no difference in average QuickDASH overall scores or subgroup scores between cohorts. Collegiate football athletes treated for thumb UCL injuries with suture anchor repair had quick return to play, reliable return to the same level of activity, and excellent long-term clinical outcomes. Skill position players had surgery sooner after injury and returned to play later than non-skill position players, with no differences in final level of play or clinical outcomes. Management of thumb UCL injuries in collegiate football athletes can be safely and effectively tailored according to the demands of the player's football position. Therapeutic IV. Copyright © 2014

Sprain of the short radial collateral ligament in a racing greyhound.

PubMed

Guilliard, M J; Mayo, A K

2000-04-01

Severe carpal lameness in a racing greyhound due to a sprain of the straight part of the short radial collateral ligament is described. The dog subsequently developed an enthesiopathy at the origin of the ligament. Treatment was by kennel rest and the dog returned to successful racing.

Long-term Outcomes After Ulnar Collateral Ligament Reconstruction in Competitive Baseball Players: Minimum 10-Year Follow-up.

PubMed

Osbahr, Daryl C; Cain, E Lyle; Raines, B Todd; Fortenbaugh, Dave; Dugas, Jeffrey R; Andrews, James R

2014-06-01

Ulnar collateral ligament reconstruction (UCLR) has afforded baseball players with excellent results; however, previous studies have described only short-term outcomes. To evaluate long-term outcomes after UCLR in baseball players. Case series; Level of evidence, 4. All UCLRs performed on competitive baseball players with a minimum 10-year follow-up were identified. Surgical data were collected prospectively and patients were surveyed by telephone follow-up, during which scoring systems were used to assess baseball career and post-baseball career outcomes. Of 313 patients, 256 (82%) were contacted at an average of 12.6 years; 83% of these baseball players (90% pitchers) were able to return to the same or higher level of competition in less than 1 year, but results varied according to preoperative level of play. Baseball career longevity was 3.6 years in general and 2.9 years at the same or higher level of play, but major and minor league players returned for longer than did collegiate and high school players after surgery (P < .001). Baseball retirement typically occurred for reasons other than elbow problems (86%). Many players had shoulder problems (34%) or surgery (25%) during their baseball career, and these occurrences most often resulted in retirement attributable to shoulder problems (P < .001). For post-baseball career outcomes, 92% of patients were able to throw without pain, and 98% were still able to participate in throwing at least on a recreational level. The 10-year minimum follow-up scores (mean ± standard deviation) for the Disabilities of the Arm, Shoulder and Hand (DASH), DASH work module, and DASH sports module were 0.80 ± 4.43, 1.10 ± 6.90, and 2.88 ± 11.91, respectively. Overall, 93% of patients were satisfied, with few reports of persistent elbow pain (3%) or limitation of function (5%). Long-term follow-up of UCLRs in baseball players indicates that most patients were satisfied, with few reports of persistent elbow pain or limitation of

Biomechanical comparison of graft fixation at 30° and 90° of elbow flexion for ulnar collateral ligament reconstruction by the docking technique.

PubMed

Cohen, Steven B; Woods, Daniel P; Siegler, Sorin; Dodson, Christopher C; Namani, Ramya; Ciccotti, Michael G

2015-02-01

Ulnar collateral ligament (UCL) injuries have been successfully treated by the docking reconstruction. Although fixation of the graft has been suggested at 30° of elbow flexion, no quantitative biomechanical data exist to provide guidelines for the optimal elbow flexion angle for graft fixation. Testing was conducted on 10 matched pairs of cadaver elbows with use of a loading system and optoelectric tracking device. After biomechanical data on the native UCL were obtained, reconstruction by the docking technique was performed with use of palmaris longus autograft with one elbow fixated at 30° and the contralateral elbow at 90° of elbow flexion. Biomechanical testing was undertaken on these specimens. The load to failure of the native UCL (mean, 20.1 N-m) was significantly higher (P = .004) than that of the reconstructed UCL (mean, 4.6 N-m). There was no statistically significant difference in load to failure of the UCL reconstructions fixated at 30° of elbow flexion (average, 4.86 N-m) compared with those at 90° (average, 4.35 N-m). Elbows reconstructed at 30° and 90° of elbow flexion produced similar kinematic coupling and valgus laxity characteristics compared with each other and with the intact UCL. Although not statistically significant, the reconstructions fixated at 30° more closely resembled the biomechanical characteristics of the intact elbow than did reconstructions fixated at 90°. No statistically significant difference was found in comparing the docking technique of UCL reconstruction with graft fixation at 30° vs. 90° of elbow flexion. Copyright © 2015 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.

MR imaging of the elbow in the injured athlete.

PubMed

Wenzke, Daniel R

2013-03-01

This article summarizes key MR imaging findings in common athletic elbow injuries including little leaguer's elbow, Panner disease, osteochondritis dissecans, olecranon stress fracture, occult fracture, degenerative osteophyte formation, flexor-pronator strain, ulnar collateral ligament tear, lateral ulnar collateral ligament and radial collateral ligament tear, lateral epicondylitis, medial epicondylitis, biceps tear, bicipitoradial bursitis, triceps tear, olecranon bursitis, ulnar neuropathy, posterior interosseous nerve syndrome, and radial tunnel syndrome. The article also summarizes important technical considerations in elbow MR imaging that enhance image quality and contribute to the radiologist's success. Copyright © 2013 Elsevier Inc. All rights reserved.

Collateral ligament strains during knee joint laxity evaluation before and after TKA.

PubMed

Delport, Hendrik; Labey, Luc; De Corte, Ronny; Innocenti, Bernardo; Vander Sloten, Jos; Bellemans, Johan

2013-08-01

Passive knee stability is provided by the soft tissue envelope. There is consensus among orthopedic surgeons that good outcome in Total Knee Arthroplasty requires equal tension in the medial/lateral compartment of the knee joint, as well as equal tension in the flexion/extension gap. The purpose of this study was to quantify the ligament laxity in the normal non-arthritic knee before and after Posterior-Stabilized Total Knee Arthroplasty. We hypothesized that the Medial/Lateral Collateral Ligament shows minimal changes in length when measured directly by extensometers in the native human knee during varus/valgus laxity testing. We also hypothesized that due to differences in material properties and surface geometry, native laxity is difficult to reconstruct using a Posterior-Stabilized Total Knee. Six specimens were used to perform this in vitro cadaver test using extensometers to provide numerical values for laxity and varus-valgus tilting in the frontal plane. This study enabled a precise measurement of varus-valgus laxity as compared with the clinical assessment. The strains in both ligaments in the replaced knee were different from those in the native knee. Both ligaments were stretched in extension, in flexion the Medial Collateral Ligament tends to relax and the Lateral Collateral Ligament remains tight. As material properties and surface geometry of the replaced knee add stiffness to the joint, we recommend to avoid overstuffing the joint, when using this type of Posterior-Stabilized Total Knee Arthroplasty, in order to obtain varus/valgus laxity close to the native joint. Copyright © 2013 Elsevier Ltd. All rights reserved.

Ulnohumeral chondral and ligamentous overload: biomechanical correlation for posteromedial chondromalacia of the elbow in throwing athletes.

PubMed

Osbahr, Daryl C; Dines, Joshua S; Breazeale, Nathan M; Deng, Xiang-Hua; Altchek, David W

2010-12-01

Previous studies have documented increased posteromedial contact forces with the elbow at lower flexion angles associated with valgus extension overload; however, the authors believe that posteromedial elbow impingement in association with valgus laxity is a complex pathological process that may occur throughout the entire throwing motion in the form of ulnohumeral chondral and ligamentous overload. Valgus laxity with the elbow at 90° of flexion may lead to chondromalacia secondary to a subtle shift in the contact point between the tip of the olecranon and the distal humeral trochlea. Controlled laboratory study. Six fresh human cadaveric elbows were dissected and subjected to a static valgus load. Pressure-sensitive Fuji film measured the contact pressure, contact area, and shift in contact area across the posteromedial elbow before and after sectioning the anterior bundle of the ulnar collateral ligament. The contact pressure between the tip of the olecranon process and the medial crista of the posterior humeral trochlea significantly increased, from an average of 0.27 ± 0.06 kg/cm² to 0.40 ± 0.08 kg/cm². The contact area also significantly decreased, from an average of 30.34 ± 9.17 mm² to 24.59 ± 6.44 mm², and shifted medially on the medial humeral crista, which corresponds to the position of the posteromedial chondral lesions that was observed in throwing athletes in the authors' clinical practice. While simulating the early acceleration phase of the throwing motion with the elbow in 90° of flexion, the results illustrate that abnormal contact may occur as a result of valgus laxity through increased contact pressures across the posteromedial elbow between the medial tip of the olecranon and medial crista of the humeral trochlea. In addition, congruency of the ulnohumeral joint changed, as there was a statistically significant medial shift of the olecranon on the posterior humeral trochlea with the elbow at 90° of flexion after sectioning the anterior

In vivo Length Change Patterns of the Medial and Lateral Collateral Ligaments along the Flexion Path of the Knee

PubMed Central

Hosseini, Ali; Qi, Wei; Tsai, Tsung-Yuan; Liu, Yujie; Rubash, Harry; Li, Guoan

2014-01-01

Purpose The knowledge of the function of the collateral ligaments – i.e., superficial medial collateral ligament (sMCL), deep medial collateral ligament (dMCL) and lateral collateral ligament (LCL) – in the entire range of knee flexion is important for soft tissue balance during total knee arthroplasty. The objective of this study was to investigate the length changes of different portions (anterior, middle and posterior) of the sMCL, dMCL and LCL during in vivo weightbearing flexion from full extension to maximal knee flexion. Methods Using a dual fluoroscopic imaging system eight healthy knees were imaged while performing a lunge from full extension to maximal flexion. The length changes of each portion of the collateral ligaments were measured along the flexion path of the knee. Results All anterior portions of the collateral ligaments were shown to have increasing length with flexion except that of the sMCL which showed a reduction in length at high flexion. The middle portions showed minimal change in lengths except that of the sMCL which showed a consistent reduction in length with flexion. All posterior portions showed reduction in lengths with flexion. Conclusions These data indicated that every portion of the ligaments may play important roles in knee stability at different knee flexion range. The soft tissue releasing during TKA may need to consider the function of the ligament portions along the entire flexion path including maximum flexion. PMID:25239504

The Effects of a Functional Elbow Brace on Medial Joint Stability: A Case Study

PubMed Central

Pincivero, Danny M.; Rijke, Arie M.; Heinrichs, Kristinn; Perrin, David H.

1994-01-01

Medical elbow ligament sprains in athletics can be traumatic and disabling. In this case report, we outline the effect of a prototype functional elbow brace on joint stability in a female collegiate javelin thrower with an ulnar collateral ligament sprain. A valgus force to both elbows was applied using graded stress radiography (Telos GA-II/E stress device) at 0, 5, 10, and 15 kiloPascals (kPa) of pressure. The increase in gap width between the coronoid process and the medial epicondyle was measured from anteroposterior radiographs to determine medial displacement. The brace resulted in less displacement in both injured and noninjured ulnar collateral ligament; injured ulnar collateral ligament demonstrated greater displacement regardless of condition. The brace restored medial stability to the elbow joint by 49%, 38%, and 35% at 5, 10, and 15 kPa of pressure, respectively. The application of the brace may be useful in athletes with ulnar collateral ligament injuries. ImagesFig 1Fig 2 PMID:16558285

Correcting deformity in total knee arthroplasty: Techniques to avoid the release of collateral ligaments in severely deformed knees.

PubMed

Mullaji, A B; Shetty, G M

2016-01-01

Collateral ligament release is advocated in total knee arthroplasty (TKA) to deal with significant coronal plane deformities, but is also associated with significant disadvantages. We describe steps to avoid release of the collateral (superficial medial and lateral collateral) ligaments during TKA in severely deformed knees, while correcting deformity and balancing the knee. ©2016 The British Editorial Society of Bone & Joint Surgery.

MRI of injury to the lateral collateral ligamentous complex of the ankle.

PubMed

Cardone, B W; Erickson, S J; Den Hartog, B D; Carrera, G F

1993-01-01

We retrospectively evaluated the lateral collateral ligamentous complex of 43 patients who had complained of ankle pain following ankle sprain. The MR signs of ligamentous abnormality included discontinuity or absence, increased signal within the ligament, and ligamentous irregularity or waviness with normal thickness and signal intensity. Using these criteria, 30 anterior talofibular, 20 calcaneofibular, and no posterior talofibular ligament injuries were diagnosed. Compared with surgery (nine patients), MRI demonstrated six of seven anterior talofibular ligament injuries and six of six calcaneofibular ligament injuries. Magnetic resonance showed ligamentous abnormalities in 12 of 23 cases with normal stress radiography. Magnetic resonance imaging provides useful information for the evaluation of patients presenting with chronic pain after ankle sprain.

Correlation Between Quality of Evidence and Number of Citations in Top 50 Cited Articles on Elbow Medial Ulnar Collateral Ligament Surgery.

PubMed

Jack, Robert A; Sochacki, Kyle R; Morehouse, Hannah A; McCulloch, Patrick C; Lintner, David M; Harris, Joshua D

2018-04-01

Several studies have analyzed the most cited articles in shoulder, elbow, pediatrics, and foot and ankle surgery. However, no study has analyzed the quality of the most cited articles in elbow medial ulnar collateral ligament (UCL) surgery. To (1) identify the top 50 most cited articles related to UCL surgery, (2) determine whether there was a correlation between the top cited articles and level of evidence, and (3) determine whether there was a correlation between study methodological quality and the top cited articles. Systematic review. Web of Science and Scopus online databases were searched to identify the top 50 cited articles in UCL surgery. Level of evidence, number of times cited, year of publication, name of journal, country of origin, and study type were recorded for each study. Study methodological quality was analyzed for each article with the Modified Coleman Methodology Score (MCMS) and the Methodological Index for Non-randomized Studies (MINORS). Correlation coefficients were calculated. The 50 most cited articles were published between 1981 and 2015. The number of citations per article ranged from 20 to 301 (mean ± SD, 71 ± 62 citations). Most articles (92%) were from the United States and were level 3 (16%), level 4 (58%), or unclassified (16%) evidence. There were no articles of level 1 evidence quality. The mean MCMS and MINORS scores were 28.1 ± 13.4 (range, 3-52) and 9.2 ± 3.6 (range, 2-19), respectively. There was no significant correlation between the mean number of citations and level of evidence or quality ( r s = -0.01, P = .917), MCMS ( r s = 0.09, P = .571), or MINORS ( r s = -0.26, P = .089). The top 50 cited articles in UCL surgery constitute a low level of evidence and low methodological quality, including no level 1 articles. There was no significant correlation between the mean number of citations and level of evidence or study methodological quality. However, weak correlations were observed for later publication date and

Development of Tissue-Engineered Ligaments: Elastin Promotes Regeneration of the Rabbit Medial Collateral Ligament.

PubMed

Hirukawa, Masaki; Katayama, Shingo; Sato, Tatsuya; Yamada, Masayoshi; Kageyama, Satoshi; Unno, Hironori; Suzuki, Yoshiaki; Miura, Yoshihiro; Shiratsuchi, Eri; Hasegawa, Masahiro; Miyamoto, Keiichi; Horiuchi, Takashi

2017-12-21

When ligaments are injured, reconstructive surgery is sometimes required to restore function. Methods of reconstructive surgery include transplantation of an artificial ligament and autotransplantation of a tendon. However, these methods have limitations related to the strength of the bone-ligament insertion and biocompatibility of the transplanted tissue after surgery. Therefore, it is necessary to develop new reconstruction methods and pursue the development of artificial ligaments. Elastin is a major component of elastic fibers and ligaments. However, the role of elastin in ligament regeneration has not been described. Here, we developed a rabbit model of a medial collateral ligament (MCL) rupture and treated animal knees with exogenous elastin [100 µg/(0.5 mL·week)] for 6 or 12 weeks. Elastin treatment increased gene expression and protein content of collagen and elastin (gene expression, 6-fold and 42-fold, respectively; protein content, 1.6-fold and 1.9-fold, respectively), and also increased the elastic modulus of MCL increased with elastin treatment (2-fold) compared with the controls. Our data suggest that elastin is involved in the regeneration of damaged ligaments. © 2017 International Center for Artificial Organs and Transplantation and Wiley Periodicals, Inc.

Accuracy of low-field magnetic resonance imaging versus radiography for guiding injection of equine distal interphalangeal joint collateral ligaments.

PubMed

Lamb, Megan M; Barrett, Jennifer G; White, Nathaniel A; Werre, Stephen R

2014-01-01

Desmopathy of the distal interphalangeal joint collateral ligament is a common cause of lameness in the horse and carries a variable prognosis for soundness. Intralesional treatment has been proposed for improving outcome; however, limited reports describe methods for injecting this ligament. The purpose of this study was to compare accuracy of low-field magnetic resonance imaging (MRI) vs. radiography for injecting the collateral ligament of the distal interphalangeal joint. Equine cadaver digit pairs (n = 10) were divided by random assignment to injection of the ligament by either technique. An observer unaware of injection technique determined injection success based on postinjection MRI and/or gross sections acquired from the proximal, middle, and distal portions of the ligament. McNemar's test was performed to determine statistical difference between injection techniques, the number of injection attempts, and injection of the medial or lateral collateral ligament. Magnetic resonance imaging guided injection was successful more frequently than radiographic-guided injection based on postinjection MRI (24 of 30 vs. 9 of 30; P = 0.0006) and gross sections (26 of 30 vs. 13 of 30; P = 0.0008). At each level of the ligament (proximal, middle, and distal), MRI-guided injection resulted in more successful injections than radiographic guidance. Statistical significance occurred at the proximal aspect of the collateral ligament based on postinjection MRI (P = 0.0143) and the middle portion of the ligament based on gross sections (P = 0.0253). Findings supported future testing of standing, low-field MRI as a technique for delivering intralesional regenerative therapy in live horses with desmopathy of these collateral ligaments. © 2013 American College of Veterinary Radiology.

Elongation of the collateral ligaments after cruciate retaining total knee arthroplasty and the maximum flexion of the knee.

PubMed

Park, Kwan Kyu; Hosseini, Ali; Tsai, Tsung-Yuan; Kwon, Young-Min; Li, Guoan

2015-02-05

The mechanisms that affect knee flexion after total knee arthroplasty (TKA) are still debatable. This study investigated the elongation of the superficial medial (sMCL) and lateral collateral ligaments (LCL) before and after a posterior cruciate retaining (CR) TKA. We hypothesized that overstretching of the collateral ligaments in high flexion after TKA could reduce maximal flexion of the knee. Three-dimensional models of 11 osteoarthritic knees of 11 patients including the insertions of the collateral ligaments were created using MR images. Each ligament was divided into three equal portions: anterior, middle and posterior portions. The shortest 3D wrapping length of each ligament portion was determined before and after the TKA surgery along a weight-bearing, single leg flexion path. The relationship between the changes of ligament elongation and the changes of the maximal knee flexion after TKAs was quantitatively analyzed. The sMCL showed significant increases in length only at low flexion after TKA; the LCL showed decreases in length at full extension, but increases with further flexion after TKA. The amount of increases of the maximum flexion angle after TKA was negatively correlated with the increases of the elongations of the anterior portion (p=0.010, r=0.733) and middle portion (p=0.049, r=0.604) of the sMCL as well as the anterior portion (p=0.010, r=0.733) of the LCL at maximal flexion of the knee. The results indicated that the increases of the length of the collateral ligaments at maximal flexion after TKA were associated with the decreases of the maximal flexion of the knee. Our data suggest that collateral ligament management should also be evaluated at higher knee flexion angles in order to optimize maximal flexion of the knee after TKAs. Copyright © 2014 Elsevier Ltd. All rights reserved.

Macroscopic and microscopic analysis of the thumb carpometacarpal ligaments: a cadaveric study of ligament anatomy and histology.

PubMed

Ladd, Amy L; Lee, Julia; Hagert, Elisabet

2012-08-15

Stability and mobility represent the paradoxical demands of the human thumb carpometacarpal joint, yet the structural origin of each functional demand is poorly defined. As many as sixteen and as few as four ligaments have been described as primary stabilizers, but controversy exists as to which ligaments are most important. We hypothesized that a comparative macroscopic and microscopic analysis of the ligaments of the thumb carpometacarpal joint would further define their role in joint stability. Thirty cadaveric hands (ten fresh-frozen and twenty embalmed) from nineteen cadavers (eight female and eleven male; average age at the time of death, seventy-six years) were dissected, and the supporting ligaments of the thumb carpometacarpal joint were identified. Ligament width, length, and thickness were recorded for morphometric analysis and were compared with use of the Student t test. The dorsal and volar ligaments were excised from the fresh-frozen specimens and were stained with use of a triple-staining immunofluorescent technique and underwent semiquantitative analysis of sensory innervation; half of these specimens were additionally analyzed for histomorphometric data. Mixed-effects linear regression was used to estimate differences between ligaments. Seven principal ligaments of the thumb carpometacarpal joint were identified: three dorsal deltoid-shaped ligaments (dorsal radial, dorsal central, posterior oblique), two volar ligaments (anterior oblique and ulnar collateral), and two ulnar ligaments (dorsal trapeziometacarpal and intermetacarpal). The dorsal ligaments were significantly thicker (p < 0.001) than the volar ligaments, with a significantly greater cellularity and greater sensory innervation compared with the anterior oblique ligament (p < 0.001). The anterior oblique ligament was consistently a thin structure with a histologic appearance of capsular tissue with low cellularity. The dorsal deltoid ligament complex is uniformly stout and robust; this

All-inside arthroscopic lateral collateral ligament repair for ankle instability with a knotless suture anchor technique.

PubMed

Vega, Jordi; Golanó, Pau; Pellegrino, Alexandro; Rabat, Eduard; Peña, Fernando

2013-12-01

Recently, arthroscopic-assisted techniques have been described to treat lateral ankle instability with excellent results. However, complications including neuritis of the superficial peroneal or sural nerve, and pain or discomfort due to a prominent anchor or suture knot have been reported. The aim of this study was to describe a novel technique, the "all-inside arthroscopic lateral collateral ankle ligament repair," and its results for treating patients with ankle instability. Sixteen patients (10 men and 6 women, mean age 29.3 years, 17-46) with lateral ankle instability were treated with an arthroscopic procedure. Using a suture passer and a knotless anchor, the ligaments were repaired with an all-inside technique. The right ankle was affected in 10 cases. Mean follow-up was 22.3 (12-35) months. On arthroscopic examination, 13 patients had an isolated anterior talofibular ligament (ATFL) injury, and in 3 patients, both the ATFL and calcaneofibular ligament (CFL) were affected. All-inside arthroscopic anatomic repair of the lateral collateral ligament complex was performed in all cases. All patients reported subjective improvement of their ankle instability. The mean AOFAS score increased from 67 preoperatively to 97 at final follow-up. No major complications were reported. The all-inside arthroscopic ligament repair was a safe, reliable, and reproducible technique that both provided an anatomic repair of the lateral collateral ligament complex and restored ankle stability while preserving all the advantages of an arthroscopic technique. Level IV, retrospective case series.

Correlation Between Quality of Evidence and Number of Citations in Top 50 Cited Articles on Elbow Medial Ulnar Collateral Ligament Surgery

PubMed Central

Jack, Robert A.; Sochacki, Kyle R.; Morehouse, Hannah A.; McCulloch, Patrick C.; Lintner, David M.; Harris, Joshua D.

2018-01-01

Background: Several studies have analyzed the most cited articles in shoulder, elbow, pediatrics, and foot and ankle surgery. However, no study has analyzed the quality of the most cited articles in elbow medial ulnar collateral ligament (UCL) surgery. Purpose: To (1) identify the top 50 most cited articles related to UCL surgery, (2) determine whether there was a correlation between the top cited articles and level of evidence, and (3) determine whether there was a correlation between study methodological quality and the top cited articles. Study Design: Systematic review. Methods: Web of Science and Scopus online databases were searched to identify the top 50 cited articles in UCL surgery. Level of evidence, number of times cited, year of publication, name of journal, country of origin, and study type were recorded for each study. Study methodological quality was analyzed for each article with the Modified Coleman Methodology Score (MCMS) and the Methodological Index for Non-randomized Studies (MINORS). Correlation coefficients were calculated. Results: The 50 most cited articles were published between 1981 and 2015. The number of citations per article ranged from 20 to 301 (mean ± SD, 71 ± 62 citations). Most articles (92%) were from the United States and were level 3 (16%), level 4 (58%), or unclassified (16%) evidence. There were no articles of level 1 evidence quality. The mean MCMS and MINORS scores were 28.1 ± 13.4 (range, 3-52) and 9.2 ± 3.6 (range, 2-19), respectively. There was no significant correlation between the mean number of citations and level of evidence or quality (rs = –0.01, P = .917), MCMS (rs = 0.09, P = .571), or MINORS (rs = –0.26, P = .089). Conclusion: The top 50 cited articles in UCL surgery constitute a low level of evidence and low methodological quality, including no level 1 articles. There was no significant correlation between the mean number of citations and level of evidence or study methodological quality. However, weak

Computer-assisted measurements of coronal knee joint laxity in vitro are related to low-stress behavior rather than structural properties of the collateral ligaments.

PubMed

Wilson, W T; Deakin, A H; Wearing, S C; Payne, A P; Clarke, J V; Picard, F

2013-01-01

The relationship between coronal knee laxity and the restraining properties of the collateral ligaments remains unknown. This study investigated correlations between the structural properties of the collateral ligaments and stress angles used in computer-assisted total knee arthroplasty (TKA), measured with an optically based navigation system. Ten fresh-frozen cadaveric knees (mean age: 81 ± 11 years) were dissected to leave the menisci, cruciate ligaments, posterior joint capsule and collateral ligaments. The resected femur and tibia were rigidly secured within a test system which permitted kinematic registration of the knee using a commercially available image-free navigation system. Frontal plane knee alignment and varus-valgus stress angles were acquired. The force applied during varus-valgus testing was quantified. Medial and lateral bone-collateral ligament-bone specimens were then prepared, mounted within a uni-axial materials testing machine, and extended to failure. Force and displacement data were used to calculate the principal structural properties of the ligaments. The mean varus laxity was 4 ± 1° and the mean valgus laxity was 4 ± 2°. The corresponding mean manual force applied was 10 ± 3 N and 11 ± 4 N, respectively. While measures of knee laxity were independent of the ultimate tensile strength and stiffness of the collateral ligaments, there was a significant correlation between the force applied during stress testing and the instantaneous stiffness of the medial (r = 0.91, p = 0.001) and lateral (r = 0.68, p = 0.04) collateral ligaments. These findings suggest that clinicians may perceive a rate of change of ligament stiffness as the end-point during assessment of collateral knee laxity.

Revision with suture-tape augmentation after failed collateral ligament reconstruction for chronic interphalangeal instability of the hallux.

PubMed

Cho, Byung-Ki; Park, Ji-Kang; Choi, Seung-Myung; SooHoo, Nelson F

2017-12-01

Chronic varus instability or recurrent subluxation following isolated interphalangeal dislocation of the hallux is a rare injury. No consensus has been reached regarding the best joint-salvage procedure for patients with the failed collateral ligament reconstruction using tendon graft. We report a case who achieved satisfactory clinical outcome through a modified surgical procedure (revision collateral ligament reconstruction augmented with suture-tape). Copyright © 2017 European Foot and Ankle Society. Published by Elsevier Ltd. All rights reserved.

Baseball Players With an Ulnar Collateral Ligament Tear Display Increased Nondominant Arm Humeral Torsion Compared With Healthy Baseball Players.

PubMed

Meyer, Casey J; Garrison, J Craig; Conway, John E

2017-01-01

Previous work has suggested that an increase in the amount of developmentally acquired, dominant arm humeral retrotorsion (D HRT) in the thrower's shoulder may be a potentially protective mechanism. Although the relationship between HRT and shoulder injuries has been reported, the relationship between HRT and ulnar collateral ligament (UCL) tears in baseball players is not known. To determine whether D HRT and nondominant arm HRT (ND HRT) measurements in baseball players with a UCL tear differ statistically from a matched healthy cohort. Case-control study; Level of evidence, 3. D HRT and ND HRT were measured in 112 male competitive high school and collegiate baseball players seen over an 18-month period from 2013 to 2015. A total of 56 participants with a clinical and magnetic resonance imaging-confirmed diagnosis of a throwing-arm UCL tear (UCLInj group) were compared with 56 healthy baseball players with no history of an elbow injury who were matched for age, experience, and position (NUCLInj group). The mean ages in the UCLInj and NUCLInj groups were 17.9 ± 2.2 and 17.6 ± 2.8 years, respectively. Using a previously validated ultrasound method, D HRT and ND HRT were measured in the supine position, and the HRT side-to-side difference (D HRT - ND HRT) was calculated. A 1-way multivariate analysis of variance was used to determine the mean statistical differences between groups ( P < .05). Baseball players with a UCL tear displayed significantly more humeral torsion (ie, less retrotorsion) in their nondominant arm compared with healthy baseball players (UCLInj = 33.27° ± 10.27°, NUCLInj = 27.82° ± 10.88°; P = .007). Baseball players with a UCL tear did not display any differences in D HRT compared with healthy baseball players (UCLInj = 18.67° ± 9.41°, NUCLInj = 17.09° ± 9.92°; P = .391). Significant side-to-side differences in HRT existed between groups (UCLInj = -14.60° ± 6.72°, NUCLInj = -10.72° ± 6.88°; P = .003). There was a significant

Return to National Basketball Association Competition Following Anterior Cruciate Ligament and Fibular Collateral Ligament Injuries: A Case Report.

PubMed

LaPrade, Robert F; O'Brien, Luke; Kennedy, Nicholas I; Cinque, Mark E; Chahla, Jorge

2017-01-01

Numerous outcome studies regarding anterior cruciate ligament (ACL) reconstruction demonstrate the ability of athletes to return to a high level of play. However, to our knowledge, there is limited literature regarding return to play following injury to both the ACL and the fibular collateral ligament (FCL). We describe the case of a National Basketball Association (NBA) player who sustained a combined ACL and FCL knee injury and subsequently underwent surgical reconstruction of both affected ligaments. He was able to return to a preinjury level of competition at 9 months postoperatively. It is possible for athletes to return to competitive basketball and maintain a high production level following a single-staged reconstruction of both the ACL and the FCL.

Factors Related to Increased Ulnar Collateral Ligament Thickness on Stress Sonography of the Elbow in Asymptomatic Youth and Adolescent Baseball Pitchers.

PubMed

Atanda, Alfred; Averill, Lauren W; Wallace, Maegen; Niiler, Tim A; Nazarian, Levon N; Ciccotti, Michael G

2016-12-01

Stress ultrasound (SUS) of the elbow has demonstrated changes in the anterior band of the ulnar collateral ligament (UCL) in professional and high school-aged pitchers. However, there have been no large reports correlating pitching history data with SUS changes in youth and adolescent baseball pitchers. Changes of the UCL on SUS will correlate with pitching volume in youth and adolescent baseball pitchers. Cross-sectional study; Level of evidence, 3. SUS of the elbow was performed in both elbows of 102 youth and adolescent baseball pitchers. UCL thickness and the width of the ulnohumeral joint, at rest and with 150 N of valgus stress, were measured using a standardized, instrumented device. Demographic data, arm measurements, and a pitching history questionnaire were recorded as well. The pitchers were separated into 2 groups based on age: group 1 (12-14 years) and group 2 (15-18 years). SUS findings of the dominant elbows were compared between the 2 groups. Correlation analysis and linear regression were used to identify relationships between SUS findings and pitching history data. In all pitchers, the mean UCL thickness was 4.40 mm in the dominant elbow and 4.11 mm in the nondominant elbow (P =.03). There was no significant difference between elbows in any joint space characteristics. A comparison of group 1 versus group 2 demonstrated significant differences in UCL thickness (4.13 vs 4.96 mm; P < .001), resting joint space width (6.56 vs 4.04 mm; P < .001), and stressed joint space width (7.68 vs 4.07 mm; P < .001). There was no difference in the change in joint space width between the 2 groups (1.11 vs 0.76 mm; P = .05). The UCL was significantly thicker in pitchers who threw more than 67 pitches per appearance (4.69 vs 4.14 mm), who pitched more than 5 innings per appearance (4.76 vs 4.11 mm), and who had more than 5.5 years of pitching experience (4.71 vs 4.07 mm; P < .001). Linear regression demonstrated that age, weight, and pitches per appearance (R 2 = 0

Effects of tibial plateau angle and spacer thickness applied during in vitro canine total knee replacement on three-dimensional kinematics and collateral ligament strain.

PubMed

Baker, Katherine M; Foutz, Timothy L; Johnsen, Kyle J; Budsberg, Steven C

2014-09-01

To quantify the 3-D kinematics and collateral ligament strain of stifle joints in cadaveric canine limbs before and after cranial cruciate ligament transection followed by total knee replacement (TKR) involving various tibial plateau angles and spacer thicknesses. 6 hemi-pelvises collected from clinically normal nonchondrodystrophic dogs (weight range, 25 to 35 kg). Hemi-pelvises were mounted on a modified Oxford knee rig that allowed 6 degrees of freedom of the stifle joint but prevented mechanical movement of the hip and tarsal joints. Kinematics and collateral ligament strain were measured continuously while stifle joints were flexed. Data were again collected after cranial cruciate ligament transection and TKR with combinations of 3 plateau angles (0°, 4°, and 8°) and spacer thicknesses (5, 7, and 9 mm). Presurgical (ie, normal) stifle joint rotations were comparable to those previously documented for live dogs. After TKR, kinematics recorded for the 8°, 5-mm implant most closely resembled those of unaltered stifle joints. Decreasing the plateau angle and increasing spacer thickness altered stifle joint adduction, internal rotation, and medial translation. Medial collateral ligament strain was minimal in unaltered stifle joints and was unaffected by TKR. Lateral collateral ligament strain decreased with steeper plateau angles but returned to a presurgical level at the flattest plateau angle. Among the constructs tested, greatest normalization of canine stifle joint kinematics in vitro was achieved with the steepest plateau angle paired with the thinnest spacer. Furthermore, results indicated that strain to the collateral ligaments was not negatively affected by TKR.

Lower extremity balance is improved at time of return to throwing in baseball players after an ulnar collateral ligament reconstruction when compared to pre-operative measurements.

PubMed

Hannon, Joseph; Garrison, J Craig; Conway, John

2014-05-01

/ Lower extremity balance deficits have been shown to lead to altered kinematics and increased injury risk in lower extremity athletes. The purpose of this study was to compare lower extremity balance in baseball players with an ulnar collateral ligament (UCL) tear pre-operatively and post-operatively at the beginning of the pre-return to throwing program stage of rehabilitation (3 months). Thirty-three competitive high school and collegiate male baseball players (18.5 ± 3.2) with a diagnosed UCL tear volunteered for the study. Of the 33 baseball players 29 were pitchers, 1 was a catcher, and 3 were infielders. Participants were seen pre-operatively and at 3 months post operatively. This 3 month point was associated with a follow-up visit to the orthopedic surgeon and subsequent release to begin the pre-return to throwing mark for baseball players following their surgery. Following surgery, each participant followed a standard UCL protocol which included focused lower extremity balance and neuromuscular control exercises. Participants were tested for single leg balance using the Y-Balance Test™ - Lower Quadrant (YBT-LQ) on both their lead and stance limbs. YBT-LQ composite scores were calculated for the stance and lead limbs pre- and post-operatively and compared over time. Paired t-tests were used to calculate differences between time 1 and time 2 (p < 0.05). Baseball players with diagnosed UCL tears demonstrated significant balance deficits on their stance (p < .001) and lead (p = .009) limbs prior to surgery compared to balance measures at the 3-month follow up (Stance Pre-Op = 89.4 ± 7.5%; Stance 3 Month = 94.9 ± 9.5%) (Lead Pre-Op = 90.2 ± 6.7%; Lead 3 Month = 93.6 ± 7.2%). Based on the results of this study, lower extremity balance is altered in baseball players with UCL tears prior to surgery. Statistically significant improvements were seen and balance measures improved at the time of return to throwing. Level 2b.

Return-to-Play Outcomes in Professional Baseball Players After Medial Ulnar Collateral Ligament Injuries: Comparison of Operative Versus Nonoperative Treatment Based on Magnetic Resonance Imaging Findings.

PubMed

Ford, Gregory M; Genuario, James; Kinkartz, Jason; Githens, Thomas; Noonan, Thomas

2016-03-01

The medial ulnar collateral ligament (UCL) is the primary static stabilizer to valgus stress of the elbow. Injuries to the UCL are common in baseball pitchers. In the 1970s, reconstructive surgery was developed. Return-to-play (RTP) rates of 67% to 95% after reconstruction have been reported. There is a paucity of published studies among professional baseball players reporting RTP with nonoperative treatment. To identify professional baseball players' ability to RTP after the nonoperative treatment of UCL injuries based on the magnetic resonance imaging (MRI) grade. Case series; Level of evidence, 4. A review of elbow injuries among a professional baseball organization from 2006 to 2011 was performed. MRI was performed on all players. Forty-three UCL injuries were diagnosed. Treatment included rehabilitation, surgery, or both. Rates of RTP and return to the same level of play or higher (RTSP) were calculated and correlated with the MRI grade, location of injury, and player position. MRI grading was as follows: I, intact ligament with or without edema; IIA, partial tear; IIB, chronic healed injury; and III, complete tear. Forty-three UCL injuries in 43 players were diagnosed. Eight had complete tears (grade III), were treated operatively with UCL reconstruction, and had an RTP rate of 75% and RTSP rate of 63% (5/8 returned to the same level and 1 to a lower level). All 8 were pitchers. The remaining 35 players had incomplete injuries (4 grade I, 8 grade IIA, and 23 grade IIB), consisting of 24 pitchers and 11 positional players. Of these 35 players, 1 underwent surgery without attempted rehabilitation, 3 initiated rehabilitation until MRI was performed and then underwent surgery, and 3 underwent surgery after failed rehabilitation. The 7 players who underwent UCL reconstruction surgery had an RTP rate of 100% and RTSP rate of 86% (6/7 returned to the same level and 1 to a lower level). The remaining 28 with nonoperative treatment had both RTP and RTSP rates of 93

A new surgical technique for medial collateral ligament balancing: multiple needle puncturing.

PubMed

Bellemans, Johan; Vandenneucker, Hilde; Van Lauwe, Johan; Victor, Jan

2010-10-01

In this article, we present our experience with a new technique for medial soft tissue balancing, where we make multiple punctures in the medial collateral ligament (MCL) using a 19-gauge needle, to progressively stretch the MCL until a correct ligament balance is achieved. Ligament status was evaluated both before and after the procedure using computer navigation and mediolateral stress testing. The procedure was considered successful when 2 to 4-mm mediolateral joint line opening was obtained in extension and 2 to 6 mm in flexion. In 34 of 35 cases, a progressive correction of medial tightness was achieved according to the above described criteria. One case was considered overreleased in extension. Needle puncturing is a new, effective, and safe technique for progressive correction of MCL tightness in the varus knee. Copyright © 2010 Elsevier Inc. All rights reserved.

CONSERVATIVE MANAGEMENT OF AN ISOLATED GRADE III LATERAL COLLATERAL LIGAMENT INJURY IN AN ADOLESCENT MULTI-SPORT ATHLETE: A CASE REPORT

PubMed Central

Haddad, M. Alex; Budich, Justin M.; Eckenrode, Brian J.

2016-01-01

ABSTRACT Study design Case report Background Isolated, grade III lateral collateral ligament knee injuries are an uncommon traumatic injury with little guidance available in the literature for conservative management and prognosis for return to sport. The purpose of this case report is to describe the clinical decision-making in both differential diagnosis and physical therapy management of an isolated grade III lateral collateral ligament sprain in an adolescent multi-sport high school athlete. Case Description A 16 year-old male, high school, multi-sport athlete (cross country, wrestling, track and field) sustained a traumatic knee injury during a wrestling match when his involved lower extremity was forcefully externally rotated by his opponent. Initial clinical presentation revealed pain and increased laxity with varus stress testing of the left knee, which was subsequently identified via MRI as a complete lateral collateral ligament rupture (grade III). A conservative physical therapy program was developed targeting the active and neuromuscular subsystems, theorized to compensate for the lack of an intact lateral collateral ligament. Outcomes The subject attended 18 visits of physical therapy over a period of 12 weeks. His rehabilitation program focused on functional strengthening of the posterolateral corner, enhancement of neuromuscular control, and graded progression to sports specific drills. Return to play decisions were based on a combination of lower extremity functional performance measures, condition specific outcome measures and subjective performance on sports specific tasks. At discharge from physical therapy, he reported 0/10 pain, scored a 76/80 on the Lower Extremity Functional Scale, and was able to return to competitive track and field events. Discussion Few descriptions in the literature exist for the conservative management of isolated, grade III lateral collateral ligament injuries. A program of selective functional strengthening

Open dislocation of the proximal interphalangeal joint of the little finger subsequent to chronic radial collateral ligament injury: a case report of primary ligament reconstruction with a half-slip of the flexor digitorum superficialis: Case Report.

PubMed

Wada, Kazuma; Hibino, Naohito; Kondo, Kenji; Yoshioka, Shinji; Terai, Tomoya; Henmi, Tatsuhiko; Sairyo, Koichi

2015-01-01

Open dislocation of the proximal interphalangeal (PIP) joint is relatively rare. We report a case of a 32-year-old man who had open dislocation of the PIP joint of the little finger while playing American football. He had a history of chronic radial collateral ligament injury. We reconstructed the radial collateral ligament with a half-slip of the flexor digitorum superficialis tendon.

Editorial Commentary: Chondrocytes Trump Ligaments! Partial Release of the Medial Collateral Ligament During Knee Arthroscopy Protects Chondrocytes.

PubMed

Leland, J Martin

2016-10-01

With knee arthroscopy being the most common orthopaedic procedure performed in the United States, it is crucial to be able to access the entire knee without iatrogenic injury. Frequently orthopaedic surgeons encounter tight medial compartments, creating difficulty in accessing the posterior horn of the medial meniscus without damaging the articular cartilage. Partial release of the medial collateral ligament during knee arthroscopy protects chondrocytes. Copyright © 2016 Arthroscopy Association of North America. Published by Elsevier Inc. All rights reserved.

Arthroscopically accessible anatomy of the tarsal collateral ligaments in the horse.

PubMed

Kümmerle, Jan M; Kummer, Martin R

2013-04-01

To describe the arthroscopically accessible anatomy of the tarsal collateral ligaments in the horse. Descriptive study. Cadaveric equine hind limbs (n = 24) obtained from horses without tarsal disease. Two pairs of tarsal joints were used to obtain silicone models of the tarsocrural joint and dissect the tarsal collateral ligaments (CLs). Ten pairs of tarsocrural joints had arthroscopic exploration and the accessible parts of the tarsal CLs were marked with an arthroscopic hook knife. Subsequently, the limbs were dissected and the marked positions were allocated to the specific parts of the CLs. Ipsilateral arthroscope and instrument portals were used in each pouch of the tarsocrural joint. Via the plantaromedial pouch, the superficial (2/20 limbs), middle (7), deep (6) or both middle and deep (3) short medial CL and the long medial CL (14) were reached. Access via the plantarolateral pouch allowed manipulation of the deep short lateral CL (20/20 limbs) and the long lateral CL (20). Dorsally, arthroscopy via the dorsomedial pouch gave access to the deep short medial CL (20/20 limbs), while the superficial (9) or middle (10) or both superficial and middle (1) short lateral CL could be reached via the dorsolateral joint recess. Limited parts of the tarsal CLs can be observed or manipulated arthroscopically in normal equine tarsocrural joints. © Copyright 2013 by The American College of Veterinary Surgeons.

Treatment for Ulnar Neuritis Around the Elbow in Adolescent Baseball Players: Factors Associated With Poor Outcome.

PubMed

Maruyama, Masahiro; Satake, Hiroshi; Takahara, Masatoshi; Harada, Mikio; Uno, Tomohiro; Mura, Nariyuki; Takagi, Michiaki

2017-03-01

Ulnar neuritis around the elbow is one of the injuries seen in throwing athletes. Outcomes of nonsurgical treatment and factors associated with failure outcomes have not been reported. To investigate the outcomes of treatments for ulnar neuritis in adolescent baseball players. Case series; Level of evidence, 4. We assessed 40 male baseball players with a mean age of 15.0 years (range, 13-17 years) who presented with ulnar neuritis. There were 19 pitchers and 21 fielders whose throwing side was affected. All patients had elbow pain, and 13 patients had hand numbness on the ulnar side. The mean Kerlan-Jobe Orthopaedic Clinic (KJOC) overhead athlete shoulder and elbow score was 52.5 at the first follow-up visit (n = 36 patients). Thirteen patients were identified with ulnar nerve subluxation, and 23 patients had concomitant elbow ulnar collateral ligament (UCL) injury. All patients underwent nonsurgical treatment, which included rehabilitation exercises and prohibition of throwing. If the nonsurgical treatment failed, we recommended surgical treatment. We investigated the outcomes of the nonsurgical and surgical treatments. Return to sports was evaluated, combined with factors associated with return to sports in nonsurgical treatment by univariate and multivariate statistical analysis. The mean follow-up period was 23.6 months (range, 6-39 months). After nonsurgical treatment, 24 patients (60%) returned to the previous competition level after a mean of 2.4 months. Two patients returned to a recreational level. One patient gave up playing baseball at 2 months. The remaining 13 patients underwent surgery and returned to sports after a mean of 2.0 months postoperatively, and 12 had no limitation of sports activities. Multivariate logistical regression analysis demonstrated that hand numbness, ulnar nerve subluxation, and UCL injury were associated with failure of nonsurgical treatment ( P < .05). In addition, KJOC score of <45 at the first follow-up tended to be

Structure and function, injury, pathology, and treatment of the medial collateral ligament of the knee.

PubMed

Schein, Aaron; Matcuk, George; Patel, Dakshesh; Gottsegen, Christopher J; Hartshorn, Timothy; Forrester, Deborah; White, Eric

2012-12-01

The medial collateral ligament (MCL) is the most commonly injured ligament of the knee. There is a spectrum of injury severity, and injuries may be acute or chronic. The MCL is also frequently injured in conjunction with other knee structures. Clinical evaluation of the knee is important to assess the degree of surgical acuity, but magnetic resonance imaging can provide details about the injury that may not be obvious clinically. In addition to injury, MCL bursitis can occur and may be treated with needle aspiration and corticosteroid injection. This review article covers the anatomy and biomechanics of the MCL, its injury patterns and approach to management, and MCL bursitis.

Ultrasound biomechanical anatomy of the soft structures in relation to the ulnar nerve in the cubital tunnel of the elbow.

PubMed

Michelin, Paul; Leleup, Grégoire; Ould-Slimane, Mourad; Merlet, Marie Caroline; Dubourg, Benjamin; Duparc, Fabrice

2017-11-01

Chronic ulnar nerve entrapment worsened by elbow flexion is the most common injury, but rare painful conditions may also be related to ulnar nerve instability. The posterior bundle of the medial collateral ligament (pMCL) and the retinaculum, respectively form a soft floor and a ceiling for the cubital tunnel. The aim of our study was to dynamically assess these soft structures of the cubital tunnel focusing on those involved in the biomechanics of the ulnar nerve. Forty healthy volunteers had a bilateral ultrasonography of the cubital tunnel. Elbows were scanned in full extension, 45° and 90°, and maximal passive flexion. Morphological changes of the nerve and related structures were dynamically assessed on transverse views. Both the pMCL and the retinaculum tightened with flexion. During elbow flexion, the tightening of the pMCL superficially moved the ulnar nerve remote from the osseous floor of the retroepicondylar groove. A retinaculum was visible in all 69 tunnels with stable nerves (86.3%), tightened in flexion, but absent in 11 tunnels with unstable nerves (13.7%). The retinaculum was fibrous in 60 elbows and muscular in nine, the nine muscular variants did not significantly influence the biomechanics of stable nerves. Stable nerves flattened in late flexion between the tightened pMCL and retinaculum, whereas unstable nerves transiently flattened when translating against the anterior osseous edge of the groove. The retinaculum and the pMCL are key structures in the biomechanics of the ulnar nerve in the cubital tunnel of the elbow.

Topographical Anatomy of the Distal Ulna Attachment of the Radioulnar Ligament.

PubMed

Shin, Won-Jeong; Kim, Jong-Pil; Yang, Hun-Mu; Lee, Eun-Young; Go, Jai-Hyang; Heo, Kang

2017-07-01

The deep component of the distal radioulnar ligament provides translational stability and rotational guidance to the forearm. However, controversy exists regarding the importance of this structure as well as the nature of its attachment to the distal ulna. We aimed to evaluate the topographic anatomy of the distal ulna attachment of both the superficial and the deep components of the radioulnar ligament and to assess the relationship between its internal and its external morphometry. Thirteen human distal ulnae attached by ulnar part of the distal radioulnar ligament were scanned using micro-computed tomography and reconstructed in 3 dimensions. In addition, the distal radioulnar ligaments were examined under polarized light microscopy to determine the histological characteristics of collagen contained within the ligaments. The deep limbs have broad marginal insertions at the fovea, whereas the superficial limbs have a circular and condensed insertion to the ulnar styloid. The center of the deep limb was separated from the base of the ulnar styloid by a mean of 2.0 ± 0.76 mm, and this distance was positively correlated with the width of the ulnar styloid. The mean distance between the center of the ulnar head and the center of the fovea was 2.4 ± 0.58 mm. The proportion of collagen type I was lower in the deep limb than in the superficial limb. This new observation of the footprint of the radioulnar ligament in the distal ulna indicates that the deep limb may serve as an internal capsular ligament of the distal radioulnar joint, whereas the superficial limb as the external ligament. Knowledge of the topographic anatomy of the radioulnar ligament's attachment to the distal ulna may provide a better understanding of distal radioulnar ligament-related pathologies. Copyright © 2017 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.

Influence of the position of the foot on MRI signal in the deep digital flexor tendon and collateral ligaments of the distal interphalangeal joint in the standing horse.

PubMed

Spriet, M; Zwingenberger, A

2009-05-01

Hyperintense signal is sometimes observed in ligaments and tendons of the equine foot on standing magnetic resonance examination without associated changes in size and shape. In such cases, the presence of a true lesion or an artifact should be considered. A change in position of a ligament or tendon relative to the magnetic field can induce increased signal intensity due to the magic angle effect. To assess if positional rotation of the foot in the solar plane could be responsible for artifactual changes in signal intensity in the collateral ligaments of the distal interphalangeal joint and in the deep digital flexor tendon. Six isolated equine feet were imaged with a standing equine magnetic resonance system in 9 different positions with different degrees of rotation in the solar plane. Rotation of the limb induced a linear hyperintense signal on all feet at the palmar aspect of one of the lobes of the deep digital flexor tendon and at the dorsal aspect of the other lobe. Changes in signal intensity in the collateral ligaments of the distal interphalangeal joint occurred with rotation of the limb only in those feet where mediolateral hoof imbalance was present. The position and conformation of the foot influence the signal intensity in the deep digital flexor tendon and in the collateral ligaments of the distal interphalangeal joint. The significance of increased signal intensity in the deep digital flexor tendon and in the collateral ligaments of the distal interphalangeal joint should be interpreted with regard to the position and the conformation of the foot.

Case report - calcification of the medial collateral ligament of the knee with simultaneous calcifying tendinitis of the rotator cuff.

PubMed

Kamawal, Yama; Steinert, Andre F; Holzapfel, Boris M; Rudert, Maximilian; Barthel, Thomas

2016-07-13

Calcification of the medial collateral ligament (MCL) of the knee is a very rare disease. We report on a case of a patient with a calcifying lesion within the MCL and simultaneous calcifying tendinitis of the rotator cuff in both shoulders. Calcification of the MCL was diagnosed both via x-ray and magnetic resonance imaging (MRI) and was successfully treated surgically. Calcifying tendinitis of the rotator cuff was successfully treated applying conservative methods. This is the first case report of a patient suffering from both a calcifying lesion within the medial collateral ligament and calcifying tendinitis of the rotator cuff in both shoulders. Clinical symptoms, radio-morphological characteristics and macroscopic features were very similar and therefore it can be postulated that the underlying pathophysiology is the same in both diseases. Our experience suggests that magnetic resonance imaging and x-ray are invaluable tools for the diagnosis of this inflammatory calcifying disease of the ligament, and that surgical repair provides a good outcome if conservative treatment fails. It seems that calcification of the MCL is more likely to require surgery than calcifying tendinitis of the rotator cuff. However, the exact reason for this remains unclear to date.

Biomechanical and histologic evaluation of tissue engineered ligaments using chitosan and hyaluronan hybrid polymer fibers: a rabbit medial collateral ligament reconstruction model.

PubMed

Irie, Toru; Majima, Tokifumi; Sawaguchi, Naohiro; Funakoshi, Tadanao; Nishimura, Shin-Ichiro; Minami, Akio

2011-05-01

In this study, we used a rabbit medial collateral ligament reconstruction model to evaluate a novel chitosan-based hyaluronan hybrid polymer fiber scaffold for ligament tissue engineering and to examine whether mechanical forces exerted in an in vivo model increased extracellular matrix production by seeded fibroblasts. Scaffolds were used 2 weeks after incubation with fibroblasts obtained from the same rabbit in a cell-seeded scaffold (CSS) group and without cells in a noncell-seeded scaffold (NCSS) group. At 3, 6, and 12 weeks after surgery, the failure loads of the engineered ligaments in the CSS groups were significantly greater than those in the NCSS groups. At 6 weeks after surgery, the reconstructed tissue of the CSS group was positive for type I collagen, whereas that in the NCSS group was negative for type I collagen. At 12 weeks after surgery, the reconstructed tissue stained positive for type I collagen in the CSS group, but negative in the NCSS group. Our results indicate that the scaffold material enhanced the production of type I collagen and led to improved mechanical strength in the engineered ligament in vivo. Copyright © 2011 Wiley Periodicals, Inc.

Physical examination and imaging of medial collateral ligament and posteromedial corner of the knee.

PubMed

Craft, Jason A; Kurzweil, Peter R

2015-06-01

The medial collateral ligament (MCL) is the most commonly injured knee ligament. Most will heal well with nonoperative treatment. However, not all medial knee injuries are the same. A detailed physical examination can help determine the severity of the medial-sided injury. When combined with advanced imaging, the examination will delineate damage to associated medial knee structures, including the location of MCL damage, posteromedial capsule injuries, and combined cruciate injuries. Failure to recognize MCL injuries that may be prone to chronic laxity can lead to significant disability, joint damage, and failure of concomitant cruciate ligament reconstructions. Magnetic resonance imaging is the mainstay of diagnostic imaging, with coronal sequences allowing full assessment of the MCL complex. Tangential views aid in the diagnosis of concomitant injuries. Stress radiography can play a role in evaluating MCL healing and subtle chronic laxity. Ultrasonography is also gaining acceptance as a means to assess MCL injuries. Use of a detailed examination and advanced imaging will allow optimal treatment of medial knee injuries and improve clinical outcomes.

Arthroscopic Treatment of Annular Drive Through and Radial Lateral Collateral Ligament Articular-Side Tear of the Elbow.

PubMed

Arrigoni, Paolo; D'Ambrosi, Riccardo; Randelli, Pietro

2015-12-01

An elongation or partial articular-sided tear of the radial lateral collateral ligament (R-LCL) is a rare injury causing disability and instability of the elbow. In our experience this condition is often associated with a pathologic sign of the annular ligament named the "annular drive through" caused by a redundancy of the ligament. The benefits of performing an arthroscopic procedure for surgical stabilization of the R-LCL include smaller incisions with less soft-tissue dissection, better visualization of the joint, better repair accessibility, and elimination of the annular drive-through sign. The main steps of the operation are as follows: evaluation of annular drive through, inspection of the radial side of the joint, anterior capsulotomy, insertion of a suture anchor through the anterolateral portal, shuttling of the suture anchor through the ligament, and elimination of the annular drive-through sign. By use of this technique, it is possible to repair a lesion of the R-LCL with a suture anchor that ensures an anatomic repair and, at the same time, returns the annular ligament to its physiological tension.

Comparison of complete distal release of the medial collateral ligament and medial epicondylar osteotomy during ligament balancing in varus knee total knee arthroplasty.

PubMed

Sim, Jae Ang; Lee, Yong Seuk; Kwak, Ji Hoon; Yang, Sang Hoon; Kim, Kwang Hui; Lee, Beom Koo

2013-12-01

During ligament balancing for severe medial contracture in varus knee total knee arthroplasty (TKA), complete distal release of the medial collateral ligament (MCL) or a medial epicondylar osteotomy can be necessary if a large amount of correction is needed. This study retrospectively reviewed 9 cases of complete distal release of the MCL and 11 cases of medial epicondylar osteotomy which were used to correct severe medial contracture. The mean follow-up periods were 46.5 months (range, 36 to 78 months) and 39.8 months (range, 32 to 65 months), respectively. There were no significant differences in the clinical results between the two groups. However, the valgus stress radiograph revealed significant differences in medial instability. In complete distal release of the MCL, some stability was obtained by repair and bracing but the medial instability could not be removed completely. Medial epicondylar osteotomy for a varus deformity in TKA could provide constant medial stability and be a useful ligament balancing technique.

Outside-In Deep Medial Collateral Ligament Release During Arthroscopic Medial Meniscus Surgery.

PubMed

Todor, Adrian; Caterev, Sergiu; Nistor, Dan Viorel

2016-08-01

Arthroscopic partial medial meniscectomy is a very common orthopaedic procedure performed for symptomatic, irreparable meniscus tears. It is usually associated with a very good outcome and minimal complications. In some patients with tight medial compartment, the posterior horn of the medial meniscus can be difficult to visualize, and access in this area with instruments may be challenging. To increase the opening of the medial compartment, after valgus-extension stress position of the knee, different techniques of deep medial collateral ligament release have been described. The outside-in pie-crusting technique shown in this technical note has documented effectiveness and good outcomes with minimal or no morbidity.

Biaxial quantification of deep layer transverse carpal ligament elastic properties by sex and region.

PubMed

Mathers, Bryan; Agur, Anne; Oliver, Michele; Gordon, Karen

2016-12-01

The transverse carpal ligament is a major component of the carpal tunnel and is an important structure in the etiology of carpal tunnel syndrome. The current study aimed to quantify biaxial elastic moduli of the transverse carpal ligament and compare differences between sex and region (Radial and Ulnar). Biaxial testing of radial and ulnar samples from twenty-two (thirteen male, nine female) human fresh frozen cadaveric transverse carpal ligaments was performed. Elastic moduli and stiffness were calculated and compared. Biaxial elastic moduli of the transverse carpal ligament ranged from 0.76MPa to 3.38MPa, varying based on region (radial and ulnar), testing direction (medial-lateral and proximal-distal) and sex. Biaxial elastic moduli were significantly larger in the medial-lateral direction than the proximal-distal direction (P<0.001). Moduli were significantly larger ulnarly than radially (P=0.001). No significant differences due to gender were noted. The regional variations in biaxial elastic moduli of the transverse carpal ligament may help improve non-invasive treatment methods for carpal tunnel syndrome, specifically manipulative therapy. The smaller biaxial elastic moduli found in the radial region suggests that manipulative therapy should be focused on the radial aspect of the transverse carpal ligament. The trend where female transverse carpal ligaments had larger stiffness in the ulnar location than males suggests that that the increased prevalence of carpal tunnel syndrome in women may be related to an increased stiffness of the transverse carpal ligament, however further work is warranted to evaluate this trend. Copyright © 2016 Elsevier Ltd. All rights reserved.

Rotational stability test for the diagnosis of radial collateral ligament rupture in the fingers: Anatomical study.

PubMed

Lazarus, P; Hidalgo Diaz, J J; Prunières, G; Pire, E; Taleb, C; Honecker, S; Bellemère, P; Fontaine, C; Liverneaux, P A

2017-04-01

Diagnosing rupture of the radial collateral ligament (RCL) of the finger metacarpophalangeal (MCP) joints is difficult. The aim of this cadaver study was to validate a rotational test for the MCP after RCL transection. With the MCP and proximal interphalangeal joints in flexion, rotation along the axis of the proximal phalanx was applied through an extended distal interphalangeal joint to 36 cadaver fingers. Each finger's pulp described an arc of pronation and supination that was noted on the palm. The test was repeated three times: before transection, after transection of the proper collateral ligament (CL) and after transection of both the proper and accessory CLs. Rotational arcs were measured in pronation and supination. Mean length of the pronation arc after transection of the main RCL was 17.53mm, while it was only 12.41mm before transection for the supination arc. Mean length of the pronation arc after transection of both CLs was 22.83mm compared to only 11.93mm before transection. Our results show a significant difference in pronation stability of the MCP joint after transection of the RCL proper. We can conclude that this rotational stability test is a valid test for diagnosing RCL rupture in MCP joints. Copyright © 2017 SFCM. Published by Elsevier Masson SAS. All rights reserved.

The influence of sex and trauma impact on the rupture site of the ulnar collateral ligament of the thumb.

PubMed

Boesmueller, Sandra; Huf, Wolfgang; Rettl, Gregor; Dahm, Falko; Meznik, Alexander; Muschitz, Gabriela; Kitzinger, Hugo; Bukaty, Adam; Fialka, Christian; Vierhapper, Martin

2017-01-01

Although sex- and gender-specific analyses have been gaining more attention during the last years they have rarely been performed in orthopaedic literature. The primary purpose of this study was to investigate whether for injuries of the UCL the specific location of the rupture is influenced by sex. A secondary study question addressed the sex-independent effect of trauma intensity on the rupture site of the UCL. This study is a retrospective analysis of all patients with either a proximal or distal bony avulsion or with a mid-substance tear or ligament avulsion of the UCL treated surgically between 1992 and 2015 at two level-I trauma centres. Trauma mechanisms leading to the UCL injury were classified into the following categories: (1) blunt trauma (i.e., strains), (2) low-velocity injuries (e.g., fall from standing height, assaults), and (3) high-velocity injuries (e.g., sports injuries, motor vehicle accidents). After reviewing the surgical records, patients were divided into three groups, depending upon the ligament rupture site: (1) mid-substance tears, (2) proximal ligament or bony avulsions and (3) distal ligament or bony avulsions. Dependencies between the specific rupture site and the explanatory variables (sex, age, and trauma intensity) were evaluated using χ2 test and logistic regression analysis. In total, 1582 patients (1094 males, 488 females) met the inclusion criteria. Mean age was 41 years (range: 9-90 years). Taking into account the effects of sex on trauma intensity (p<0.001) and of trauma intensity on rupture site (p<0.001), mid-substance tears occurred more frequently in women, whereas men were more prone to distal ligament or bony avulsions (p<0.001). In other words, sex and rupture site correlated due to the effects of sex on trauma intensity and of trauma intensity on rupture site, but taking into account those effects there still was a significant effect of sex on rupture site. The results of this study demonstrate that with regression

Load Sharing Among Collateral Ligaments, Articular Surfaces, and the Tibial Post in Constrained Condylar Knee Arthroplasty.

PubMed

Wang, Xiaonan; Malik, Aamer; Bartel, Donald L; Wright, Timothy M; Padgett, Douglas E

2016-08-01

The normal knee joint maintains stable motion during activities of daily living. After total knee arthroplasty (TKA), stability is achieved by the conformity of the bearing surfaces of the implant components, ligaments, and constraint structures incorporated in the implant design. The large, rectangular tibial post in constrained condylar knee (CCK) arthroplasty, often used in revision surgery, provides added stability, but increases susceptibility to polyethylene wear as it contacts the intercondylar box on the femoral component. We examined coronal plane stability to understand the relative contributions of the mechanisms that act to stabilize the CCK knee under varus-valgus loading, namely, load distribution between the medial and lateral condyles, contact of the tibial post with the femoral intercondylar box, and elongation of the collateral ligaments. A robot testing system was used to determine the joint stability in human cadaveric knees as described by the moment versus angular rotation behavior under varus-valgus moments at 0 deg, 30 deg, and 90 deg of flexion. The angular rotation of the CCK knee in response to the physiological moments was limited to ≤1.5 deg. The primary stabilizing mechanism was the redistribution of the contact force on the bearing surfaces. Contact between the tibial post and the femoral box provided a secondary stabilizing mechanism after lift-off of a condyle had occurred. Collateral ligaments provide limited stability because little ligament elongation occurred under such small angular rotations. Compressive loads applied across the knee joint, such as would occur with the application of muscle forces, enhanced the ability of the bearing surfaces to provide resisting internal varus-valgus moment and, thus, reduced the exposure of the tibial post to the external varus-valgus loads. Our results suggest that the CCK stability can be refined by considering both the geometry of the bearing surfaces and the contacting geometry

Ulnar Impaction Syndrome: A case series investigating the appropriate diagnosis, management, and post-operative considerations.

PubMed

Woitzik, Erin; deGraauw, Chris; Easter, Brock

2014-12-01

Ulnar sided wrist pain is a common site for upper extremity disability. Ulnar impaction syndrome results in a spectrum of triangular fibrocartilage complex (TFCC) injuries and associated lunate, triquetrum, and ligamentous damage. Patients commonly present with insidious ulnar sided wrist pain and clicking, and a history of trauma or repetitive axial loading and rotation. In this case series, three patients presented to a sports chiropractor for evaluation and were subsequently diagnosed with ulnar impaction syndrome. Treatment strategies consist of conservative management, arthroscopic debridement or repair, arthroscopic wafer procedure, or ulnar shortening osteotomy. For the athlete, intervention should be individualized and sport-specific, considering athletic priorities, healing potential, return to play, and long-term health concerns.

Sex-Based Differences of Medial Collateral Ligament and Anterior Cruciate Ligament Strains With Cadaveric Impact Simulations.

PubMed

Schilaty, Nathan D; Bates, Nathaniel A; Nagelli, Christopher V; Krych, Aaron J; Hewett, Timothy E

2018-04-01

Female patients sustain noncontact knee ligament injuries at a greater rate compared with their male counterparts. The cause of these differences in the injury rate and the movements that load the ligaments until failure are still under dispute in the literature. This study was designed to determine differences in anterior cruciate ligament (ACL) and medial collateral ligament (MCL) strains between male and female cadaveric specimens during a simulated athletic task. The primary hypothesis tested was that female limbs would demonstrate significantly greater ACL strain compared with male limbs under similar loading conditions. A secondary hypothesis was that MCL strain would not differ between sexes. Controlled laboratory study. Motion analysis of 67 athletes performing a drop vertical jump was conducted. Kinetic data were used to categorize injury risk according to tertiles, and these values were input into a cadaveric impact simulator to assess ligamentous strain during a simulated landing task. Uniaxial and multiaxial load cells and differential variable reluctance transducer strain sensors were utilized to collect mechanical data for analysis. Conditions of external loads applied to the cadaveric limbs (knee abduction moment, anterior tibial shear, and internal tibial rotation) were varied and randomized. Data were analyzed using 1-way analysis of variance (ANOVA), 2-way repeated-measures ANOVA, and the Fisher exact test. There were no significant differences ( P = .184) in maximum ACL strain between male (13.2% ± 8.1%) and female (16.7% ± 8.3%) specimens. Two-way ANOVA demonstrated that across all controlled external load conditions, female specimens consistently attained at least 3.5% increased maximum ACL strain compared with male specimens ( F 1,100 = 4.188, P = .043); however, when normalized to initial contact, no significant difference was found. There were no significant differences in MCL strain between sexes for similar parameters. When compared with

Thumb Sprains

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... Thumb Sprains Find a hand surgeon near you. Videos Figures Figure 1: The ulnar collateral ligament (UCL) ... or "in." Also, avoid using media types like "video," "article," and "picture." Tip 4: Your results can ...

The influence of sex and trauma impact on the rupture site of the ulnar collateral ligament of the thumb

PubMed Central

Huf, Wolfgang; Rettl, Gregor; Dahm, Falko; Meznik, Alexander; Muschitz, Gabriela; Kitzinger, Hugo; Bukaty, Adam; Fialka, Christian; Vierhapper, Martin

2017-01-01

Purpose and hypothesis Although sex- and gender-specific analyses have been gaining more attention during the last years they have rarely been performed in orthopaedic literature. The primary purpose of this study was to investigate whether for injuries of the UCL the specific location of the rupture is influenced by sex. A secondary study question addressed the sex-independent effect of trauma intensity on the rupture site of the UCL. Methods This study is a retrospective analysis of all patients with either a proximal or distal bony avulsion or with a mid-substance tear or ligament avulsion of the UCL treated surgically between 1992 and 2015 at two level-I trauma centres. Trauma mechanisms leading to the UCL injury were classified into the following categories: (1) blunt trauma (i.e., strains), (2) low-velocity injuries (e.g., fall from standing height, assaults), and (3) high-velocity injuries (e.g., sports injuries, motor vehicle accidents). After reviewing the surgical records, patients were divided into three groups, depending upon the ligament rupture site: (1) mid-substance tears, (2) proximal ligament or bony avulsions and (3) distal ligament or bony avulsions. Dependencies between the specific rupture site and the explanatory variables (sex, age, and trauma intensity) were evaluated using χ2 test and logistic regression analysis. Results In total, 1582 patients (1094 males, 488 females) met the inclusion criteria. Mean age was 41 years (range: 9–90 years). Taking into account the effects of sex on trauma intensity (p<0.001) and of trauma intensity on rupture site (p<0.001), mid-substance tears occurred more frequently in women, whereas men were more prone to distal ligament or bony avulsions (p<0.001). In other words, sex and rupture site correlated due to the effects of sex on trauma intensity and of trauma intensity on rupture site, but taking into account those effects there still was a significant effect of sex on rupture site. Conclusions The

Biomechanical study using fuzzy systems to quantify collagen fiber recruitment and predict creep of the rabbit medial collateral ligament.

PubMed

Ali, A F; Taha, M M Reda; Thornton, G M; Shrive, N G; Frank, C B

2005-06-01

In normal daily activities, ligaments are subjected to repeated loads, and respond to this environment with creep and fatigue. While progressive recruitment of the collagen fibers is responsible for the toe region of the ligament stress-strain curve, recruitment also represents an elegant feature to help ligaments resist creep. The use of artificial intelligence techniques in computational modeling allows a large number of parameters and their interactions to be incorporated beyond the capacity of classical mathematical models. The objective of the work described here is to demonstrate a tool for modeling creep of the rabbit medial collateral ligament that can incorporate the different parameters while quantifying the effect of collagen fiber recruitment during creep. An intelligent algorithm was developed to predict ligament creep. The modeling is performed in two steps: first, the ill-defined fiber recruitment is quantified using the fuzzy logic. Second, this fiber recruitment is incorporated along with creep stress and creep time to model creep using an adaptive neurofuzzy inference system. The model was trained and tested using an experimental database including creep tests and crimp image analysis. The model confirms that quantification of fiber recruitment is important for accurate prediction of ligament creep behavior at physiological loads.

Classification of ulnar triangular fibrocartilage complex tears. A treatment algorithm for Palmer type IB tears.

PubMed

Atzei, A; Luchetti, R; Garagnani, L

2017-05-01

The classical definition of 'Palmer Type IB' triangular fibrocartilage complex tear, includes a spectrum of clinical conditions. This review highlights the clinical and arthroscopic criteria that enable us to categorize five classes on a treatment-oriented classification system of triangular fibrocartilage complex peripheral tears. Class 1 lesions represent isolated tears of the distal triangular fibrocartilage complex without distal radio-ulnar joint instability and are amenable to arthroscopic suture. Class 2 tears include rupture of both the distal triangular fibrocartilage complex and proximal attachments of the triangular fibrocartilage complex to the fovea. Class 3 tears constitute isolated ruptures of the proximal attachment of the triangular fibrocartilage complex to the fovea; they are not visible at radio-carpal arthroscopy. Both Class 2 and Class 3 tears are diagnosed with a positive hook test and are typically associated with distal radio-ulnar joint instability. If required, treatment is through reattachment of the distal radio-ulnar ligament insertions to the fovea. Class 4 lesions are irreparable tears due to the size of the defect or to poor tissue quality and, if required, treatment is through distal radio-ulnar ligament reconstruction with tendon graft. Class 5 tears are associated with distal radio-ulnar joint arthritis and can only be treated with salvage procedures. This subdivision of type IB triangular fibrocartilage complex tear provides more insights in the pathomechanics and treatment strategies. II.

A quantitative comparison of morphological and histological characteristics of collagen in the rabbit medial collateral ligament.

PubMed

Wan, Chao; Hao, Zhixiu; Wen, Shizhu

2013-12-01

Collagen fiber is one of the critical factors in determining mechanical properties of ligaments and both the morphological and histological characteristics of collagen have been widely studied. However, there was still no consensus about whether the morphological characteristics of collagen correlated with its histological characteristics in physiological ligaments. Rabbit medial collateral ligaments (MCLs) were measured under a transmission electron microscope and a polarized light microscope plus picrosirius red-staining to obtain the distributions of collagen fibril diameters and types at different anatomical sites of rabbit MCLs, respectively. The correlation between the fibril diameter and type was determined by a correlation analysis. The collagen fibril diameters at the different anatomical sites had different distributions (unimodal or bimodal) and mean fibril diameters were found to increase significantly from the anterior part to the posterior part (P=0.0482) as well as from the proximal to the distal sections (P=0.0208). Type I collagen in the core portion of MCLs was significantly less than at the other four peripheral areas (P<0.005) but no significant variation was found in each respective portion (P>0.05). The low coefficient in the correlation analysis (r=0.3759) demonstrated collagen fibril diameters had no correlation with collagen types. This may provide a new view of collagen types in studying the mechanical behavior of ligaments. Copyright © 2013 Elsevier GmbH. All rights reserved.

Clarification of Eponymous Anatomical Terminology: Structures Named After Dr Geoffrey V. Osborne That Compress the Ulnar Nerve at the Elbow.

PubMed

Wali, Arvin R; Gabel, Brandon; Mitwalli, Madhawi; Tubbs, R Shane; Brown, Justin M

2017-05-01

In 1957, Dr Geoffrey Osborne described a structure between the medial epicondyle and the olecranon that placed excessive pressure on the ulnar nerve. Three terms associated with such structures have emerged: Osborne's band, Osborne's ligament, and Osborne's fascia. As anatomical language moves away from eponymous terminology for descriptive, consistent nomenclature, we find discrepancies in the use of anatomic terms. This review clarifies the definitions of the above 3 terms. We conducted an extensive electronic search via PubMed and Google Scholar to identify key anatomical and surgical texts that describe ulnar nerve compression at the elbow. We searched the following terms separately and in combination: "Osborne's band," "Osborne's ligament," and "Osborne's fascia." A total of 36 papers were included from 1957 to 2016. Osborne's band, Osborne's ligament, and Osborne's fascia were found to inconsistently describe the etiology of ulnar neuritis, referring either to the connective tissue between the 2 heads of the flexor carpi ulnaris muscle as described by Dr Osborne or to the anatomically distinct fibrous tissue between the olecranon process of the ulna and the medial epicondyle of the humerus. The use of eponymous terms to describe ulnar pathology of the elbow remains common, and although these terms allude to the rich history of surgical anatomy, these nonspecific descriptions lead to inconsistencies. As Osborne's band, Osborne's ligament, and Osborne's fascia are not used consistently across the literature, this research demonstrates the need for improved terminology to provide reliable interpretation of these terms among surgeons.

Enhanced Medial Collateral Ligament Healing using Mesenchymal Stem Cells: Dosage Effects on Cellular Response and Cytokine Profile

PubMed Central

Saether, Erin E.; Chamberlain, Connie S.; Leiferman, Ellen M.; Kondratko-Mittnacht, Jaclyn R.; Li, Wan Ju; Brickson, Stacey L.; Vanderby, Ray

2013-01-01

Mesenchymal stem cells (MSCs) have potential therapeutic applications for musculoskeletal injuries due to their ability to differentiate into several tissue cell types and modulate immune and inflammatory responses. These immune-modulatory properties were examined in vivo during early stage rat medial collateral ligament healing. Two different cell doses (low dose 1×106 or high dose 4×106 MSCs) were administered at the time of injury and compared with normal ligament healing at days 5 and 14 post-injury. At both times, the high dose MSC group demonstrated a significant decrease in M2 macrophages compared to controls. At day 14, fewer M1 macrophages were detected in the low dose group compared to the high dose group. These results, along with significant changes in procollagen I, proliferating cells, and endothelialization suggest that MSCs can alter the cellular response during healing in a dose-dependent manner. The higher dose ligaments also had increased expression of several pro-inflammatory cytokines at day 5 (IL-1β, IFNγ, IL-2) and increased expression of IL-12 at day 14. Mechanical testing at day 14 revealed increased failure strength and stiffness in low dose ligaments compared to controls. Based on these improved mechanical properties, MSCs enhanced functional healing when applied at a lower dose. Different doses of MSCs uniquely affected the cellular response and cytokine expression in healing ligaments. Interestingly, the lower dose of cells proved to be most effective in improving functional properties. PMID:24174129

Outcomes of Medial Collateral Ligament Injuries during Total Knee Arthroplasty.

PubMed

Siqueira, Marcelo B P; Haller, Kathryn; Mulder, Andrew; Goldblum, Andrew S; Klika, Alison K; Barsoum, Wael K

2016-01-01

Intraoperative medial collateral ligament (MCL) disruption during total knee arthroplasty (TKA) is often managed with either primary repair or use of a constrained implant. A total of 23 patients with an MCL injury during TKA between 2003 and 2009 were compared with 92 matched controls. Of the 23 patients, 10 were treated with an unconstrained implant and primary MCL repair, 8 with constrained implants, 3 with constrained implants and MCL repair, and 2 with unconstrained implants and no MCL repair. After an average 5-year follow-up, patients had lower Knee Society Scores (KSS), 79 versus 87 (p = 0.03), but similar Knee Function Scores (KFS), 68 versus 72 (p = 0.35). The improvement between preoperative and postoperative KSS and KFS did not vary among the two groups (p = 0.88 and p = 0.77, respectively). Postoperative scores did not vary significantly among the four treatment modalities. Conservative treatment can provide satisfactory outcomes and avoid potential complications of increased constraint. Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.

Elastin governs the mechanical response of medial collateral ligament under shear and transverse tensile loading.

PubMed

Henninger, Heath B; Valdez, William R; Scott, Sara A; Weiss, Jeffrey A

2015-10-01

Elastin is a highly extensible structural protein network that provides near-elastic resistance to deformation in biological tissues. In ligament, elastin is localized between and along the collagen fibers and fascicles. When ligament is stretched along the primary collagen axis, elastin supports a relatively high percentage of load. We hypothesized that elastin may also provide significant load support under elongation transverse to the primary collagen axis and shear along the collagen axis. Quasi-static transverse tensile and shear material tests were performed to quantify the mechanical contributions of elastin during deformation of porcine medial collateral ligament. Dose response studies were conducted to determine the level of elastase enzymatic degradation required to produce a maximal change in the mechanical response. Maximal changes in peak stress occurred after 3h of treatment with 2U/ml porcine pancreatic elastase. Elastin degradation resulted in a 60-70% reduction in peak stress and a 2-3× reduction in modulus for both test protocols. These results demonstrate that elastin provides significant resistance to elongation transverse to the collagen axis and shear along the collagen axis while only constituting 4% of the tissue dry weight. The magnitudes of the elastin contribution to peak transverse and shear stress were approximately 0.03 MPa, as compared to 2 MPa for axial tensile tests, suggesting that elastin provides a highly anisotropic contribution to the mechanical response of ligament and is the dominant structural protein resisting transverse and shear deformation of the tissue. Copyright © 2015 Acta Materialia Inc. Published by Elsevier Ltd. All rights reserved.

Motion deficit in nodal interphalangeal joint osteoarthritis by digital goniometer in housewives.

PubMed

Ventura-Ríos, L; Hayes-Salinas, M; Ferrusquia-Toriz, D; Cariño-Escobar, R I; Cruz-Arenas, E; Gutiérrez-Martínez, J; González-Ramírez, L; Hernández-Díaz, C

2018-06-01

Range of motion (ROM) measured objectively in nodal hand osteoarthritis (NHOA) is missing. Evaluation of collateral ligaments by ultrasound (US) is unknown in NHOA also. To compare ROM in interphalangeal joints in housewives with nodal OA, with a control group by a digital system using angle to voltage (Multielgon). The second objective was to assess correlation between collateral radial and ulnar ligaments thickness and ROM. For this cross-sectional observational study, we assessed 60 hands with symptomatic NHOA and 30 hands of healthy housewives matched for age. We obtained clinical and demographic characteristics (a complete standardized physical examination of hand joints, DASH questionnaire, pain surveys, gross grasp hand goniometer, and ROM measurements by Multielgon. Presence of synovitis, power Doppler signal, osteophytes, and collateral ligaments thickness was evaluated by US. We used descriptive statistics, Spearman correlation, X 2 test, t test and odds ratio. Significant less gross grasp and ROM in the right hand were observed in NHOA (p = 0.01 for both). Presence of OA, painful joints, disease duration, and score DASH were significant correlated with reduced ROM (OR 4.12, 4.12, 1.04 and 1.09, respectively). Reduced ROM was statistical significant in thumb MCP and IP joints, second and third DIP in dominant hand. There was no association between collateral radial and ulnar ligaments and reduced ROM. Synovitis and osteophytes were more prevalent in OA group. Multielgon demonstrated the pattern of reduced ROM in nodal OA of housewives particularly in MCP and IP thumb joints, second and third distal interphalangeal joints.

In vivo and 3-dimensional functional anatomy of the anterior bundle of the medial collateral ligament of the elbow.

PubMed

Miyake, Junichi; Moritomo, Hisao; Masatomi, Takashi; Kataoka, Toshiyuki; Murase, Tsuyoshi; Yoshikawa, Hideki; Sugamoto, Kazuomi

2012-08-01

Although the anterior bundle of the medial collateral ligament (AMCL) is a critical stabilizer of the elbow joint, little information exists on in vivo and 3-dimensional functional anatomy of the AMCL. The purposes of this study were to investigate in vivo changes in the length of the AMCL during elbow flexion and to clarify the 3-dimensional functional anatomy of the AMCL. We created 3-dimensional models of the AMCL and bones from computed tomography data of 4 healthy elbows in 5 different elbow positions. The AMCL was subdivided into 9 ligaments. We calculated changes in lengths of ligaments during flexion and related ligament origins to the axis of rotation of the elbow joint. There were 4 uniquely configured isometric ligaments, where their origins aligned broadly along the course of the axis of rotation in the coronal plane. The medially originating ligaments inserted on the posterior portion of the tubercle of the coronoid process, whereas the laterally originating ligaments inserted on its anterior portion. There were 5 non-isometric ligaments, 3 of which had origins proximal to the axis and became taut only in extension and the other 2 having origins distal to the axis and becoming taut only in flexion. Isometric ligaments within the AMCL do not originate from a narrow area; rather, they originate from a broader area that extends more medially in the coronal plane than previously thought, which explains how the AMCL reconciles isometricity and robustness. The proximal and distal ligaments act as checkreins that work only at the limits of elbow motion. Copyright © 2012 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Mosby, Inc. All rights reserved.

ACL/MCL transection affects knee ligament insertion distance of healing and intact ligaments during gait in the Ovine model.

PubMed

Tapper, Janet E; Funakoshi, Yusei; Hariu, Mitsuhiro; Marchuk, Linda; Thornton, Gail M; Ronsky, Janet L; Zernicke, Ron; Shrive, Nigel G; Frank, Cyril B

2009-08-25

The objective of this study was to assess the impact of combined transection of the anterior cruciate and medial collateral ligaments on the intact and healing ligaments in the ovine stifle joint. In vivo 3D stifle joint kinematics were measured in eight sheep during treadmill walking (accuracy: 0.4+/-0.4mm, 0.4+/-0.4 degrees ). Kinematics were measured with the joint intact and at 2, 4, 8, 12, 16 and 20 weeks after either surgical ligament transection (n=5) or sham surgery without transection (n=3). After sacrifice at 20 weeks, the 3D subject-specific bone and ligament geometry were digitized, and the 3D distances between insertions (DBI) of ligaments during the dynamic in vivo motion were calculated. Anterior cruciate ligament/medial collateral ligament (ACL/MCL) transection resulted in changes in the DBI of not only the transected ACL, but also the intact lateral collateral ligament (LCL) and posterior cruciate ligament (PCL), while the DBI of the transected MCL was not significantly changed. Increases in the maximal ACL DBI (2 week: +4.2mm, 20 week: +5.7mm) caused increases in the range of ACL DBI (2 week: 3.6mm, 20 week: +3.8mm) and the ACL apparent strain (2 week: +18.9%, 20 week: +24.0%). Decreases in the minimal PCL DBI (2 week: -3.2mm, 20 week: -4.3mm) resulted in increases in the range of PCL DBI (2 week: +2.7mm, 20 week: +3.2mm). Decreases in the maximal LCL DBI (2 week: -1.0mm, 20 week: -2.0mm) caused decreased LCL apparent strain (2 week: -3.4%, 20 week: -6.9%). Changes in the mechanical environment of these ligaments may play a significant role in the biological changes observed in these ligaments.

Anterolateral Ligament of the Knee Shows Variable Anatomy in Pediatric Specimens.

PubMed

Shea, Kevin G; Milewski, Matthew D; Cannamela, Peter C; Ganley, Theodore J; Fabricant, Peter D; Terhune, Elizabeth B; Styhl, Alexandra C; Anderson, Allen F; Polousky, John D

2017-06-01

Anterior cruciate ligament (ACL) reconstruction failure rates are highest in youth athletes. The role of the anterolateral ligament in rotational knee stability is of increasing interest, and several centers are exploring combined ACL and anterolateral ligament reconstruction for these young patients. Literature on the anterolateral ligament of the knee is sparse in regard to the pediatric population. A single study on specimens younger than age 5 years demonstrated the presence of the anterolateral ligament in only one of eight specimens; therefore, much about the prevalence and anatomy of the anterolateral ligament in pediatric specimens remains unknown. We sought to (1) investigate the presence or absence of the anterolateral ligament in prepubescent anatomic specimens; (2) describe the anatomic relationship of the anterolateral ligament to the lateral collateral ligament; and (3) describe the anatomic relationship between the anterolateral ligament and the physis. Fourteen skeletally immature knee specimens (median age, 8 years; range, 7-11 years) were dissected (12 male, two female specimens). The posterolateral structures were identified in all specimens, including the lateral collateral ligament and popliteus tendon. The presence or absence of the anterolateral ligament was documented in each specimen, along with origin, insertion, and dimensions, when applicable. The relationship of the anterolateral ligament origin to the lateral collateral ligament origin was recorded. The anterolateral ligament was identified in nine of 14 specimens. The tibial attachment point was consistently located in the same region on the proximal tibia, between the fibular head and Gerdy's tubercle; however, the femoral origin of the anterolateral ligament showed considerable variation with respect to the lateral collateral ligament origin. The median femoral origin of the anterolateral ligament was 10 mm (first interquartile 6 mm, third interquartile 13) distal to the distal

A study on operative findings and pathogenic factors in ulnar neuropathy at the elbow.

PubMed

Kojima, T; Kurihara, K; Nagano, T

1979-01-01

A study was made of operative findings obtained in 44 cases of ulnar nerve neuropathy at the elbow in an attempt to help elucidate the pathogenetic factors for the condition. Distinction must be made between Lig. epitrochleo-anconeum or a ligament-like thickening at the same site and the tendinous arch of M. flexor carpi ulnaris. These 2 sites constitute the entrapment points for the condition. A thick tendinous arch, Lig. epitrochleo-anconeum of M. anconeus epitrochlearis deters the ulnar nerve from being mobile, thereby contributing to the development of neuropathy with trauma acting as a precipitating factor. Dislocation of the ulnar nerve cannot be considered a factor of major etiologic significance. An important part is played by the tendinous arch in the pathogenesis of neuropathy, regardless of whether it is in association with ganglion, osteochondromatosis or osteoarthritis. In surgery for ulnar neuropathy decompression of the nerve is of primary necessity. Division of the tendinous arch is mandatory. Medial epicondylectomy may be added as required.

Internet resources for Tommy John injuries: what are patients reading?

PubMed

Johnson, Christine C; Garcia, Grant H; Liu, Joseph N; Stepan, Jeffrey G; Patel, Ronak M; Dines, Joshua S

2016-12-01

The quality of medical information on the Internet has come under scrutiny. This study investigates the quality, accuracy, and readability of online information regarding ulnar collateral ligament (UCL) injuries. Three search terms ("elbow ulnar collateral ligament injury," "tommy john injury," and "pitcher's elbow") were entered into 3 Internet search engines. Three independent reviewers evaluated the content and accuracy of the information with a set of predetermined scoring criteria. Website quality was further assessed by the Journal of the American Medical Association benchmark criteria and Health on the Net Foundation certification. Website readability was ascertained with the Flesch-Kincaid score. We evaluated 113 unique websites. The average quality for all websites was 8.88 ± 6.8 (maximum, 32 points). Website quality and accuracy were lower with use of the search term "pitcher's elbow" as compared with "elbow ulnar collateral ligament injury" or "tommy john injury" (P ≤ .001). Sites certified by the Health on the Net Foundation had higher quality scores than non-certified sites (P = .034). The mean reading grade level was 10.7. Reading level was significantly correlated with website accuracy and quality (P ≤ .001) and physician authorship (P = .012). Forty-three websites (38.1%) described surgical reconstruction; of these, 16 (37.2%) mentioned improved pitching performance postoperatively. Online information on UCL injuries is often inaccurate and written at an inappropriate reading level. Information quality depends on the search term used, website authorship, and commercial bias. Clinicians must be aware of factors influencing website quality in order to direct patients to appropriate resources. Copyright © 2016 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.

Anterolateral ligament abnormalities in patients with acute anterior cruciate ligament rupture are associated with lateral meniscal and osseous injuries.

PubMed

Van Dyck, Pieter; Clockaerts, Stefan; Vanhoenacker, Filip M; Lambrecht, Valérie; Wouters, Kristien; De Smet, Eline; Gielen, Jan L; Parizel, Paul M

2016-10-01

To determine the frequency of anterolateral ligament (ALL) injury in patients with acute anterior cruciate ligament (ACL) rupture and to analyse its associated injury patterns. Ninety patients with acute ACL rupture for which MRI was obtained within 8 weeks after the initial trauma were retrospectively identified. Two radiologists assessed the status of the ALL on MRI by consensus. The presence or absence of an ALL abnormality was compared with the existence of medial and lateral meniscal tears diagnosed during arthroscopy. Associated collateral ligament and osseous injuries were documented with MRI. Forty-one of 90 knees (46 %) demonstrated ALL abnormalities on MRI. Of 49 knees with intact ALL, 15 (31 %) had a torn lateral meniscus as compared to 25 torn lateral menisci in 41 knees (61 %) with abnormal ALL (p = 0.008). Collateral ligament (p ≤ 0.05) and osseous injuries (p = 0.0037) were more frequent and severe in ALL-injured as compared with ALL-intact knees. ALL injuries are fairly common in patients with acute ACL rupture and are statistically significantly associated with lateral meniscal, collateral ligament and osseous injuries. • ALL injuries are fairly common in patients with acute ACL rupture. • ALL injuries are highly associated with lateral meniscal and osseous injuries. • MRI assessment of ACL-injured knees should include evaluation of the ALL.

Smart instrumentation for determination of ligament stiffness and ligament balance in total knee arthroplasty.

PubMed

Hasenkamp, W; Villard, J; Delaloye, J R; Arami, A; Bertsch, A; Jolles, B M; Aminian, K; Renaud, P

2014-06-01

Ligament balance is an important and subjective task performed during total knee arthroplasty (TKA) procedure. For this reason, it is desirable to develop instruments to quantitatively assess the soft-tissue balance since excessive imbalance can accelerate prosthesis wear and lead to early surgical revision. The instrumented distractor proposed in this study can assist surgeons on performing ligament balance by measuring the distraction gap and applied load. Also the device allows the determination of the ligament stiffness which can contribute a better understanding of the intrinsic mechanical behavior of the knee joint. Instrumentation of the device involved the use of hall-sensors for measuring the distractor displacement and strain gauges to transduce the force. The sensors were calibrated and tested to demonstrate their suitability for surgical use. Results show the distraction gap can be measured reliably with 0.1mm accuracy and the distractive loads could be assessed with an accuracy in the range of 4N. These characteristics are consistent with those have been proposed, in this work, for a device that could assist on performing ligament balance while permitting surgeons evaluation based on his experience. Preliminary results from in vitro tests were in accordance with expected stiffness values for medial collateral ligament (MCL) and lateral collateral ligament (LCL). Copyright © 2013 IPEM. Published by Elsevier Ltd. All rights reserved.

Use of platelet-rich plasma for patellar tendon and medial collateral ligament injuries: best current clinical practice.

PubMed

Andia, Isabel; Maffulli, Nicola

2015-02-01

Platelet-rich plasmas (PRPs) are complex molecular therapies prepared from the patient's own blood through minimal manipulation. Clinical studies examining the efficacy of PRPs to manage patellar tendinopathy and medial collateral ligament (MCL) injuries have been reviewed. We found three controlled trials, two of them randomized, and seven case series in the management of patellar tendinopathy. In addition, three other randomized studies showed that PRPs help to regenerate the patellar tendon harvest site for anterior cruciate ligament reconstruction and to reduce patellar donor site morbidity. On the other hand, the use of PRP in MCL injuries is reported in a single case study. Seven of the 11 studies used leukocyte and PRP which was buffered in four studies. Seven of the 11 studies applied two or three injections. Given the heterogeneity of PRP protocols and the paucity of high-quality data, the most effective approach to guide clinical decisions regarding patellar tendinopathy cannot be deduced from the present published studies. Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.

The developmental morphology of a "periosteal" ligament insertion: growth and maturation of the tibial insertion of the rabbit medial collateral ligament.

PubMed

Matyas, J R; Bodie, D; Andersen, M; Frank, C B

1990-05-01

The structural properties of ligament insertions change dramatically during growth and maturation, but little is known about their developmental anatomy. This study describes and quantifies changes in the gross and microscopic anatomy of the tibial insertion of the rabbit medial collateral ligament (MCL) during development and at skeletal maturity. Eighty animals were used for growth and descriptive studies. From this group, 27 animals, ranging in age from 1 to 24 months, were injected with fluorescent bone markers and their tibial insertions were processed undecalcified for histology. Sections were examined by polarized light and fluorescence microscopy to identify matrix and cells and to quantify mineral formation. Results showed that animals achieved histological skeletal maturity between 9 and 12 months of age. Body weights were a poor index of skeletal maturity. The tibial insertion was composed of five tissue layers, which changed proportions during growth and maturation. In immature animals, MCL fibers entered the periosteum; in older animals, MCL fibers were cemented to the tibia by advancing mineral. The tibial attachment of the MCL was thus transferred from the periosteum to the cortex during growth, suggesting that the term "periosteal insertion" is imprecise in adults. The hypothesis is put forward that these structural changes account for the reported increase in tensile failure of this insertion near skeletal maturity.

Effect of Elastin Digestion on the Quasi-static Tensile Response of Medial Collateral Ligament

PubMed Central

Henninger, Heath B.; Underwood, Clayton J.; Romney, Steven J.; Davis, Grant L.; Weiss, Jeffrey A.

2014-01-01

Elastin is a structural protein that provides resilience to biological tissues. We examined the contributions of elastin to the quasi-static tensile response of porcine medial collateral ligament through targeted disruption of the elastin network with pancreatic elastase. Elastase concentration and treatment time were varied to determine a dose response. Whereas elastin content decreased with increasing elastase concentration and treatment time, the change in peak stress after cyclic loading reached a plateau above 1 U/ml elastase and 6 hr treatment. For specimens treated with 2 U/ml elastase for 6 hr, elastin content decreased approximately 35%. Mean peak tissue strain after cyclic loading (4.8%, p≥0.300), modulus (275 MPa, p≥0.114) and hysteresis (20%, p≥0.553) were unaffected by elastase digestion, but stress decreased significantly after treatment (up to 2 MPa, p≤0.049). Elastin degradation had no effect on failure properties, but tissue lengthened under the same pre-stress. Stiffness in the linear region was unaffected by elastase digestion, suggesting that enzyme treatment did not disrupt collagen. These results demonstrate that elastin primarily functions in the toe region of the stress-strain curve, yet contributes load support in the linear region. The increase in length after elastase digestion suggests that elastin may pre-stress and stabilize collagen crimp in ligaments. PMID:23553827

Laxity after complete release of the medial collateral ligament in primary total knee arthroplasty.

PubMed

Cho, Woo-Shin; Byun, Seong-Eun; Lee, Sang-Jun; Yoon, Jaeyoun

2015-06-01

Medial collateral ligament (MCL) release is one of the essential steps toward the achievement of ligament balancing during the total knee arthroplasty (TKA) in patients with varus deformity. When the varus deformity is severe, complete release of the MCL until balanced is often required. However, it is believed that complete MCL release may lead to catastrophic laxity. The purpose of this prospective study is to compare the medial joint gap opening in postoperative valgus stress radiograph in patients with complete MCL release against patients with partial release. Out of 209 primary TKAs performed for degenerative osteoarthritis, complete MCL release was required in 33 cases (group I) by sub-periosteal detachment at proximal tibia using periosteal elevator. For the remaining 176 knees (group II), partial release of MCL was done. At postoperative 6 months and 1 year, both groups were evaluated for comparing the joint gap on valgus stress radiographs using modified Telos device in 0°, 45°, and 90° of flexion. Additional parameters which were analyzed included preoperative varus and valgus stress radiographs in full extension and pre- and postoperative mechanical alignment in each group. The knee range of motion (ROM) and clinical scores were evaluated at 1-year follow-up. The mean values of the joint opening on the postoperative valgus stress test with the knee joint extended, and in the 45° and 90° flexed states at 6 months and at 1 year postoperatively in group I were not statistically significantly different from those of group II. The clinical scores also did not show a statistically significant difference between two groups. There was a statistically significant difference in ROM between two groups, pre- and postoperatively and the difference was 5°, respectively. This study suggests that complete MCL release for ligament balancing is a safe procedure and does not lead to postoperative laxity.

A Quantitative Study of the Relationship between the Distribution of Different Types of Collagen and the Mechanical Behavior of Rabbit Medial Collateral Ligaments

PubMed Central

Wan, Chao; Hao, Zhixiu; Wen, Shizhu; Leng, Huijie

2014-01-01

The mechanical properties of ligaments are key contributors to the stability and function of musculoskeletal joints. Ligaments are generally composed of ground substance, collagen (mainly type I and III collagen), and minimal elastin fibers. However, no consensus has been reached about whether the distribution of different types of collagen correlates with the mechanical behaviors of ligaments. The main objective of this study was to determine whether the collagen type distribution is correlated with the mechanical properties of ligaments. Using axial tensile tests and picrosirius red staining-polarization observations, the mechanical behaviors and the ratios of the various types of collagen were investigated for twenty-four rabbit medial collateral ligaments from twenty-four rabbits of different ages, respectively. One-way analysis of variance was used in the comparison of the Young's modulus in the linear region of the stress-strain curves and the ratios of type I and III collagen for the specimens (the mid-substance specimens of the ligaments) with different ages. A multiple linear regression was performed using the collagen contents (the ratios of type I and III collagen) and the Young's modulus of the specimens. During the maturation of the ligaments, the type I collagen content increased, and the type III collagen content decreased. A significant and strong correlation () was identified by multiple linear regression between the collagen contents (i.e., the ratios of type I and type III collagen) and the mechanical properties of the specimens. The collagen content of ligaments might provide a new perspective for evaluating the linear modulus of global stress-strain curves for ligaments and open a new door for studying the mechanical behaviors and functions of connective tissues. PMID:25062068

Chronic medial instability of the elbow

PubMed Central

Savoie, Felix H.; O’Brien, Michael

2017-01-01

Damage to the medial collateral ligament of the elbow from an instability episode usually heals with non-operative treatment. In some cases, residual instability may occur, leading to functional impairment.Non-operative management can be successful when bracing, taping and therapy are used to stabilise the elbow.A recent report detailing the efficacy of platelet-rich plasma in effectively treating ulnar collateral ligament (UCL) injuries in throwers has shown promise. However, there remain specific groups that should be considered for repair or reconstruction. These may include throwing athletes, wrestlers and some individuals involved in highly active physical activity which demands stability of the elbow.The results of surgical repair and reconstruction allowing a return to sports are quite good, ranging from 84% to 94%. Complications are generally low and mostly centred on ulnar nerve injuries.This report represents a review of the literature concerning valgus instability over the past five years, supplemented by selective older articles where relevant. Cite this article: EFORT Open Rev 2017;2:1-6. DOI:10.1302/2058-5241.2.160037. PMID:28607764

Modified technique for correction of isolated radial head dislocation without apparent ulnar bowing: a retrospective case study

PubMed Central

Tan, Lei; Li, Yan-Hui; Sun, Da-Hui; Zhu, Dong; Ning, Shu-Yan

2015-01-01

Objective: There is currently no general consensus on the optimal treatment of chronic radial head dislocation. Material and Methods: Considering that the annular ligament is important in maintaining elbow stability, we developed a modified method for annular ligament reconstruction in pediatric cases of radial head dislocation without ulnar bowing. We retrospectively investigated the therapeutic outcomes of this technique in a series of cases. We used our modified technique for the treatment of five patients between January 2006 and January 2012. The average age of the patients at the time of injury was 9 years (range, 6-14 years), and the patients were followed up for 1 to 3 years. Results: The perioperative and follow-up data of the patients were examined. All five surgical procedures were completed uneventfully and had been tolerated well by the patients, with minimal complications. Remarkable improvement was noted in all the cases at the end of the follow-up period. Conclusions: Our modified technique for annular ligament reconstruction was effective in achieving good reduction of the radial head dislocation with minimal complications in pediatric cases of isolated radial head dislocation without apparent ulnar bowing. PMID:26770420

Sports Injury-Related Fingers and Thumb Deformity Due to Tendon or Ligament Rupture.

PubMed

Bai, Rong-Jie; Zhang, Hui-Bo; Zhan, Hui-Li; Qian, Zhan-Hua; Wang, Nai-Li; Liu, Yue; Li, Wen-Ting; Yin, Yu-Ming

2018-05-05

Hand injuries are very common in sports, such as skiing and ball sports. One of the major reasons causing hand and finger deformity is due to ligament and tendon injury. The aim of this study was to investigate if the high-resolution 3T magnetic resonance imaging (MRI) can demonstrate the complex anatomy of the fingers and thumb, especially the tendons and ligaments, and provide the accurate diagnosis of clinically important fingers and thumbs deformity due to ligamentous and tendinous injuries during sport activities. Sixteen fresh un-embalmed cadaveric hands were harvested from eight cadavers. A total of 20 healthy volunteers' hands and 44 patients with fingers or thumb deformity due to sports-related injuries were included in this study. All subjects had MR examination with T1-weighted images and proton density-weighted imaging with fat suppression (PD FS) in axial, coronal, and sagittal plane, respectively. Subsequently, all 16 cadaveric hands were sliced into 2-mm thick slab with a band saw (six in coronal plane, six in sagittal plane, and four in axial plane). The correlation of anatomic sections and the MRI characteristics of tendons of fingers and the ulnar collateral ligament (UCL) at the metacarpal phalangeal joint (MCPJ) of thumb between 20 healthy volunteers and 44 patients (confirmed by surgery) were analyzed. The normal ligaments and tendons in 16 cadaveric hands and 20 volunteers' hands showed uniform low-signal intensity on all the sequences of the MRI. Among 44 patients with tendinous and ligamentous injuries in the fingers or thumb, 12 cases with UCL injury at MCPJ of the thumb (Stener lesion = 8 and non-Stener lesion = 4), 6 cases with the central slip injury, 12 cases with terminal tendon injury, and 14 cases with flexor digitorum profundus injury. The ligaments and tendons disruption manifested as increased signal intensity and poor definition, discontinuity, and heterogeneous signal intensity of the involved ligaments and tendons. Sports

Craniocervical junction in dogs revisited--new ligaments and confirmed presence of enthesis fibrocartilage.

PubMed

Kupczynska, M; Wieladek, A; Janczyk, P

2012-06-01

The study was performed to investigate and to describe features of gross and microscopic morphology of craniocervical junction (CCJ) in dogs. Seventy mature dogs (38 females, 32 males) of different body weight, representing small, medium and large breeds of dolicho-, mesati-, and brachycephalic morphotype were dissected. Morphological details were localised using an operating microscope with integrated video channel. Occurrence and distribution of fibrocartilage in the ligaments from 10 dogs was analysed histologically. Three new pairs of ligaments were described and named: dorsal ligaments of atlas, cranial internal collateral ligaments of atlas, and caudal internal collateral ligaments of atlas. Several new findings in the course of the known ligaments were found relating to breed and body weight. For the first time enthesis fibrocartilage was identified in ligaments of CCJ in dogs. Sesamoidal fibrocartilage was identified in the transversal ligament of atlas in large dogs. The findings are discussed for clinical importance. Copyright © 2011 Elsevier Ltd. All rights reserved.

ULNAR NERVE COMPONENT TO INNERVATION OF THUMB CARPOMETACARPAL JOINT

PubMed Central

Miki, Roberto Augusto; Kam, Check C; Gennis, Elisabeth R; Barkin, Jodie A; Riel, Ryan U; Robinson, Philip G; Owens, Patrick W

2011-01-01

Purpose Thumb carpometacarpal (CMC) joint arthritis is one of the most common problems addressed by hand surgeons. The gold standard of treatment for thumb CMC joint arthritis is trapeziectomy, ligament reconstruction and tendon interposition. Denervation of the thumb CMC joint is not currently used to treat arthritis in this joint due to the failure of the procedure to yield significant symptomatic relief. The failure of denervation is puzzling, given that past anatomic studies show the radial nerve is the major innervation of the thumb CMC joint with the lateral antebrachial nerve and the median nerve also innervating this joint. Although no anatomic study has ever shown that the ulnar nerve innervates the CMC joint, due to both the failure of denervation and the success of arthroscopic thermal ablation, we suspect that previous anatomic studies may have overlooked innervation of the thumb CMC joint via the ulnar nerve. Methods We dissected 19 formalin-preserved cadaveric hand-to-mid-forearm specimens. The radial, median and ulnar nerves were identified in the proximal forearm and then followed distally. Any branch heading toward the radial side of the hand were followed to see if they innervated the thumb CMC joint. Results Eleven specimens (58%) had superficial radial nerve innervation to the thumb CMC joint. Nine specimens (47%) had median nerve innervation from the motor branch. Nine specimens (47%) had ulnar nerve innervation from the motor branch. Conclusions We believe this is the first study to demonstrate that the ulnar nerve innervates the thumb CMC joint This finding may explain the poor results seen in earlier attempts at denervation of the thumb CMC, but the more favorable results with techniques such as arthroscopy with thermal ablation. PMID:22096446

A quantitative study of the relationship between the distribution of different types of collagen and the mechanical behavior of rabbit medial collateral ligaments.

PubMed

Wan, Chao; Hao, Zhixiu; Wen, Shizhu; Leng, Huijie

2014-01-01

The mechanical properties of ligaments are key contributors to the stability and function of musculoskeletal joints. Ligaments are generally composed of ground substance, collagen (mainly type I and III collagen), and minimal elastin fibers. However, no consensus has been reached about whether the distribution of different types of collagen correlates with the mechanical behaviors of ligaments. The main objective of this study was to determine whether the collagen type distribution is correlated with the mechanical properties of ligaments. Using axial tensile tests and picrosirius red staining-polarization observations, the mechanical behaviors and the ratios of the various types of collagen were investigated for twenty-four rabbit medial collateral ligaments from twenty-four rabbits of different ages, respectively. One-way analysis of variance was used in the comparison of the Young's modulus in the linear region of the stress-strain curves and the ratios of type I and III collagen for the specimens (the mid-substance specimens of the ligaments) with different ages. A multiple linear regression was performed using the collagen contents (the ratios of type I and III collagen) and the Young's modulus of the specimens. During the maturation of the ligaments, the type I collagen content increased, and the type III collagen content decreased. A significant and strong correlation (R2 = 0.839, P < 0.05) was identified by multiple linear regression between the collagen contents (i.e., the ratios of type I and type III collagen) and the mechanical properties of the specimens. The collagen content of ligaments might provide a new perspective for evaluating the linear modulus of global stress-strain curves for ligaments and open a new door for studying the mechanical behaviors and functions of connective tissues.

[Rupture of lateral ligaments of the ankle joint: MR imaging before and after functional therapy].

PubMed

Grebe, P; Kreitner, K F; Roeder, W; Kersjes, W; Hennes, R; Runkel, M

1995-09-01

Documentation via MRI of the healing of ruptured lateral collateral ankle ligaments after functional therapy. 35 patients with ankle sprain were examined by MRI and stress radiographs, 13 were operated afterwards, 22 patients underwent a functional conservative therapy and were examined by MRI and stress radiographs and second time after three months. MRI reports were correct in 12 of 13 operated cases. After conservative therapy we did not find any disrupted ankle ligament. MRI showed intact ligaments thickened by scar. MRI is able to show injuries of the lateral collateral ankle ligaments and demonstrates the healing by scar after conservative therapy.

Combined injuries of the medial collateral ligament and the anterior cruciate ligament. Early ACL reconstruction versus late ACL reconstruction.

PubMed

Petersen, W; Laprell, H

1999-01-01

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

TGF-beta1 induces the different expressions of lysyl oxidases and matrix metalloproteinases in anterior cruciate ligament and medial collateral ligament fibroblasts after mechanical injury.

PubMed

Xie, Jing; Wang, Chunli; Huang, Dong-Yue; Zhang, Yanyan; Xu, Jianwen; Kolesnikov, Stanislav S; Sung, K L Paul; Zhao, Hucheng

2013-03-15

The anterior cruciate ligament (ACL) is known to have a poor self-healing ability. In contrast, the medial collateral ligament (MCL) can heal relatively well and restore the joint function. Transforming growth factor-beta1 (TGF-β1) is considered to be an important chemical mediator in the wound healing of the ligaments. While the role of TGF-β1-induced expressions of the lysyl oxidases (LOXs) and matrix metalloproteinases (MMPs), which respectively facilitate the extracellular matrix (ECM) repair and degradation, is poorly understood. In this study, we used equibiaxial stretch chamber to mimic mechanical injury of ACL and MCL fibroblasts, and aimed to determine the intrinsic differences between ACL and MCL by characterizing the differential expressions of LOXs and MMPs in response to TGF-β1 after mechanical injury. By using semi-quantitative PCR, quantitative real-time PCR, western blot and zymography, we found TGF-β1 induced injured MCL to express more LOXs than injured ACL (up to 1.85-fold in LOX, 2.21-fold in LOXL-1, 1.71-fold in LOXL-2, 2.52-fold in LOXL-3 and 3.32-fold in LOXL-4). Meanwhile, TGF-β1 induced injured ACL to express more MMPs than injured MCL fibroblasts (up to 2.33-fold in MMP-1, 2.45-fold in MMP-2, 1.89-fold in MMP-3 and 1.50-fold in MMP-12). The further protein results were coincident with the gene expressions above. The different expressions of LOXs and MMPs inferred the intrinsic differences between ACL and MCL, and the intrinsic differences could help to explain their differential healing abilities. Copyright © 2012 Elsevier Ltd. All rights reserved.

Computing muscle, ligament, and osseous contributions to the elbow varus moment during baseball pitching

PubMed Central

Buffi, James H.; Werner, Katie; Kepple, Tom; Murray, Wendy M.

2014-01-01

Baseball pitching imposes a dangerous valgus load on the elbow that puts the joint at severe risk for injury. The goal of this study was to develop a musculoskeletal modeling approach to enable evaluation of muscle-tendon contributions to mitigating elbow injury risk in pitching. We implemented a forward dynamic simulation framework that used a scaled biomechanical model to reproduce a pitching motion recorded from a high school pitcher. The medial elbow muscles generated substantial, protective, varus elbow moments in our simulations. For our subject, the triceps generated large varus moments at the time of peak valgus loading; varus moments generated by the flexor digitorum superficialis were larger, but occurred later in the motion. Increasing muscle-tendon force output, either by augmenting parameters associated with strength and power or by increasing activation levels, decreased the load on the ulnar collateral ligament. Published methods have not previously quantified the biomechanics of elbow muscles during pitching. This simulation study represents a critical advancement in the study of baseball pitching and highlights the utility of simulation techniques in the study of this difficult problem. PMID:25281409

Elbow dislocation with intra-articular fracture: the results of operative treatment without repair of the medial collateral ligament.

PubMed

Forthman, Christopher; Henket, Marjolijn; Ring, David C

2007-10-01

To determine the effectiveness of a protocol for the treatment of fracture-dislocations of the elbow based on the concept that, if dislocation of the elbow with associated fractures can be made to resemble a simple elbow dislocation by repairing or reconstructing the fractured structures, repair of the medial collateral ligament (MCL) will not be necessary. Over a 5-year period, a single surgeon operated on 34 patients with a posterior dislocation of the elbow associated with one or more intra-articular fractures. The mean age of these 19 men and 15 women was 48 years. Associated fractures included the capitellum, trochlea, and lateral epicondyle in 3 patients; the olecranon in 1 patient; and the radial head in 30 patients (with concomitant fracture of the coronoid process-the so-called "terrible triad" of the elbow-in 22 patients, and concomitant fracture of the coronoid and olecranon in 1 patient). Operative treatment consisted of open reduction internal fixation (ORIF) or prosthetic replacement of all fractures and reattachment of the origin of the lateral collateral ligament (LCL) complex to the lateral epicondyle. The MCL was not repaired. Two patients (1 with a terrible triad injury and 1 with fracture of the capitellum and trochlea) had postoperative instability related to noncompliance, had reconstructive procedures, and were considered failures. An average of 32 months after injury, the remaining 32 patients regained an average of 120 degrees ulnohumeral motion and 142 degrees forearm rotation. Twenty-five of 34 patients (74%) had good or excellent results according to the system of Broberg and Morrey. Patients with terrible triad injuries had an average of 117 degrees ulnohumeral motion and 137 degrees forearm rotation, and 17 of 22 patients (77%) had good or excellent results. MCL repair is unnecessary in the treatment of dislocation of the elbow with associated intra-articular fractures, provided that the articular fractures and the LCL are repaired or

[Diagnostic significance of "bay sign" of medial meniscus under arthroscope in medial collateral ligament rupture of knee].

PubMed

Zhang, Wentao; Zhang, Xintao; Huang, Wei

2012-03-01

When knee medial collateral ligament (MCL) rupture, the upper surface of medial meniscus is exposed totally, like the gulf panoramic, which is called "panoramic views of the bay sign" or the "bay sign". To investigate the reliability and significance of the "bay sign" in diagnosis of knee MCL rupture under arthroscope. Between March 2007 and March 2011, 127 patients with knees injuries were divided into the observation group (n = 59) and control group (n = 68) based on the MRI results. In the observation group, 59 patients had MCL rupture by MRI, including 12 cases of MCL injury alone, 16 cases of MCL injury with lateral meniscus torn, 27 cases of MCL injury with anterior cruciate ligament (ACL) injury, 3 cases of MCL injury with ACL and posterior cruciate ligament (PCL) injury, and 1 case of MCL injury with patellar dislocation; there were 38 males and 21 females with an average age of 23.2 years (range, 16-39 years). In the control group, 68 patients had no MCL rupture by MRI, including 38 cases of ACL injury, 4 cases of ACL and PCL injury, and 26 cases of ACL and lateral meniscus injury; there were 45 males and 23 females with an average age of 31.8 years (range, 25-49 years). The "bay sign" was observed under arthroscope in 2 groups before and after operation. The positive "bay sign" was seen under arthroscope in the patients of the observation group before MCL repair; the "bay sign" disappeared after repair. No "bay sign" was seen in patients of the control group before and after ACL reconstruction. The "bay sign" is a reliable diagnostic evidence of MCL injury. It can be used as a basis to judge the success of MCL reconstruction during operation.

Histological studies on the triangular fibrocartilage complex of the wrist.

PubMed Central

Benjamin, M; Evans, E J; Pemberton, D J

1990-01-01

The triangular fibrocartilage complex of the wrist was serially sectioned for routine histology. Results from eight dissecting room cadavers show that the complex is attached to hyaline cartilage on the radius via its articular disc. In contrast, the dorsal and volar radio-ulnar ligaments attach to the radius via zones of calcified and uncalcified fibrocartilage. The articular disc is thus a wide labrum that provides an articular surface for the ulna and for the carpal bones, and the radio-ulnar ligaments strengthen the attachment of the disc to the radius. Medially, the complex divides into upper and lower laminae. Arching strands of collagen fibres emerge from the upper lamina and pass through a region of highly vascular connective tissue to be attached to the ulna between the articular cartilage on the head and that at the tip of the styloid process. Much of the ulnar attachment is via zones of calcified and uncalcified fibrocartilage which blend with the adjacent articular cartilages. Such an arrangement of tissues prevents undue wear and tear at the ulnar attachment zone during pronation and supination of the forearm. The lower lamina blends with the sheath of extensor carpi ulnaris and the ulnar collateral ligament and allows the whole complex to attach to the carpal and metacarpal bones. The meniscus homologue is a region of dense irregular connective tissue with no independent histological identity. Images Fig. 2 Fig. 3 Fig. 4 Fig. 5 Fig. 6 Fig. 7 Fig. 8 Fig. 9 Fig. 10 Fig. 11 Fig. 12 PMID:2272909

The effects of plasma rich in growth factors (PRGF-Endoret) on healing of medial collateral ligament of the knee.

PubMed

Yoshioka, Tomokazu; Kanamori, Akihiro; Washio, Toshikatsu; Aoto, Katsuya; Uemura, Kenta; Sakane, Masataka; Ochiai, Naoyuki

2013-08-01

Platelet-rich plasma (PRP) has been increasingly used in sports-related injuries for therapeutic applications. However, there are numerous manufacturing procedures and treatment protocols of PRP use, which make difficult to assess its real efficacy for tissue healing. This study addressed to evaluate the therapeutic effects of locally delivered plasma rich in growth factors (PRGF-Endoret) on the early healing of medial collateral ligament (MCL) in rabbit knees. Thirty-one Japanese white rabbits were subjected to a mop-end tear in the MCL of the left knee. PRGF-Endoret was prepared using Anitua's technique. Two groups were set up. In 17 knees, prepared 1.0 ml of PRGF-Endoret after clotting was applied on the tear site, while in 14 knees the tear site was untreated serving as a control. Quantitative aspects of PRGF-Endoret, the concentration of platelets, leukocytes and erythrocytes and therapeutic growth factors such as PDGF-BB and TGF-β1 were measured. Rabbits were sacrificed at 3 and 6 weeks after the operation and histological and biomechanical evaluation were performed. No leukocytes were measured and certain amount of growth factors such as PDGF-BB and TGF-β1 were confirmed in the PRGF-Endoret. PRGF-Endoret stimulated proliferation of fibroblasts and neovascularization, and induced statistically better structural properties in repaired MCL. Our findings provide evidence that local administration of PRGF-Endoret promotes early steps in ligament healing and the repair of structural properties in a rabbit model. PRGF-Endoret would be a useful product in clinical treatment of ligament injuries.

Arthroscopic pullout repair of posterior root tear of the medial meniscus: the anterior approach using medial collateral ligament pie-crusting release.

PubMed

Park, Young-Sik; Moon, Hong-Kyo; Koh, Yong-Gon; Kim, Yong-Chan; Sim, Dong-Sik; Jo, Seung-Bae; Kwon, Se-Kwang

2011-08-01

Posterior root tears of the medial meniscus are frequently encountered and should be repaired if possible to prevent osteoarthritis of the medial compartment. Various surgical techniques have been proposed to repair posterior root tears. The anterior arthroscopic approach can cause an iatrogenic chondral injury due to the narrow medial joint space. The posterior approaches might be technically unfamiliar to many surgeons because they require the establishment of a posteromedial or trans-septal portal. This paper describes the medial collateral ligament pie-crusting release technique for arthroscopic double transosseous pullout repair of posterior root tears of the medial meniscus through the anterior approach to provide the good visualization of the footprint and sufficient working space.

Electron microscopic quantification of collagen fibril diameters in the rabbit medial collateral ligament: a baseline for comparison.

PubMed

Frank, C; Bray, D; Rademaker, A; Chrusch, C; Sabiston, P; Bodie, D; Rangayyan, R

1989-01-01

To establish a normal baseline for comparison, thirty-one thousand collagen fibril diameters were measured in calibrated transmission electron (TEM) photomicrographs of normal rabbit medial collateral ligaments (MCL's). A new automated method of quantitation was used to compare statistically fibril minimum diameter distributions in one midsubstance location in both MCL's from six animals at 3 months of age (immature) and three animals at 10 months of age (mature). Pooled results demonstrate that rabbit MCL's have statistically different (p less than 0.001) mean minimum diameters at these two ages. Interanimal differences in mean fibril minimum diameters were also significant (p less than 0.001) and varied by 20% to 25% in both mature and immature animals. Finally, there were significant differences (p less than 0.001) in mean diameters and distributions from side-to-side in all animals. These mean left-to-right differences were less than 10% in all mature animals but as much as 62% in some immature animals. Statistical analysis of these data demonstrate that animal-to-animal comparisons using these protocols require a large number of animals with appropriate numbers of fibrils being measured to detect small intergroup differences. With experiments which compare left to right ligaments, far fewer animals are required to detect similarly small differences. These results demonstrate the necessity for rigorous control of sampling, an extensive normal baseline and statistically confirmed experimental designs in any TEM comparisons of collagen fibril diameters.

Hindlimb unloading alters ligament healing

NASA Technical Reports Server (NTRS)

Provenzano, Paolo P.; Martinez, Daniel A.; Grindeland, Richard E.; Dwyer, Kelley W.; Turner, Joanne; Vailas, Arthur C.; Vanderby, Ray Jr

2003-01-01

We investigated the hypothesis that hindlimb unloading inhibits healing in fibrous connective tissue such as ligament. Male rats were assigned to 3- and 7-wk treatment groups with three subgroups each: sham control, ambulatory healing, and hindlimb-suspended healing. Ambulatory and suspended animals underwent surgical rupture of their medial collateral ligaments, whereas sham surgeries were performed on control animals. After 3 or 7 wk, mechanical and/or morphological properties were measured in ligament, muscle, and bone. During mechanical testing, most suspended ligaments failed in the scar region, indicating the greatest impairment was to ligament and not to bone-ligament insertion. Ligament testing revealed significant reductions in maximum force, ultimate stress, elastic modulus, and low-load properties in suspended animals. In addition, femoral mineral density, femoral strength, gastrocnemius mass, and tibialis anterior mass were significantly reduced. Microscopy revealed abnormal scar formation and cell distribution in suspended ligaments with extracellular matrix discontinuities and voids between misaligned, but well-formed, collagen fiber bundles. Hence, stress levels from ambulation appear unnecessary for formation of fiber bundles yet required for collagen to form structurally competent continuous fibers. Results support our hypothesis that hindlimb unloading impairs healing of fibrous connective tissue. In addition, this study provides compelling morphological evidence explaining the altered structure-function relationship in load-deprived healing connective tissue.

Ulnar-Sided Wrist Pain due to Long Ulnar Styloid: A Case Report

PubMed Central

Ahsan, Zahab S.; Rivlin, Michael; Jupiter, Jesse B.

2016-01-01

Ulnar styloid impaction syndrome involves repetitive friction between an excessively long ulnar styloid and the carpus, resulting in chondromalacia, synovitis, and pain. The arthroscopic diagnosis, evaluation, and management of this syndrome are not well characterized. We present a patient with chronic wrist pain of unknown origin, culminating with arthroscopic findings demonstrating substantial loss of articular cartilage on both the lunate and triquetrum. The patient successfully underwent operative ulnar styloid excision, ultimately resolving chronic wrist pain symptomology. PMID:27777823

[Instability of the distal radioulnar joint: Treatment options for ulnar lesions of the triangular fibrocartilage complex].

PubMed

Spies, C K; Prommersberger, K J; Langer, M; Müller, L P; Hahn, P; Unglaub, F

2015-08-01

Injuries of the triangular fibrocartilage complex (TFCC) may be fatal to the distal radioulnar joint (DRUJ). This structure is one of the crucial stabilizers and guarantees unrestricted pronosupination of the forearm. A systematic examination is mandatory to diagnose DRUJ instability reliably. A clinical examination in comparison to the contralateral side is obligatory. Plain radiographs are required to exclude osseous lesions or deformities. Computed tomography of both wrists in neutral, pronation and supination is necessary to verify DRUJ instability in ambiguous situations. Based on a systematic examination wrist and DRUJ arthroscopy identify lesions clearly. Injuries of the radioulnar ligaments which entail DRUJ instability, should be reconstructed preferably anatomically. Ulnar-sided TFCC lesions may often cause DRUJ instability. Osseous ligament avulsions are mostly treated osteosynthetically. Ligament tears may be refixated using anchor or transosseous sutures. Tendon transplants are necessary for an anatomical reconstruction in cases of irreparable ruptures.

Ulnar nerve damage (image)

MedlinePlus

The ulnar nerve originates from the brachial plexus and travels down arm. The nerve is commonly injured at the elbow because of elbow fracture or dislocation. The ulnar nerve is near the surface of the body where ...

Computational knee ligament modeling using experimentally determined zero-load lengths.

PubMed

Bloemker, Katherine H; Guess, Trent M; Maletsky, Lorin; Dodd, Kevin

2012-01-01

This study presents a subject-specific method of determining the zero-load lengths of the cruciate and collateral ligaments in computational knee modeling. Three cadaver knees were tested in a dynamic knee simulator. The cadaver knees also underwent manual envelope of motion testing to find their passive range of motion in order to determine the zero-load lengths for each ligament bundle. Computational multibody knee models were created for each knee and model kinematics were compared to experimental kinematics for a simulated walk cycle. One-dimensional non-linear spring damper elements were used to represent cruciate and collateral ligament bundles in the knee models. This study found that knee kinematics were highly sensitive to altering of the zero-load length. The results also suggest optimal methods for defining each of the ligament bundle zero-load lengths, regardless of the subject. These results verify the importance of the zero-load length when modeling the knee joint and verify that manual envelope of motion measurements can be used to determine the passive range of motion of the knee joint. It is also believed that the method described here for determining zero-load length can be used for in vitro or in vivo subject-specific computational models.

Computational Knee Ligament Modeling Using Experimentally Determined Zero-Load Lengths

PubMed Central

Bloemker, Katherine H; Guess, Trent M; Maletsky, Lorin; Dodd, Kevin

2012-01-01

This study presents a subject-specific method of determining the zero-load lengths of the cruciate and collateral ligaments in computational knee modeling. Three cadaver knees were tested in a dynamic knee simulator. The cadaver knees also underwent manual envelope of motion testing to find their passive range of motion in order to determine the zero-load lengths for each ligament bundle. Computational multibody knee models were created for each knee and model kinematics were compared to experimental kinematics for a simulated walk cycle. One-dimensional non-linear spring damper elements were used to represent cruciate and collateral ligament bundles in the knee models. This study found that knee kinematics were highly sensitive to altering of the zero-load length. The results also suggest optimal methods for defining each of the ligament bundle zero-load lengths, regardless of the subject. These results verify the importance of the zero-load length when modeling the knee joint and verify that manual envelope of motion measurements can be used to determine the passive range of motion of the knee joint. It is also believed that the method described here for determining zero-load length can be used for in vitro or in vivo subject-specific computational models. PMID:22523522

Medial elbow pain

PubMed Central

Barco, Raul; Antuña, Samuel A.

2017-01-01

Medial elbow pain is uncommon when compared with lateral elbow pain. Medial epicondylitis is an uncommon diagnosis and can be confused with other sources of pain. Overhead throwers and workers lifting heavy objects are at increased risk of medial elbow pain. Differential diagnosis includes ulnar nerve disorders, cervical radiculopathy, injured ulnar collateral ligament, altered distal triceps anatomy or joint disorders. Children with medial elbow pain have to be assessed for ‘Little League elbow’ and fractures of the medial epicondyle following a traumatic event. This paper is primarily focused on the differential diagnosis of medial elbow pain with basic recommendations on treatment strategies. Cite this article: EFORT Open Rev 2017;2:362-371. DOI: 10.1302/2058-5241.2.160006 PMID:28932488

Portal placement in elbow arthroscopy by novice surgeons: cadaver study.

PubMed

Claessen, Femke M A P; Kachooei, Amir R; Kolovich, Gregory P; Buijze, Geert A; Oh, Luke S; van den Bekerom, Michel P J; Doornberg, Job N

2017-07-01

In this anatomical cadaver study, the distance between major nerves and ligaments at risk for injury and portal sites created by trainees was measured. Trainees, inexperienced in elbow arthroscopy, have received a didactic lecture and cadaver instruction prior to portal placement. The incidence of iatrogenic injury from novice portal placement was also determined. Anterolateral, direct lateral, and anteromedial arthroscopic portals were created in ten cadavers by ten inexperienced trainees in elbow arthroscopy. After creating each portal, the trajectory of the portal was marked with a guide pin. Subsequently, the cadavers were dissected and the distances between the guide pin in the anterolateral, direct lateral, and anteromedial portals and important ligaments and nerves were measured. The difference between the distance of the direct lateral portal and the posterior antebrachial cutaneous nerve (PABCN) (22 mm, p < 0.001), the lateral antebrachial cutaneous nerve (4.0 mm, p < 0.001), and the radial nerve (25 mm, p < 0.001) was different from the average reported distances in the literature. A difference was found between the distance of the anterolateral portal and the PABCN (32 mm, p < 0.001) compared to previous studies. Three major iatrogenic complications were observed, including: laceration of the posterior bundle of the medial ulnar collateral ligament, lateral ulnar collateral ligament midsubstance laceration, and median nerve partial laceration. Surgeons increasingly consider arthroscopic treatment as an option for elbow pathology. In the present study a surgical complication rate of 30 % was found with novice portal placement during elbow arthroscopy. Furthermore, as the results from this study have indicated, accurate, precise, and safe portal placement in elbow arthroscopy is not easily achieved by didactic lecture and cadaver instruction session alone. Level of evidence V.

Photoplethysmography using a smartphone application for assessment of ulnar artery patency: a randomized clinical trial

PubMed Central

Di Santo, Pietro; Harnett, David T.; Simard, Trevor; Ramirez, F. Daniel; Pourdjabbar, Ali; Yousef, Altayyeb; Moreland, Robert; Bernick, Jordan; Wells, George; Dick, Alexander; Le May, Michel; Labinaz, Marino; So, Derek; Motazedian, Pouya; Jung, Richard G.; Chandrasekhar, Jaya; Mehran, Roxana; Chong, Aun-Yeong

2018-01-01

BACKGROUND: Radial artery access is commonly performed for coronary angiography and invasive hemodynamic monitoring. Despite limitations in diagnostic accuracy, the modified Allen test (manual occlusion of radial and ulnar arteries followed by release of the latter and assessment of palmar blush) is used routinely to evaluate the collateral circulation to the hand and, therefore, to determine patient eligibility for radial artery access. We sought to evaluate whether a smartphone application may provide a superior alternative to the modified Allen test. METHODS: We compared the modified Allen test with a smartphone heart rate–monitoring application (photoplethysmography readings detected using a smartphone camera lens placed on the patient’s index finger) in patients undergoing a planned cardiac catheterization. Test order was randomly assigned in a 1:1 fashion. All patients then underwent conventional plethysmography of the index finger, followed by Doppler ultrasonography of the radial and ulnar arteries (the diagnostic standard). The primary outcome was diagnostic accuracy of the heart rate–monitoring application. RESULTS: Among 438 patients who were included in the study, we found that the heart rate–monitoring application had a superior diagnostic accuracy compared with the modified Allen test (91.8% v. 81.7%, p = 0.002), attributable to its greater specificity (93.0% v. 82.8%, p = 0.001). We also found that this application had greater diagnostic accuracy for assessment of radial or ulnar artery patency in the ipsilateral and contralateral wrist (94.0% v. 84.0%, p < 0.001). INTERPRETATION: A smartphone application used at the bedside was diagnostically superior to traditional physical examination for confirming ulnar patency before radial artery access. This study highlights the potential for smartphone-based diagnostics to aid in clinical decision-making at the patient’s bedside. Trial registration: Clinicaltrials.gov, no. NCT02519491. PMID

Photoplethysmography using a smartphone application for assessment of ulnar artery patency: a randomized clinical trial.

PubMed

Di Santo, Pietro; Harnett, David T; Simard, Trevor; Ramirez, F Daniel; Pourdjabbar, Ali; Yousef, Altayyeb; Moreland, Robert; Bernick, Jordan; Wells, George; Dick, Alexander; Le May, Michel; Labinaz, Marino; So, Derek; Motazedian, Pouya; Jung, Richard G; Chandrasekhar, Jaya; Mehran, Roxana; Chong, Aun-Yeong; Hibbert, Benjamin

2018-04-03

Radial artery access is commonly performed for coronary angiography and invasive hemodynamic monitoring. Despite limitations in diagnostic accuracy, the modified Allen test (manual occlusion of radial and ulnar arteries followed by release of the latter and assessment of palmar blush) is used routinely to evaluate the collateral circulation to the hand and, therefore, to determine patient eligibility for radial artery access. We sought to evaluate whether a smartphone application may provide a superior alternative to the modified Allen test. We compared the modified Allen test with a smartphone heart rate-monitoring application (photoplethysmography readings detected using a smartphone camera lens placed on the patient's index finger) in patients undergoing a planned cardiac catheterization. Test order was randomly assigned in a 1:1 fashion. All patients then underwent conventional plethysmography of the index finger, followed by Doppler ultrasonography of the radial and ulnar arteries (the diagnostic standard). The primary outcome was diagnostic accuracy of the heart rate-monitoring application. Among 438 patients who were included in the study, we found that the heart rate-monitoring application had a superior diagnostic accuracy compared with the modified Allen test (91.8% v. 81.7%, p = 0.002), attributable to its greater specificity (93.0% v. 82.8%, p = 0.001). We also found that this application had greater diagnostic accuracy for assessment of radial or ulnar artery patency in the ipsilateral and contralateral wrist (94.0% v. 84.0%, p < 0.001). A smartphone application used at the bedside was diagnostically superior to traditional physical examination for confirming ulnar patency before radial artery access. This study highlights the potential for smartphone-based diagnostics to aid in clinical decision-making at the patient's bedside. Trial registration: Clinicaltrials.gov, no. NCT02519491. © 2018 Joule Inc. or its licensors.

Do Tibial Plateau Fractures Worsen Outcomes of Knee Ligament Injuries? A Matched Cohort Analysis

PubMed Central

Cinque, Mark E.; Godin, Jonathan A.; Moatshe, Gilbert; Chahla, Jorge; Kruckeberg, Bradley M.; Pogorzelski, Jonas; LaPrade, Robert F.

2017-01-01

Background: Tibial plateau fractures account for a small portion of all fractures; however, these fractures can pose a surgical challenge when occurring concomitantly with ligament injuries. Purpose/Hypothesis: The purpose of this study was to compare 2-year outcomes of soft tissue reconstruction with or without a concomitant tibial plateau fracture and open reduction internal fixation. We hypothesized that patients with a concomitant tibial plateau fracture at the time of soft tissue surgery would have inferior outcomes compared with patients without an associated tibial plateau fracture. Study Design: Cohort study; Level of evidence, 3. Methods: Forty patients were included in this study: 8 in the fracture group and 32 in the matched control group. Inclusion criteria for the fracture group included patients who were at least 18 years old at the time of surgery and sustained a tibial plateau fracture and a concomitant injury of the anterior cruciate ligament, posterior cruciate ligament, medial collateral ligament, or fibular collateral ligament in isolation or any combination of cruciate or collateral ligaments and who subsequently underwent isolated or combined ligament reconstruction. Patients were excluded if they underwent prior ipsilateral knee surgery, sustained additional bony injuries, or sustained an isolated extra-articular ligament injury at the time of injury. Each patient with a fracture was matched with 4 patients from a control group who had no evidence of a tibial plateau fracture but underwent the same soft tissue reconstruction procedure. Results: Patients in the fracture group improved significantly from preoperatively to postoperatively with respect to Short Form–12 (P < .05) and Western Ontario and McMaster Universities Osteoarthritis Index total scores (P < .05). The Lysholm (P = .075) and Tegner scores (P = .086) also improved, although this was not statistically significant. Patients in the control group improved significantly from

Accessory superficial ulnar artery: a case report.

PubMed

Solan, Shweta

2013-12-01

Variations in the arterial system of the upper limb have been well documented. A thorough knowledge on variations of arteries of upper extremity is necessary during performance of vascular and reconstructive surgeries and also, during evaluation of angiographic images. A case of accessory superficial ulnar artery was reported. The ulnar artery had a high origin from the brachial artery, in the upper third of the arm and it proceeded superficially and lateral to ulnar nerve in forearm, but it had a normal termination in the hand. The brachial artery had a usual course in the arm, but in the cubital fossa, it divided into the radial and deep ulnar arteries. This deep ulnar artery ended by dividing into ulnar recurrent and common interosseous arteries. Knowledge on this variation is important for the radiologists, orthopaedic and plastic surgeons, for appropriate planning of operative procedures involving the arteries of the upper limb.

Ultrasound-guided percutaneous lavage of calcific bursitis of the medial collateral ligament of the knee: a case report and review of the literature.

PubMed

Del Castillo-González, Federico; Ramos-Álvarez, Juan José; González-Pérez, José; Jiménez-Herranz, Elena; Rodríguez-Fabián, Guillermo

2016-10-01

Calcification of the medial collateral ligament (MCL) of the knee is rare. The literature reports no positive outcomes when conservative treatment has been followed. This paper reports a case of such calcification and its treatment using ultrasound-guided percutaneous lavage (UGPL). A 66-year-old patient presented with medial knee pain. X-ray, ultrasound, and magnetic resonance (MR) examinations revealed calcific bursitis of the MCL, which was treated by UGPL. One month after treatment the patient was asymptomatic. X-ray, ultrasound, and MR examinations confirmed the almost complete disappearance of the calcification; only very tiny fragments remained. Calcific bursitis of the MCL of the knee is very uncommon, but should be taken into account in differential diagnoses for medial knee pain. UGPL is proposed as a treatment for this condition.

Use of three-dimensional finite element models of the lateral ankle ligaments to evaluate three surgical techniques

PubMed Central

Wang, Cheng-Wei; Muheremu, Aikeremujiang; Bai, Jing-Ping

2017-01-01

Objective To compare three surgical techniques for lateral ankle ligament reconstruction using finite element (FE) models. Methods A three-dimensional FE model of the left foot of a healthy volunteer and lateral collateral ligament injury models were developed. Three tendons [one-half of the autologous peroneus longus tendon (PLT), one-half of the peroneus brevis tendon (PBT), and an allogeneic tendon] were used for lateral collateral ligament reconstruction. The ankle varus stress and anterior drawer tests were performed to compare the three surgical techniques. Results The ankle varus stress test showed that the equivalent stresses of the anterior talofibular ligament (ATFL) (84.00 MPa) and calcaneofibular ligament (CFL) (27.01 MPa) were lower in allogeneic tendon reconstruction than in the other two techniques but similar to those of normal individuals (138.48 and 25.90 MPa, respectively). The anterior drawer test showed that the equivalent stresses of the ATFL and CFL in autologous PLT reconstruction (31.31 and 28.60 MPa, respectively) and PBT reconstruction (31.47 and 29.07 MPa, respectively) were lower than those in allogeneic tendon reconstruction (57.32 and 52.20 MPa, respectively). Conclusions The allogeneic tendon reconstruction outcome was similar to normal individuals. Allogeneic tendon reconstruction may be superior for lateral ankle ligament reconstruction without considering its complications. PMID:29239256

Simultaneous Reconstruction of the Anterior Cruciate Ligament and Medial Collateral Ligament in Patients With Chronic ACL-MCL Lesions: A Minimum 2-Year Follow-up Study.

PubMed

Zhang, Hangzhou; Sun, Yu; Han, Xiaorui; Wang, Yanfeng; Wang, Lin; Alquhali, Ali; Bai, Xizhuang

2014-07-01

In cases of chronic anterior cruciate ligament (ACL)-medial collateral ligament (MCL) lesions, nonoperative treatment of the MCL lesion may lead to chronic valgus instability and rotatory instability. The optimal management for patients who have combined ACL-MCL injuries remains controversial. To present a case series of 21 patients who underwent simultaneous ACL-MCL reconstruction with a 2- to 5-year follow-up. Case series; Level of evidence, 4. From October 2007 to December 2010, a total of 21 patients with chronic ACL-MCL injuries, for which the 2 ligaments were reconstructed during the same surgical procedure, were studied. All patients were available for follow-up for at least 2 years. The International Knee Documentation Committee (IKDC) subjective knee scores, valgus and sagittal stability, anteromedial rotatory stability, range of motion, and complications were assessed both preoperatively and postoperatively. At follow-up, valgus and sagittal laxity were not observed in any of the patients. The mean medial knee opening was significantly reduced to 0.80 ± 0.96 mm (range, -1.2 to 2.6 mm) postoperatively compared with 8.0 ± 1.3 mm (range, 6.1 to 10.7 mm) preoperatively (P < .01). The mean postoperative side-to-side difference measured with the KT-1000 arthrometer was reduced to 0.8 ± 0.9 mm (range, -1.2 to 2.3 mm) compared with 8.4 ± 1.6 mm (range, 6.2 to 13.2 mm) preoperatively (P < .01). Preoperative anteromedial instability was seen in 71% of patients (15/21), whereas none of the patients had anteromedial rotatory instability at the last follow-up. The mean IKDC subjective score improved overall from 45.3 ± 12.0 (range, 28.7-69.0) preoperatively to 87.7 ± 8.2 (range, 65.5-100.0) at the last follow-up (P < .01). Most patients (20/21) had normal or nearly normal range of motion of the knee joint; only 1 patient (5%) had a limitation of flexion of 15° compared with the contralateral knee at the last follow-up. In patients with chronic ACL-MCL lesions

Accessory Superficial Ulnar Artery: A Case Report

PubMed Central

Solan, Shweta

2013-01-01

Variations in the arterial system of the upper limb have been well documented. A thorough knowledge on variations of arteries of upper extremity is necessary during performance of vascular and reconstructive surgeries and also, during evaluation of angiographic images. A case of accessory superficial ulnar artery was reported. The ulnar artery had a high origin from the brachial artery, in the upper third of the arm and it proceeded superficially and lateral to ulnar nerve in forearm, but it had a normal termination in the hand. The brachial artery had a usual course in the arm, but in the cubital fossa, it divided into the radial and deep ulnar arteries. This deep ulnar artery ended by dividing into ulnar recurrent and common interosseous arteries. Knowledge on this variation is important for the radiologists, orthopaedic and plastic surgeons, for appropriate planning of operative procedures involving the arteries of the upper limb. PMID:24551682

[Application of silk-based tissue engineering scaffold for tendon / ligament regeneration].

PubMed

Hu, Yejun; Le, Huihui; Jin, Zhangchu; Chen, Xiao; Yin, Zi; Shen, Weiliang; Ouyang, Hongwei

2016-03-01

Tendon/ligament injury is one of the most common impairments in sports medicine. The traditional treatments of damaged tissue repair are unsatisfactory, especially for athletes, due to lack of donor and immune rejection. The strategy of tissue engineering may break through these limitations, and bring new hopes to tendon/ligament repair, even regeneration. Silk is a kind of natural biomaterials, which has good biocompatibility, wide range of mechanical properties and tunable physical structures; so it could be applied as tendon/ligament tissue engineering scaffolds. The silk-based scaffold has robust mechanical properties; combined with other biological ingredients, it could increase the surface area, promote more cell adhesion and improve the biocompatibility. The potential clinical application of silk-based scaffold has been confirmed by in vivo studies on tendon/ligament repairing, such as anterior cruciate ligament, medial collateral ligament, achilles tendon and rotator cuff. To develop novel biomechanically stable and host integrated tissue engineered tendon/ligament needs more further micro and macro studies, combined with product development and clinical application, which will give new hope to patients with tendon/ligament injury.

Baseball and softball injuries.

PubMed

Wang, Quincy

2006-05-01

Baseball and softball injuries can be a result of both acute and overuse injuries. Soft tissue injuries include contusions, abrasions, and lacerations. Return to play is allowed when risk of further injury is minimized. Common shoulder injuries include those to the rotator cuff, biceps tendon, and glenoid labrum. Elbow injuries are common in baseball and softball and include medial epicondylitis, ulnar collateral ligament injury, and osteochondritis dissecans. Typically conservative treatment with relative rest, medication, and a rehabilitation program will allow return to play. Surgical intervention may be needed for certain injuries or conservative treatment failure.

The thrower's elbow.

PubMed

Patel, Ronak M; Lynch, T Sean; Amin, Nirav H; Calabrese, Gary; Gryzlo, Stephen M; Schickendantz, Mark S

2014-07-01

Overhead throwing activities expose the elbow to tremendous valgus stress, making athletes vulnerable to a specific constellation of injuries. Although baseball players, in particular pitchers, are the athletes affected most commonly, overhead throwing athletes in football, volleyball, tennis, and javelin tossing also are affected. The purpose of this review is to review the anatomy, biomechanics, pathophysiology, and treatment of elbow disorders related to overhead throwing athletes. Although focus is on management of ulnar collateral ligament injuries, all common pathologies are discussed. Copyright © 2014 Elsevier Inc. All rights reserved.

Ulnar nerve sonography in leprosy neuropathy.

PubMed

Wang, Zhu; Liu, Da-Yue; Lei, Yang-Yang; Yang, Zheng; Wang, Wei

2016-01-01

A 23-year-old woman presented with a half-year history of right forearm sensory and motor dysfunction. Ultrasound imaging revealed definite thickening of the right ulnar nerve trunk and inner epineurium, along with heterogeneous hypoechogenicity and unclear nerve fiber bundle. Color Doppler exhibited a rich blood supply, which was clearly different from the normal ulnar nerve presentation with a scarce blood supply. The patient subsequently underwent needle aspiration of the right ulnar nerve, and histopathological examination confirmed that granulomatous nodules had formed with a large number of infiltrating lymphocytes and a plurality of epithelioid cells in the fibrous connective tissues, with visible atypical foam cells and proliferous vascularization, consistent with leprosy. Our report will familiarize readers with the characteristic sonographic features of the ulnar nerve in leprosy, particularly because of the decreasing incidence of leprosy in recent years.

Functional tissue engineering of ligament healing

PubMed Central

2010-01-01

Ligaments and tendons are dense connective tissues that are important in transmitting forces and facilitate joint articulation in the musculoskeletal system. Their injury frequency is high especially for those that are functional important, like the anterior cruciate ligament (ACL) and medial collateral ligament (MCL) of the knee as well as the glenohumeral ligaments and the rotator cuff tendons of the shoulder. Because the healing responses are different in these ligaments and tendons after injury, the consequences and treatments are tissue- and site-specific. In this review, we will elaborate on the injuries of the knee ligaments as well as using functional tissue engineering (FTE) approaches to improve their healing. Specifically, the ACL of knee has limited capability to heal, and results of non-surgical management of its midsubstance rupture have been poor. Consequently, surgical reconstruction of the ACL is regularly performed to gain knee stability. However, the long-term results are not satisfactory besides the numerous complications accompanied with the surgeries. With the rapid development of FTE, there is a renewed interest in revisiting ACL healing. Approaches such as using growth factors, stem cells and scaffolds have been widely investigated. In this article, the biology of normal and healing ligaments is first reviewed, followed by a discussion on the issues related to the treatment of ACL injuries. Afterwards, current promising FTE methods are presented for the treatment of ligament injuries, including the use of growth factors, gene delivery, and cell therapy with a particular emphasis on the use of ECM bioscaffolds. The challenging areas are listed in the future direction that suggests where collection of energy could be placed in order to restore the injured ligaments and tendons structurally and functionally. PMID:20492676

Ulnar neuropathy and ulnar neuropathy-like symptoms in relation to biomechanical exposures assessed by a job exposure matrix: a triple case-referent study.

PubMed

Svendsen, Susanne Wulff; Johnsen, Birger; Fuglsang-Frederiksen, Anders; Frost, Poul

2012-11-01

We aimed to evaluate relations between occupational biomechanical exposures and (1) ulnar neuropathy confirmed by electroneurography (ENG) and (2) ulnar neuropathy-like symptoms with normal ENG. In this triple case-referent study, we identified all patients aged 18-65 years, examined with ENG at a neurophysiological department on suspicion of ulnar neuropathy, 2001-2007. We mailed a questionnaire to 546 patients with ulnar neuropathy, 633 patients with ulnar neuropathy-like symptoms and two separate groups of community referents, matched on sex, age and primary care centre (risk set sampling). The two patient groups were also compared to each other directly. We constructed a Job Exposure Matrix to provide estimates of exposure to non-neutral postures, repetitive movements, hand-arm vibrations and forceful work. Conditional and unconditional logistic regressions were used. The proportion who responded was 59%. Ulnar neuropathy was related to forceful work with an exposure-response pattern reaching an OR of 3.85 (95% CI 2.04 to 7.24); non-neutral postures strengthened effects of forceful work. No relation was observed with repetitive movements. Ulnar neuropathy-like symptoms were related to repetitive movements with an OR of 1.89 (95% CI 1.01 to 3.52) in the highest-exposure category (≥2.5 h/day); forceful work was unrelated to the outcome. Ulnar neuropathy and ulnar neuropathy-like symptoms differed with respect to associations with occupational biomechanical exposures. Findings suggested specific effects of forceful work on the ulnar nerve. Thus, results corroborated the importance of an electrophysiological diagnosis when evaluating risk factors for ulnar neuropathy. Preventive effects may be achieved by reducing biomechanical exposures at work.

Repair of acute injuries of the lateral ligament complex of the ankle by suture anchors

PubMed Central

Liu, Xiang-Fei; Fang, Yang; Cao, Zhong-Hua; Li, Guang-Feng; Yang, Guo-Qing

2015-01-01

Objective: The objective of this study was to investigate the clinical curative effect of stage I repair of acute injuries of the lateral ligament complex of the ankle by the application of suture anchors. Methods: We retrospectively analyzed 18 cases of III degree acute injuries of the lateral ligament complex of the ankle. Results: There were statistically significant differences in preoperative and last follow-up VAS pain scores and AOFAS ankle hind-foot function scores. The X-ray talus displacement values in the anterior drawer test and pressure anteroposterior X-ray talar tilt in the ankle talar tilt test also showed statistically significant differences. Complications occurred in 2 patients, incision surface infection in one, and postoperative lateral dorsal skin numbness in one. All these cases were cured after symptomatic treatment. At the last follow-up all patients’ ankle joint activity recovered to their preinjury function levels. Conclusion: The application of suture anchors for small incision stage I repair of the lateral collateral ligament of ankle joint degree III injury, can effectively restored the stability of ankle joint, and prevent the occurrence of chronic ankle instability complications. It is effective and feasible for the treatment of ankle joint lateral collateral ligament injuries. PMID:26885144

Surgical Techniques for the Reconstruction of Medial Collateral Ligament and Posteromedial Corner Injuries of the Knee: A Systematic Review.

PubMed

DeLong, Jeffrey M; Waterman, Brian R

2015-11-01

To systematically review reconstruction techniques of the medial collateral ligament (MCL) and associated medial structures of the knee (e.g., posterior oblique ligament). A systematic review of Medline/PubMed Database (1966 to November 2013), reference list scanning and citation searches of included articles, and manual searches of high-impact journals (2000 to July 2013) and conference proceedings (2009 to July 2013) were performed to identify publications describing MCL reconstruction techniques of the knee. Exclusion criteria included (1) MCL primary repair techniques or advancement procedures, (2) lack of clear description of MCL reconstruction technique, (3) animal models, (4) nonrelevant study design, (5) and foreign language articles without available translation. After review of 4,600 references, 25 publications with 359 of 388 patients (92.5%) were isolated for analysis, including 18 single-bundle MCL and 10 double-bundle reconstruction techniques. Only 2 techniques were classified as anatomic reconstructions, and clinical and objective outcomes (n = 28; 100% <3 mm side-to-side difference [SSD]) were superior to those with nonanatomic reconstruction (n = 182; 79.1% <3 mm SSD) and tendon transfer techniques (n = 114; 52.6% <3 mm SSD). This systematic review demonstrated that numerous medial reconstruction techniques have been used in the treatment of isolated and combined medial knee injuries in the existent literature. Many variations exist among reconstruction techniques and may differ by graft choices, method of fixation, number of bundles, tensioning protocol, and degree of anatomic restoration of medial and posteromedial corner knee restraints. Further studies are required to better ascertain the comparative clinical outcomes with anatomic, non-anatomic, and tendon transfer techniques for medial knee reconstruction. Level IV, systematic review of level IV studies and surgical techniques. Published by Elsevier Inc.

The influence of ligament modelling strategies on the predictive capability of finite element models of the human knee joint.

PubMed

Naghibi Beidokhti, Hamid; Janssen, Dennis; van de Groes, Sebastiaan; Hazrati, Javad; Van den Boogaard, Ton; Verdonschot, Nico

2017-12-08

In finite element (FE) models knee ligaments can represented either by a group of one-dimensional springs, or by three-dimensional continuum elements based on segmentations. Continuum models closer approximate the anatomy, and facilitate ligament wrapping, while spring models are computationally less expensive. The mechanical properties of ligaments can be based on literature, or adjusted specifically for the subject. In the current study we investigated the effect of ligament modelling strategy on the predictive capability of FE models of the human knee joint. The effect of literature-based versus specimen-specific optimized material parameters was evaluated. Experiments were performed on three human cadaver knees, which were modelled in FE models with ligaments represented either using springs, or using continuum representations. In spring representation collateral ligaments were each modelled with three and cruciate ligaments with two single-element bundles. Stiffness parameters and pre-strains were optimized based on laxity tests for both approaches. Validation experiments were conducted to evaluate the outcomes of the FE models. Models (both spring and continuum) with subject-specific properties improved the predicted kinematics and contact outcome parameters. Models incorporating literature-based parameters, and particularly the spring models (with the representations implemented in this study), led to relatively high errors in kinematics and contact pressures. Using a continuum modelling approach resulted in more accurate contact outcome variables than the spring representation with two (cruciate ligaments) and three (collateral ligaments) single-element-bundle representations. However, when the prediction of joint kinematics is of main interest, spring ligament models provide a faster option with acceptable outcome. Copyright © 2017 Elsevier Ltd. All rights reserved.

MR imaging of knees having isolated and combined ligament injuries.

PubMed

Rubin, D A; Kettering, J M; Towers, J D; Britton, C A

1998-05-01

Although clinical evaluation and MR imaging both accurately reveal injuries in knees with isolated ligament tears, physical examination becomes progressively less reliable when multiple lesions exist. We investigated the accuracy of MR imaging of knees having varying degrees and numbers of ligament injuries. We prospectively interpreted the MR images of 340 consecutive injured knees and compared these interpretations with the results of subsequent arthroscopy or open surgery, which served as the gold standard. Our interpretations of MR images focused on five soft-tissue supporting structures (the two cruciate ligaments, the two collateral ligaments, and the patellar tendon) and the two menisci. Patients were divided into three groups: no ligament injuries, single ligament injuries, and multiple ligament injuries. Using MR imaging, we found overall sensitivity and specificity for diagnosing ligament tears to be 94% and 99%, respectively, when no or one ligament was torn and 88% and 84%, respectively, when two or more supporting structures were torn. The difference in specificity was statistically significant (p < .0001). Sensitivity for diagnosing meniscal tears decreased as the number of injured structures increased, but the relationship achieved statistical significance (p = .001) only for the medial meniscus. For all categories of injury, MR imaging was more accurate than clinical evaluation, statistics for which were taken from the orthopedic literature. In knees with multiple ligament injuries, the diagnostic specificity of MR imaging for ligament tears decreases, as does the sensitivity for medial meniscal tears.

Ulnar nerve injury associated with trampoline injuries.

PubMed

Maclin, Melvin M; Novak, Christine B; Mackinnon, Susan E

2004-08-01

This study reports three cases of ulnar neuropathy after trampoline injuries in children. A chart review was performed on children who sustained an ulnar nerve injury from a trampoline accident. In all cases, surgical intervention was required. Injuries included upper-extremity fractures in two cases and an upper-extremity laceration in one case. All cases required surgical exploration with internal neurolysis and ulnar nerve transposition. Nerve grafts were used in two cases and an additional nerve transfer was used in one case. All patients had return of intrinsic hand function and sensation after surgery. Children should be followed for evolution of ulnar nerve neuropathy after upper-extremity injury with consideration for electrical studies and surgical exploration if there is no improvement after 3 months.

Superficial ulnar artery perforator flap.

PubMed

Schonauer, Fabrizio; Marlino, Sergio; Turrà, Francesco; Graziano, Pasquale; Dell'Aversana Orabona, Giovanni

2014-09-01

Superficial ulnar artery is a rare finding but shows significant surgical implications. Its thinness and pliability make this flap an excellent solution for soft tissue reconstruction, especially in the head and neck region. We hereby report a successful free superficial ulnar artery perforator forearm flap transfer for tongue reconstruction. A 64-year-old man presenting with a squamous cell carcinoma of the left tongue underwent a wide resection of the tumor, left radical neck dissection, and reconstruction of the tongue and the left tonsillar pillar with the mentioned flap. No complications were observed postoperatively. The flap survived completely; no recurrence at 6 months of follow-up was detected. Superficial ulnar artery perforator flap has shown to be a safe alternative to other free tissue flaps in specific forearm anatomic conditions.

Kinematics of Different Components of the Posterolateral Corner of the Knee in the Lateral Collateral Ligament-intact State: A Human Cadaveric Study.

PubMed

Domnick, Christoph; Frosch, Karl-Heinz; Raschke, Michael J; Vogel, Nils; Schulze, Martin; von Glahn, Mathias; Drenck, Tobias C; Herbort, Mirco

2017-10-01

To determine the static stabilizing effects of different anatomical structures of the posterolateral corner (PLC) of the knee in the lateral collateral ligament (LCL)-intact state. Thirteen fresh-frozen human cadaveric knees were dissected and tested using an industrial robot with an optical tracking system. Kinematics were determined for 134 N anterior/posterior loads, 10 N m valgus/varus loads, and 5 N m internal/external rotatory loads in 0°, 20°, 30°, 60°, and 90° of knee flexion. The PLC structures were dissected and consecutively released: (I) intact knee joint, (II) with released posterior cruciate ligament (PCL), (III) popliteomeniscal fibers, (IV) popliteofibular ligament, (V) arcuat and popliteotibial fibers, (VI) popliteus tendon (PLT), and (VII) LCL. Repeated-measures analysis of variance was performed with significance set at P < .05. After releasing the PCL, posterior tibial translation increased by 5.2 mm at 20° to 9.4 mm at 90° of joint flexion (P < .0001). A mild 1.8° varus instability was measured in 0° of flexion (P = .0017). After releasing the PLC structures, posterior tibial translation further increased by 2.9 mm at 20° to 5.9 mm at 90° of flexion (P < .05) and external rotation angle increased by 2.6° at 0° to 7.9° at 90° of flexion (P < .05, vs II). Varus stability did not decrease. Mild differences between states V and VI were found in 60° and 90° external rotation tests (2.1° and 3.1°; P < .05). The connecting ligaments/fibers to the PLT act as a primary static stabilizer against external rotatory loads and a secondary stabilizer against posterior tibial loads (when PCL is injured). After releasing these structures, most static stabilizing function of the intact PLT is lost. The PLC has no varus-stabilizing function in the LCL-intact knee. Anatomy and function of these structures for primary and secondary joint stability should be considered for clinical diagnostics and when performing surgery in

The role of the deep medial collateral ligament in controlling rotational stability of the knee.

PubMed

Cavaignac, Etienne; Carpentier, Karel; Pailhé, Regis; Luyckx, Thomas; Bellemans, Johan

2015-10-01

The tibial insertion of the deep medial collateral ligament (dMCL) is frequently sacrificed when the proximal tibial cut is performed during total knee arthroplasty. The role of the dMCL in controlling the knee's rotational stability is still controversial. The aim of this study was to quantify the rotational laxity induced by an isolated lesion of the dMCL as it occurs during tibial preparation for knee arthroplasty. An isolated resection of the deep MCL was performed in 10 fresh-frozen cadaver knees. Rotational laxity was measured during application of a standard 5.0 N.m rotational torque. Maximal tibial rotation was measured at different knee flexion angles using an image-guided navigation system (Medivision Surgetics system, Praxim, Grenoble, France) before and after dMCL resection. In all cases, internal and external tibial rotation increased after dMCL resection. Total rotational laxity increased significantly for all knee flexion angles, with an average difference of +7.8° (SD 5.7) with the knee in extension, +8.9° (SD 1.9) in 30° flexion, +7° (SD 2.9) in 60° flexion and +5.3° (SD 2.8) in 90° flexion. Sacrificing the tibial insertion of the deep MCL increases rotational laxity of the knee by 5°-9°, depending on the knee flexion angle. Based on our findings, new surgical techniques and implants that preserve the dMCL insertion such as tibial inlay components should be developed. Further clinical evaluations are necessary.

Combined use of bFGF and GDF-5 enhances the healing of medial collateral ligament injury

DOE Office of Scientific and Technical Information (OSTI.GOV)

Saiga, Kenta; Furumatsu, Takayuki, E-mail: matino@md.okayama-u.ac.jp; Yoshida, Aki

Research highlights: {yields} bFGF/GDF-5 treatment increases cellular proliferation and migration of MCL fibroblasts. {yields} bFGF/GDF-5 hydrogels stimulate the healing of MCL injury in vivo. {yields} bFGF/GDF-5 hydrogels stimulate Col1a1 expression and type I collagen synthesis. {yields} Combined use of bFGF/GDF-5 enhances MCL healing. -- Abstract: Basic fibroblast growth factor (bFGF) and growth and differentiation factor (GDF)-5 stimulate the healing of medial collateral ligament (MCL) injury. However, the effect of isolated and combined use of bFGF/GDF-5 remains still unclear. We investigated cellular proliferation and migration responding to bFGF/GDF-5 using rabbit MCL fibroblasts. Rabbit MCL injury was treated by bFGF and/or GDF-5more » with peptide hydrogels. Gene expression and deposition of collagens in healing tissues were evaluated. bFGF/GDF-5 treatment additively enhanced cell proliferation and migration. bFGF/GDF-5 hydrogels stimulated Col1a1 expression without increasing Col3a1 expression. Combined use of bFGF/GDF-5 stimulated type I collagen deposition and the reorganization of fiber alignment, and induced better morphology of fibroblasts in healing MCLs. Our study indicates that combined use of bFGF/GDF-5 might enhance MCL healing by increasing proliferation and migration of MCL fibroblasts, and by regulating collagen synthesis and connective fiber alignment.« less

[Application of pie-crusting the medial collateral ligament release in arthroscopic surgery for posterior horn of 
medial meniscus in knee joint].

PubMed

Zhu, Weihong; Tang, Qi; Liao, Lele; Li, Ding; Yang, Yang; Chen, You

2017-09-28

To explore the effectiveness and safety of pie-crusting the medial collateral ligament release (MCL) in treating posterior horn of medial meniscus (PHMM) tear in tight medial tibiofemoral compartment of knee joint.
 Methods: Thirty-two consecutive patients with PHMM tear in tight medial tibiofemoral compartment of knee joint were admitted to our department from January, 2013 to December, 2014. All patients were performed pie-crusting the MCL release at its tibial insertion with 18-gauge intravenous needle. All patients were evaluated by valgus stress test and bilateral valgus stress radiograph at postoperative 1st day, 4th week and 12th week. Visual Analogue Scales (VAS), Lysholm scores, Tegner scores and International Knee Documentation Committee (IKDC) scores were recorded at the 1st, 3th, 6th month follow-up, then follow-up every 6 months.
 Results: The mean follow-up was 28 (24-36) months. All cases were negative in valgus stress test. MCL rupture, femoral fracture, articular cartilage lesion and neurovascular injury were not found at the last follow-up. The median medial joint space width of affected side and unaffected side for valgus stress radiographs were 6.8 mm and 4.3 mm (P<0.05) at the 1st day, 5.5 mm and 4.2 mm 
(P<0.05) in the 4th week and 4.8 mm and 4.3 mm (P>0.05) at the 12th week, respectively. VAS scores was changed from 4.5±1.5 preoperatively to 1.7±1.0 at the final follow-up (t=16.561, P<0.05). Lysholm scores was changed from 52.3±5.8 preoperatively to 93.2±6.3 at the final follow-up (t=-41.353, P<0.05). Tegner scores was changed from 4.1±1.1 preoperatively to 5.5±0.6 at the final follow-up (t=-18.792, P<0.05). IKDC scores was changed from 54.5±6.2 preoperative to 93.8±4.5 at the final follow-up (t=-38.253, P<0.05).
 Conclusion: Pie-crusting the medial collateral ligament release is a safe, minimal invasive and effective surgical option for posterior horn of medial meniscus tear in tight medial tibiofemoral compartment of knee

Anatomical dissection and CT imaging of the posterior cruciate and lateral collateral ligaments in skeletally immature cadaver knees.

PubMed

Shea, Kevin G; Polousky, John D; Jacobs, John C; Ganley, Theodore J

2014-05-07

Understanding the relationship of the posterior cruciate ligament (PCL) and the lateral collateral ligament (LCL) to the femoral and tibial physes is important to reducing the risk of physeal injury during surgical reconstruction. The purpose of this study was to identify the location of the attachments of the PCL and LCL in skeletally immature cadaveric knee specimens and to determine their position relative to the physes. Seven skeletally immature cadaveric knee specimens were examined through gross dissection. These specimens were divided into two groups: infants (an age at death of one month for one specimen and eleven months for two specimens) and children (an age at death of eight years for one specimen, ten years for one specimen, and eleven years for two specimens). Metallic markers were placed at the femoral origins of the PCL and LCL and at the tibial insertion of the PCL. Computed tomography (CT) scans were made for each specimen and analyzed with the use of OsiriX imaging software. The width of the PCL tibial insertion footprint and the height of the PCL femoral origin footprint, the distance from the midpoints of the PCL and LCL femoral origin to the distal femoral physis, and the distance from the PCL insertion footprint midpoint to the proximal tibial physis were measured. The mean distance from the midpoint of the femoral origin footprint of the PCL to the femoral physis was 11.1 mm (range, 10.6 to 11.7 mm) and 18.8 mm (range, 18.2 to 19.2 mm) distal to the physis for infants and children, respectively. The mean distance from the midpoint of the tibial insertion footprint of the PCL to the tibial physis was 3.1 mm (range, 0.0 to 5.7 mm) and 5.8 mm (range, 2.5 to 8.9 mm) proximal to the physis for infants and children, respectively. The mean width of the tibial insertion of the PCL was 5.5 mm (range, 1.1 to 8.3 mm) for infants and 10.2 mm (range, 8.4 to 11.9 mm) for children. The mean distance from the midpoint of the femoral origin of the LCL to the

Instrument-assisted cross-fiber massage accelerates knee ligament healing.

PubMed

Loghmani, M Terry; Warden, Stuart J

2009-07-01

Controlled laboratory study. To investigate the effects of instrument-assisted cross-fiber massage (IACFM) on tissue-level healing of knee medial collateral ligament (MCL) injuries. Ligament injuries are common and significant clinical problems for which there are few established interventions. IACFM represents an intervention that may mediate tissue-level healing following ligament injury. Bilateral knee MCL injuries were created in 51 rodents, while 7 rodents were maintained as ligament-intact, control animals. IACFM was commenced 1 week following injury and introduced 3 sessions per week for 1 minute per session. IACFM was introduced unilaterally (IACFM-treated), with the contralateral, injured MCL serving as an internal control (nontreated). Thirty-one injured animals received 9 ACFM treatments, while the remaining 20 injured animals received 30 treatments. Ligament biomechanical properties and morphology were assessed at either 4 or 12 weeks postinjury. IACFM-treated ligaments were 43.1% stronger (P<.05), 39.7% stiffer (P<.01), and could absorb 57.1% more energy before failure (P<.05) than contralateral, injured, nontreated ligaments at 4 weeks postinjury. On histological and scanning electron microscopy assessment, IACFM-treated ligaments appeared to have improved collagen fiber bundle formation and orientation within the scar region than nontreated ligaments. There were minimal differences between IACFM-treated and contralateral, nontreated ligaments at 12 weeks postinjury, although IACFM-treated ligaments were 15.4% stiffer (P<.05). IACFM-accelerated ligament healing, possibly via favorable effects on collagen formation and organization, but had minimal effect on the final outcome of healing. These findings are clinically interesting, as there are few established interventions for ligament injuries, and IACFM is a simple and practical therapy technique. J Orthop Sports Phys Ther 2009;39(7):506-514, Epub 24 February 2009. doi:10.2519/jospt.2009.2997.

Ulnar neuropathy at wrist: entrapment at a very "congested" site.

PubMed

Coraci, Daniele; Loreti, Claudia; Piccinini, Giulia; Doneddu, Pietro E; Biscotti, Silvia; Padua, Luca

2018-05-19

Ulnar tunnel syndrome indicates ulnar neuropathy at different sites within the wrist. Several classifications of ulnar tunnel syndrome are present in literature, based upon typical nerve anatomy. However, anatomical variations are not uncommon and can complicate assessment. The etiology is also complex, due to the numerous potential causes of entrapment. Clinical examination, neurophysiological testing, and imaging are all used to support the diagnosis. At present, many therapeutic approaches are available, ranging from observation to surgical management. Although ulnar neuropathy at the wrist has undergone extensive prior study, unresolved questions on diagnosis and treatment remain. In the current paper, we review relevant literature and present the current knowledge on ulnar tunnel syndrome.

Where Is the Ulnar Styloid Process? Identification of the Absolute Location of the Ulnar Styloid Process Based on CT and Verification of Neutral Forearm Rotation on Lateral Radiographs of the Wrist.

PubMed

Shin, Seung-Han; Lee, Yong-Suk; Kang, Jin-Woo; Noh, Dong-Young; Jung, Joon-Yong; Chung, Yang-Guk

2018-03-01

The location of the ulnar styloid process can be confusing because the radius and the hand rotate around the ulna. The purpose of this study was to identify the absolute location of the ulnar styloid process, which is independent of forearm pronation or supination, to use it as a reference for neutral forearm rotation on lateral radiographs of the wrist. Computed tomography (CT) images of 23 forearms taken with elbow flexion of 70° to 90° were analyzed. The axial CT images were reconstructed to be perpendicular to the distal ulnar shaft. The absolute location of the ulnar styloid process in this study was defined as the position of the ulnar styloid process on the axial plane of the ulnar head relative to the long axis of the humeral shaft with the elbow set in the position for standard lateral radiographs of the wrist. To identify in which direction the ulnar styloid is located on the axial plane of the ulnar head, the angle between "the line of humeral long axis projected on the axial plane of the ulna" and "the line passing the center of the ulnar head and the center of the ulnar styloid" was measured (ulnar styloid direction angle). To identify how volarly or dorsally the ulnar styloid should appear on the true lateral view of the wrist, the ratio of "the volar-dorsal diameter of the ulnar head" and "the distance between the volar-most aspect of the ulnar head and the center of the ulnar styloid" was calculated (ulnar styloid location ratio). The mean ulnar styloid direction angle was 12° dorsally. The mean ulnar styloid location ratio was 1:0.55. The ulnar styloid is located at nearly the ulnar-most (the opposite side of the humerus with the elbow flexed) and slightly dorsal aspects of the ulnar head on the axial plane. It should appear almost midway (55% dorsally) from the ulnar head on the standard lateral view of the wrist in neutral forearm rotation. These location references could help clinicians determine whether the forearm is in neutral or rotated

Ultrasound phonophoresis of panax notoginseng improves the strength of repairing ligament: a rat model.

PubMed

Ng, Gabriel Y F; Wong, Richard Y F

2008-12-01

This study examined the phonophoretic effect of a therapeutic ultrasound coupled with a Panax notoginseng (PN) gel and compared it with a therapeutic ultrasound alone for medial collateral ligament repair in rats. Twenty mature male Sprague-Dawley rats receiving surgical transection to the left medial collateral ligament (MCL) were divided randomly into three groups: ultrasound (US, n = 7), ultrasound with PN coupling gel (PNUS, n = 7) and control (n = 6). The treatments started on day 3 after surgery for six days per week over a two-week period. The US group received 4 min of pulsed ultrasound (1 MHz) at the intensity of 0.5W/cm(2) with a normal ultrasonic coupling gel. The PNUS group received the same ultrasound treatment, but with a coupling gel that contained PN extract. The control group received a placebo ultrasound treatment similar to the other two groups. On day 17, the ligaments were mechanically tested for load-relaxation, stiffness and ultimate tensile strength (UTS). Values of the left side were normalized against that of the right side of each animal for analysis. Results revealed significantly higher normalized stiffness (p = 0.009) and UTS (p = 0.022) in the PNUS group than the other two groups, but insignificant difference in load-relaxation among all groups. This study reveals a positive ultrasonic phonophoretic effect of Panax notoginseng extract for improving the strength of ligament repair than ultrasound therapy alone.

Cerebral collaterals and collateral therapeutics for acute ischemic stroke.

PubMed

Winship, Ian R

2015-04-01

Cerebral collaterals are vascular redundancies in the cerebral circulation that can partially maintain blood flow to ischemic tissue when primary conduits are blocked. After occlusion of a cerebral artery, anastomoses connecting the distal segments of the MCA with distal branches of the ACA and PCA (known as leptomeningeal or pial collaterals) allow for partially maintained blood flow in the ischemic penumbra and delay or prevent cell death. However, collateral circulation varies dramatically between individuals, and collateral extent is significant predictor of stroke severity and recanalization rate. Collateral therapeutics attempt to harness these vascular redundancies by enhancing blood flow through pial collaterals to reduce ischemia and brain damage after cerebral arterial occlusion. While therapies to enhance collateral flow remain relatively nascent neuroprotective strategies, experimental therapies including inhaled NO, transient suprarenal aortic occlusion, and electrical stimulation of the parasympathetic sphenopalatine ganglion show promise as collateral therapeutics with the potential to improve treatment of acute ischemic stroke. © 2014 John Wiley & Sons Ltd.

Anterior cruciate ligament rupture secondary to a 'heel hook': a dangerous martial arts technique.

PubMed

Baker, Joseph F; Devitt, Brian M; Moran, Ray

2010-01-01

The 'heel hook' is a type of knee lock used in some forms of martial arts to stress the knee and cause opponent to concede defeat. While the knee is in a flexed and valgus disposition, an internal rotation force is applied to the tibia. Reports are lacking on serious knee trauma as a result of this technique. We report the case of a 32-year-old Mixed Martial Arts exponent who sustained complete anterior cruciate ligament rupture and an medial collateral ligament injury from the use of a 'heel hook'.

Dynamic Knee Alignment and Collateral Knee Laxity and Its Variations in Normal Humans

PubMed Central

Deep, Kamal; Picard, Frederic; Clarke, Jon V.

2015-01-01

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. PMID:26636090

Revision allograft reconstruction of the lateral collateral ligament complex in elbows with previous failed reconstruction and persistent posterolateral rotatory instability.

PubMed

Baghdadi, Yaser M K; Morrey, Bernard F; O'Driscoll, Shawn W; Steinmann, Scott P; Sanchez-Sotelo, Joaquin

2014-07-01

Primary reconstruction of the lateral collateral ligament complex (LCLC) using graft tissue restores elbow stability in many, but not all, elbows with acute or chronic posterolateral rotatory instability (PLRI). Revision reconstruction using a tendon allograft is occasionally considered for persistent PLRI, but the outcome of revision ligament reconstruction in this setting is largely unknown. We determined whether revision allograft ligament reconstruction can (1) restore the stability and (2) result in improved elbow scores for patients with persistent PLRI of the elbow after a previous failed primary reconstructive attempt and in the context of the diverse pathology being addressed. Between 2001 and 2011, 160 surgical elbow procedures were performed at our institution for the LCLC reconstruction using allograft tissue. Only patients undergoing revision allograft reconstruction of the LCLC for persistent PLRI with a previous failed primary reconstructive attempt using graft tissue and at least I year of followup were included in the study. Eleven patients (11 elbows) fulfilled our inclusion criteria and formed our study cohort. The cohort consisted of six female patients and five male patients. The mean age at the time of revision surgery was 36 years (range, 14-59 years). The revision allograft reconstruction was carried out after a mean of 3 years (range, 2.5 months to 9 years) from a failed attempted reconstruction of the LCLC. Osseous deficiency to some extent was identified in the preoperative radiographs of eight elbows. Mean followup was 5 years (range, 1-12 years). Revision allograft reconstruction of the LCLC restored elbow stability in eight of the 11 elbows; two of the three elbows with persistent instability were operated on a third time (at 6 and 7 months after allograft revision reconstruction). For elbows with no persistent instability, the mean Mayo Elbow Performance Score at most recent followup was 83 points (range, 60-100 points), and

Viability of ligaments after freezing: an experimental study in a rabbit model.

PubMed

Frank, C; Edwards, P; McDonald, D; Bodie, D; Sabiston, P

1988-01-01

Our purpose in this study was to assess ligament fibroblast viability after freezing by quantifying the subsequent ability of fibroblasts to synthesize collagen in vitro. Both medial collateral ligament (MCL) complexes from 40 adolescent rabbits were studied. Collagen production was determined by in vitro incubation of ligaments in 3H-proline (a collagen precursor) and subsequent analysis of 3H-hydroxyproline (a marker of newly synthesized collagen). Autoradiographs determined the distributions of ligament cell activity. All right MCL complexes served as fresh controls, providing a baseline of collagen production. Each left MCL was assigned to an experimental group and was either incubated fresh (10 animals); "killed" by drying, multiple freeze thawing, or cycloheximide (six animals); or slowly frozen at -70 degrees C without cryoprotection (24 animals). Collagen production of rapidly thawed ligaments was studied by proline incubation at 1 day, 9 days, or 6 weeks after freezing and was compared with that of contralateral fresh controls. Results demonstrate that some cells in the substance of these rabbit ligaments retained the ability to synthesize collagen in vitro after being frozen for up to 6 weeks. Mean collagen production of frozen ligaments was decreased, but tests of mean and median values as well as ratios were statistically similar to fresh contralateral ligaments in all animals. This postfreezing ligament cell survival and collagen production after -70 degrees C storage may have implications for ligament transplantation.

Posterior horn medial meniscal root repair with cruciate ligament/medial collateral ligament combined injuries.

PubMed

Wilson, Brian F; Johnson, Darren L

2011-12-01

Many meniscal root tears remain unrepaired, potentially due to under-recognition and the technical challenge of repairing them. A great effort is made to preserve the native meniscus and restore the circumferential fibers for hoop stress resistance. It has been well demonstrated in the literature that failure to repair this will lead to increased contact pressures in the medial compartment and early degenerative changes in the articular cartilage. Our technique is one that allows the meniscus to resume its important role of knee stability. A thorough understanding of meniscal root anatomy, as well as repair techniques, is important for the cruciate ligament surgeon. Copyright © 2011, SLACK Incorporated.

The Blocking Flap for Ulnar Nerve Instability After In Situ Release: Technique and a Grading System of Ulnar Nerve Instability to Guide Treatment.

PubMed

Tang, Peter

2017-12-01

In situ ulnar nerve release has been gaining popularity as a simple, effective, and low-morbidity procedure for the treatment of cubital tunnel syndrome. One concern with the technique is how to manage the unstable ulnar nerve after release. It is unclear how much nerve subluxation will lead to problems and surprisingly there is no grading system to assess ulnar nerve instability. I propose such a grading system, as well as a new technique to stabilize the unstable ulnar nerve. The blocking flap technique consists of raising a rectangular flap off the flexor/pronator fascia and attaching it to the posterior subcutaneous flap so that it blocks the nerve from subluxation/dislocation.

The Influence of Interleukin-4 on Ligament Healing

PubMed Central

Chamberlain, Connie S; Leiferman, Ellen M; Frisch, Kayt E; Wang, Sijian; Yang, Xipei; Brickson, Stacey L; Vanderby, Ray

2011-01-01

Despite a complex cascade of cellular events to reconstruct the damaged extracellular matrix, ligament healing results in a mechanically inferior scarred ligament. During normal healing, granulation tissue expands into any residual normal ligamentous tissue (creeping substitution), resulting in a larger region of healing, greater mechanical compromise, and an inefficient repair process. To control creeping substitution and possibly enhance the repair process, the anti-inflammatory cytokine, interleukin-4 (IL-4) was administered to rats prior to and after rupture of their medial collateral ligaments. In vitro experiments demonstrated a time-dependent effect on fibroblast proliferation after interleukin-4 treatment. In vivo treatments with interleukin-4 (100 ng/ml i.v.) for 5 days resulted in decreased wound size and type III collagen and increased type I procollagen, indicating a more regenerative early healing in response to the interleukin-4 treatment. However, continued treatment of interleukin-4 to day 11 antagonized this early benefit and slowed healing. Together, these results suggest that interleukin-4 influences the macrophages and T-lymphocytes but also stimulates fibroblasts associated with the proliferative phase of healing in a dose-, cell-, and time-dependent manner. Although treatment significantly influenced healing in the first week after injury, interleukin-4 alone was unable to maintain this early regenerative response. PMID:21518087

The Posterior Bundle's Effect on Posteromedial Elbow Instability After a Transverse Coronoid Fracture: A Biomechanical Study.

PubMed

Shukla, Dave R; Golan, Elan; Weiser, Mitch C; Nasser, Philip; Choueka, Jack; Hausman, Michael

2018-04-01

There has been increased interest in the role of the posterior bundle of the medial collateral ligament (pMUCL) in the elbow, particularly its effects on posteromedial rotatory stability. The ligament's effect in the context of an unfixable coronoid fracture has not been the focus of any study. The purposes of this biomechanical study were to evaluate the stabilizing effect of the pMUCL with a transverse coronoid fracture and to assess the effect of graft reconstruction of the ligament. We simulated a varus and internal rotatory subluxation in 7 cadaveric elbows at 30°, 60°, and 90° elbow flexion. The amount of ulnar rotation and medial ulnohumeral joint gapping were assessed in the intact elbow after we created a transverse coronoid injury, after we divided the pMUCL, and finally, after we performed a graft reconstruction of the pMUCL. At all angles tested, some stability was lost after cutting the pMUCL once the coronoid had been injured, because mean proximal ulnohumeral joint gapping increased afterward by 2.1, 2.2, and 1.3 mm at 90°, 60°, and 30°, respectively. Ulnar internal rotation significantly increased after pMUCL transection at 90°. At 60° and 30° elbow flexion, ulnar rotation increased after resection of the coronoid but not after pMUCL resection. An uninjured pMUCL stabilizes against varus internal rotatory instability in the setting of a transverse coronoid fracture at higher flexion angles. Further research is needed to optimize graft reconstruction of the pMUCL. The pMUCL is an important secondary stabilizer against posteromedial instability in the coronoid-deficient elbow. In the setting of an unfixable coronoid fracture, the surgeon should examine for posteromedial instability and consider addressing the pMUCL surgically. Copyright © 2018 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.

[SEMITENDINOUS AND GRACILIS TRANSFER FOR TREATMENT OF MEDIAL COLLATERAL LIGAMENT INJURY CAUSED BY TOTAL KNEE ARTHROPLASTY].

PubMed

Cao Jiangang; Wang, Lei; Zhao, Huiwen; Liu, Jun

2016-02-01

To evaluate the effectiveness of semitendinous and gracilis transfer for the treatment of medial collateral ligament (MCL) injury caused by total knee arthroplasty (TKA). Between March 2009 and May 2014, 11 patients (11 knees) with MCL injuries caused by primary TKA were treated by semitendinous and gracilis transfer in primary TKA (injury group). Another 18 patients (21 knees) without MCL injury were included as the control group. There was no significant difference in gender, age, injury sides, disease duration, body mass index, knee varus deformity, and preoperative Knee Society Score (KSS) between 2 groups (P>0.05), with comparability. KSS score was used to evaluate the function after operation. Primary healing of incision was obtained in all patients, and no complications of joint instability and pain occurred. The follow-up time was-6-29 months in injury group and was 7-34 months in control group. At last follow-up, the KSS clinical score and ftinctional score were significantly increased to 89.82 +/- 3.76 and 89.54 +/- 3.50 in the injury group (P<0.05) and were significantly increased to 90.19 +/- 3.39 and 90.00 +/- 3.53 in the control group (P<0.05) respectively, but no significant difference was shown between 2 groups (t=0.158, P=0.877; t=0.820, P=0.432). X-ray films showed no prosthetic loosening or subsidence during follow-up. The semitendinous and gracilis transfer is reliable for the treatment of MCL injury caused by TKA. The insertions of semitendinous tendon and gracilis are close to that of the knee MCL, which can effectively improve knee function.

[Ligamentous injuries to the ankle joint].

PubMed

Rammelt, S; Schneiders, W; Grass, R; Rein, S; Zwipp, H

2011-10-01

Injuries to the lateral ankle ligaments are the most common sports injuries. Determination of their severity and exclusion of relevant accompanying injuries requires a subtle clinical and a focussed radiological assessment. Treatment is non-operative and functional in the majority of cases. Consequent application of orthoses limiting supination and proprioceptive training are essential to avoid chronic instability. With recurrent ankle sprains one has to distinguish between functional and mechanical instability. The latter can be treated successfully with anatomic reconstruction and ligamentoplasty in more than 80 % of cases. Extraanatomic tenodeses should be reserved for cases of combined ankle and subtalar instability. Isolated injuries to the medial collateral ligaments are rare. Therefore, osseous injuries or underlying deformities have to be excluded. Isolated deltoid ligament ruptures may be treated non-operatively. Unstable injuries to the distal tibiofibular syndesmosis resulting in a manifest or latent diastasis are treated with open reduction and fixation with two tibiofibular set screws. Anatomic reduction of the distal fibula into the tibial groove is of utmost prognostic relevance and therefore should be reliably proved with either intraoperative 3D fluoroscopy or postoperative CT scanning. For chronic syndesmotic instability an anatomic ligamentoplasty using half the peroneus longus tendon is recommended. © Georg Thieme Verlag KG Stuttgart · New York.

True Ulnar Artery Aneurysm in the Proximal Forearm: Case Report and Literature Review.

PubMed

McHugh, Seamus Mark; Moloney, Michael Anthony; Greco, Elisa; Wheatcroft, Mark

2017-10-01

Ulnar artery aneurysms are rare with less than 150 previously reported. Previously ulnar aneurysms have been most commonly noted as occurring in the distal ulnar artery close to the palmar arch. We present the case of a 47-year-old male with a background history of human immunodeficiency virus (HIV) who attended our outpatient clinic with symptoms of distal embolization from a proximal ulnar artery aneurysm. Preoperatively, the aneurysm was thought to arise from the distal brachial artery, and only intraoperatively was the diagnosis of ulnar aneurysm made. The aneurysm was excised, and a reverse vein bypass graft anastomosed end to side on the brachial artery, and end to end on the distal ulnar. True ulnar artery aneurysms also involving the more proximal ulnar artery have been previously reported associated with vasculitic disorders. HIV has been previously associated with aneurysm formation in a number of anatomical locations. This case is noteworthy as it reports on the presentation and successful operative management of a true ulnar artery aneurysm arising in the proximal forearm in the setting of HIV, which has not been previously reported in medical literature. We present successful operative management of a true ulnar aneurysm in the proximal forearm using a reverse venous interposition bypass. Diagnosis of a proximal ulnar artery aneurysm may represent a diagnostic challenge given its rarity as it may mimic brachial artery aneurysm. Copyright © 2017 Elsevier Inc. All rights reserved.

Sex Differences in the Incidence of Anterior Cruciate Ligament, Medial Collateral Ligament, and Meniscal Injuries in Collegiate and High School Sports: 2009-2010 Through 2013-2014.

PubMed

Stanley, Laura E; Kerr, Zachary Y; Dompier, Thomas P; Padua, Darin A

2016-06-01

Previous research has noted sex-based differences in anterior cruciate ligament (ACL) injury rates in young athletes, while little is known about medial collateral ligament (MCL) and meniscal injury rates in this population. The objective of this study was to compare injury rates for traumatic knee injuries (ie, ACL, MCL, and meniscal injuries) in collegiate and high school (HS) varsity student-athletes across multiple sports. Knee injury rates vary by sex and across different sports and levels of competition. Descriptive epidemiology study. Injury and athlete-exposure data were utilized from the National Athletic Treatment, Injury and Outcomes Network (NATION) and National Collegiate Athletic Association (NCAA) Injury Surveillance Program (ISP) during the 2009-2010 to 2013-2014 academic years. Analyses focused on ACL, MCL, and meniscal injuries. Injury rates and injury rate ratios (IRRs) with 95% CIs were calculated for basketball, ice hockey, lacrosse, soccer, and baseball/softball. The ACL injury rate was higher for female than male athletes at the collegiate (IRR, 2.49; 95% CI, 1.81-3.41) and HS (IRR, 2.30; 95% CI, 1.67-3.18) levels. At the collegiate level, the highest ACL IRR comparing female to male athletes was reported in softball/baseball (IRR, 6.61; 95% CI, 1.48-29.55). At the HS level, the highest ACL IRR was reported in basketball (IRR, 3.68; 95% CI, 1.91-7.10). The MCL injury rate was higher for female than male athletes at the HS level (IRR, 2.11; 95% CI, 1.25-3.56) but lower for female than male athletes at the collegiate level (IRR, 0.73; 95% CI, 0.59-0.92). The meniscal injury rate was lower for female than male athletes at the HS level (IRR, 0.47; 95% CI, 0.31-0.71), while no differences by sex were seen at the collegiate level (IRR, 1.35; 95% CI, 0.90-2.02). Knee injury rates varied by sex across 5 different sports in the HS and collegiate settings. Female athletes sustained ACL injuries at a higher rate than male athletes at both the HS and

Should the Ipsilateral Hamstrings Be Used for Anterior Cruciate Ligament Reconstruction in the Case of Medial Collateral Ligament Insufficiency? Biomechanical Investigation Regarding Dynamic Stabilization of the Medial Compartment by the Hamstring Muscles.

PubMed

Herbort, Mirco; Michel, Philipp; Raschke, Michael J; Vogel, Nils; Schulze, Martin; Zoll, Alexander; Fink, Christian; Petersen, Wolf; Domnick, Christoph

2017-03-01

Semitendinosus and gracilis muscles are frequently harvested for autologous tendon grafts for cruciate ligament reconstruction. This study investigated the joint-stabilizing effects of these hamstring muscles in cases of insufficiency of the medial collateral ligament (MCL). First, both the semitendinosus and gracilis muscles can actively stabilize the joint against valgus moments in the MCL-deficient knee. Second, the stabilizing influence of these muscles decreases with an increasing knee flexion angle. Controlled laboratory study. The kinematics was examined in 10 fresh-frozen human cadaveric knees using a robotic/universal force moment sensor system and an optical tracking system. The knee kinematics under 5- and 10-N·m valgus moments were determined in the different flexion angles of the (1) MCL-intact and (2) MCL-deficient knee using the following simulated muscle loads: (1) 0-N (idle) load, (2) 200-N semitendinosus (ST) load, and (3) 280-N (200/80-N) combined semitendinosus/gracilis (STGT) load. Cutting the MCL increased the valgus angle under all tested conditions and angles compared with the MCL-intact knee by 4.3° to 8.1° for the 5-N·m valgus moment and 6.5° to 11.9° for the 10-N·m valgus moment ( P < .01). The applied 200-N simulated ST load reduced the valgus angle significantly at 0°, 10°, 20°, and 30° of flexion under 5- and 10-N·m valgus moments ( P < .05). At 0°, 10°, and 20° of flexion, these values were close to those for the MCL-intact joint under the respective moments (both P > .05). The combined 280-N simulated STGT load significantly reduced the valgus angle in 0°, 10°, and 20° of flexion under 5- and 10-N·m valgus moments ( P < .05) to values near those for the intact joint (5 N·m: 0°, 10°; 10 N·m: 0°, 10°, 20°; P > .05). In 60° and 90° of flexion, ST and STGT loads did not decrease the resulting valgus angle of the MCL-deficient knee without hamstring loads ( P > .05 vs deficient; P = .0001 vs intact). In this

Does a conservative tibial cut in conventional total knee arthroplasty violate the deep medial collateral ligament?

PubMed

Maes, Michael; Luyckx, Thomas; Bellemans, Johan

2014-11-01

Based on the anatomy of the deep medial collateral ligament (MCL), it was hypothesized that at least part of its cross-sectional insertion area is jeopardized while performing a standard tibial cut in conventional total knee arthroplasty (TKA). The aim of this study was to determine whether it is anatomically possible to preserve the tibial deep MCL insertion during conventional TKA. Thirty-three unpaired cadaveric knee specimens were used for this study. Knees with severe varus/valgus deformity or damage to the medial structures of the knee were excluded. In the first part of the study, the dimensions of the tibial insertion of the deep MCL and its relationship to the joint line were recorded. Next, the cross-sectional area of the deep MCL insertion was determined using calibrated digital photographic analysis. In the second part, the effect of a standard 9-mm 3° sloped tibial cut on the structural integrity of the deep MCL cross-sectional insertion area was determined using conventional instrumentation. The proximal border of the deep MCL insertion site on the tibia was located on average 4.7 ± 1.2 mm distally to the joint line. After performing a standard 9-mm 3° sloped tibial cut, on average 54% of the deep MCL insertion area was resected. In 29% of the cases, the deep MCL insertion area was completely excised. The deep MCL cannot routinely be preserved in conventional TKA. The deep MCL insertion is at risk and may be jeopardized in case of a tibial cut 9 mm below the native joint line. As the deep MCL is a distinct medial stabilizer and plays an important role in rotational stability, this may have implications in future designs of both unicondylar and total knee arthroplasty, but further research is necessary.

Ulnar osteosarcoma in dogs: 30 cases (1992-2008).

PubMed

Sivacolundhu, Ramesh K; Runge, Jeffrey J; Donovan, Taryn A; Barber, Lisa G; Saba, Corey F; Clifford, Craig A; de Lorimier, Louis-Philippe; Atwater, Stephen W; DiBernardi, Lisa; Freeman, Kim P; Bergman, Philip J

2013-07-01

To examine the biological behavior of ulnar osteosarcoma and evaluate predictors of survival time in dogs. Retrospective case series. 30 dogs with primary ulnar osteosarcoma. Medical records were reviewed. Variables recorded and examined to identify predictors of survival time were signalment, tumor location in the ulna, tumor length, serum alkaline phosphatase activity, surgery type, completeness of excision, tumor stage, tumor grade, histologic subtype, development of metastases, and use of chemotherapy. 30 cases were identified from 9 institutions. Eleven dogs were treated with partial ulnar ostectomy and 14 with amputation; in 5 dogs, a resection was not performed. Twenty-two dogs received chemotherapy. Median disease-free interval and survival time were 437 and 463 days, respectively. Negative prognostic factors for survival time determined via univariate analyses were histologic subtype and development of lung metastases. Telangiectatic or telangiectatic-mixed subtype (n = 5) was the only negative prognostic factor identified via multivariate analysis (median survival time, 208 days). Dogs with telangiectatic subtype were 6.99 times as likely to die of the disease. The prognosis for ulnar osteosarcoma in this population was no worse and may have been better than the prognosis for dogs with osteosarcoma involving other appendicular sites. Partial ulnar ostectomy was associated with a low complication rate and good to excellent function and did not compromise survival time. Telangiectatic or telangiectatic-mixed histologic subtype was a negative prognostic factor for survival time. The efficacy of chemotherapy requires further evaluation.

Median and ulnar neuropathies in university guitarists.

PubMed

Kennedy, Rachel H; Hutcherson, Kimberly J; Kain, Jennifer B; Phillips, Alicia L; Halle, John S; Greathouse, David G

2006-02-01

Descriptive study. To determine the presence of median and ulnar neuropathies in both upper extremities of university guitarists. Peripheral nerve entrapment syndromes of the upper extremities are well documented in musicians. Guitarists and plucked-string musicians are at risk for entrapment neuropathies in the upper extremities and are prone to mild neurologic deficits. Twenty-four volunteer male and female guitarists (age range, 18-26 years) were recruited from the Belmont University School of Music and the Vanderbilt University Blair School of Music. Individuals were excluded if they were pregnant or had a history of recent upper extremity or neck injury. Subjects completed a history form, were interviewed, and underwent a physical examination. Nerve conduction status of the median and ulnar nerves of both upper extremities was obtained by performing motor, sensory, and F-wave (central) nerve conduction studies. Descriptive statistics of the nerve conduction study variables were computed using Microsoft Excel. Six subjects had positive findings on provocative testing of the median and ulnar nerves. Otherwise, these guitarists had normal upper extremity neural and musculoskeletal function based on the history and physical examinations. When comparing the subjects' nerve conduction study values with a chart of normal nerve conduction studies values, 2 subjects had prolonged distal motor latencies (DMLs) of the left median nerve of 4.3 and 4.7 milliseconds (normal, < 4.2 milliseconds). Prolonged DMLs are compatible with median neuropathy at or distal to the wrist. Otherwise, all electrophysiological variables were within normal limits for motor, sensory, and F-wave (central) values. However, comparison studies of median and ulnar motor latencies in the same hand demonstrated prolonged differences of greater than 1.0 milliseconds that affected the median nerve in 2 additional subjects, and identified contralateral limb involvement in a subject with a prolonged

Altered ulnar nerve kinematic behavior in a cadaver model of entrapment.

PubMed

Mahan, Mark A; Vaz, Kenneth M; Weingarten, David; Brown, Justin M; Shah, Sameer B

2015-06-01

Ulnar nerve entrapment at the elbow is more than a compressive lesion of the nerve. The tensile biomechanical consequences of entrapment are currently marginally understood. To evaluate the effects of tethering on the kinematics of the ulnar nerve as a model of entrapment neuropathy. The ulnar nerve was exposed in 7 fresh cadaver arms, and markers were placed at 1-cm increments along the nerve, centered on the retrocondylar region. Baseline translation (pure sliding) and strain (stretch) were measured in response to progressively increasing tension produced by varying configurations of elbow flexion and wrist extension. Then the nerves were tethered by suturing to the cubital tunnel retinaculum and again exposed to progressively increasing tension from joint positioning. In the native condition, for all joint configurations, the articular segment of the ulnar nerve exhibited greater strain than segments proximal and distal to the elbow, with a maximum strain of 28 ± 1% and translation of 11.6 ± 1.8 mm distally. Tethering the ulnar nerve suppressed translation, and the distal segment experienced strains that were more than 50% greater than its maximum strain in an untethered state. This work provides a framework for evaluating regional nerve kinematics. Suppressed translation due to tethering shifted the location of high strain from articular to more distal regions of the ulnar nerve. The authors hypothesize that deformation is thus shifted to a region of the nerve less accustomed to high strains, thereby contributing to the development of ulnar neuropathy.

Median and ulnar muscle and sensory evoked potentials.

PubMed

Felsenthal, G

1978-08-01

The medical literature was reviewed to find suggested clinical applications of the study of the amplitude of evoked muscle action potentials (MAP) and sensory action potentials (SAP). In addition, the literature was reviewed to ascertain the normal amplitude and duration of the evoked MAP and SAP as well as the factors affecting the amplitude: age, sex, temperature, ischemia. The present study determined the normal amplitude and duration of the median and ulnar MAP and SAP in fifty normal subjects. The amplitude of evoked muscle or sensory action potentials depends on multiple factors. Increased skin resistance, capacitance, and impedance at the surface of the recording electrode diminishes the amplitude. Similarly, increased distance from the source of the action potential diminishes its amplitude. Increased interelectrode distance increases the amplitude of the bipolarly recorded sensory action potential until a certain interelectrode distance is exceeded and the diphasic response becomes tri- or tetraphasic. Artifact or poor technique may reduce the potential difference between the recording electrodes or obscure the late positive phase of the action potential and thus diminish the peak to peak amplitude measurement. Intraindividual comparison indicated a marked difference of amplitude in opposite hands. The range of the MAP of the abductor pollicis brevis in one hand was 40.0--100% of the response in the opposite hand. For the abductor digiti minimi, the MAP was 58.5--100% of the response of the opposite hand. The median and ulnar SAP was between 50--100% of the opposite SAP. Consequent to these findings the effect of hand dominance on the amplitude of median and ulnar evoked muscle and sensory action potentials was studied in 41 right handed volunteers. The amplitudes of the median muscle action potential (p less than 0.02) and the median and ulnar sensory action potentials (p less than 0.001) were significantly less in the dominant hand. There was no

A Comparison of Ulnar Shortening Osteotomy Alone Versus Combined Arthroscopic Triangular Fibrocartilage Complex Debridement and Ulnar Shortening Osteotomy for Ulnar Impaction Syndrome

PubMed Central

Song, Hyun Seok

2011-01-01

Background This study compared the results of patients treated for ulnar impaction syndrome using an ulnar shortening osteotomy (USO) alone with those treated with combined arthroscopic debridement and USO. Methods The results of 27 wrists were reviewed retrospectively. They were divided into three groups: group A (USO alone, 10 cases), group B (combined arthroscopic debridement and USO, 9 cases), and group C (arthroscopic triangular fibrocartilage complex [TFCC] debridement alone, 8 cases). The wrist function was evaluated using the modified Mayo wrist score, disabilities of the arm, shoulder and hand (DASH) score and Chun and Palmer grading system. Results The modified Mayo wrist score in groups A, B, and C was 74.5 ± 8.9, 73.9 ± 11.6, and 61.3 ± 10.2, respectively (p < 0.05). The DASH score in groups A, B, and C was 15.6 ± 11.8, 19.3 ± 11.9, and 33.2 ± 8.5, respectively (p < 0.05). The average Chun and Palmer grading score in groups A and B was 85.7 ± 8.9 and 84.7 ± 6.7, respectively. The difference in the Mayo wrist score, DASH score and Chun and Palmer grading score between group A and B was not significant (p > 0.05). Conclusions Both USO alone and combined arthroscopic TFCC debridement with USO improved the wrist function and reduced the level of pain in the patients treated for ulnar impaction syndrome. USO alone may be the preferred method of treatment in patients if the torn flap of TFCC is not unstable. PMID:21909465

Quantification of hand function by power grip and pinch strength force measurements in ulnar nerve lesion simulated by ulnar nerve block.

PubMed

Wachter, Nikolaus Johannes; Mentzel, Martin; Krischak, Gert D; Gülke, Joachim

2017-06-24

In the assessment of hand and upper limb function, grip strength is of the major importance. The measurement by dynamometers has been established. In this study, the effect of a simulated ulnar nerve lesion on different grip force measurements was evaluated. In 25 healthy volunteers, grip force measurement was done by the JAMAR dynamometer (Fabrication Enterprises Inc, Irvington, NY) for power grip and by a pinch strength dynamometer for tip pinch strength, tripod grip, and key pinch strength. A within-subject research design was used in this prospective study. Each subject served as the control by preinjection measurements of grip and pinch strength. Subsequent measurements after ulnar nerve block were used to examine within-subject change. In power grip, there was a significant reduction of maximum grip force of 26.9% with ulnar nerve block compared with grip force without block (P < .0001). Larger reductions in pinch strength were observed with block: 57.5% in tip pinch strength (P < .0001), 61.0% in tripod grip (P < .0001), and 58.3% in key pinch strength (P < .0001). The effect of the distal ulnar nerve block on grip and pinch force could be confirmed. However, the assessment of other dimensions of hand strength as tip pinch, tripod pinch and key pinch had more relevance in demonstrating hand strength changes resulting from an distal ulnar nerve lesion. The measurement of tip pinch, tripod grip and key pinch can improve the follow-up in hand rehabilitation. II. Copyright © 2017 Hanley & Belfus. Published by Elsevier Inc. All rights reserved.

Ulnar nerve entrapment in Guyon's canal due to a lipoma.

PubMed

Ozdemir, O; Calisaneller, T; Gerilmez, A; Gulsen, S; Altinors, N

2010-09-01

Guyon's canal syndrome is an ulnar nerve entrapment at the wrist or palm that can cause motor, sensory or combined motor and sensory loss due to various factors . In this report, we presented a 66-year-old man admitted to our clinic with a history of intermittent pain in the left palm and numbness in 4th and 5th finger for two years. His neurological examination revealed a sensory impairment in the right fifth finger. Also, physical examination displayed a subcutaneous mobile soft tissue in ulnar side of the wrist. Electromyographic examination confirmed the diagnosis of type-1 Guyon's canal syndrome. Under axillary blockage, a lipoma compressing the ulnar nerve was excised totally and ulnar nerve was decompressed. The symptoms were improved after the surgery and patient was symptom free on 3rd postoperative week.

Biomechanics of an orthosis-managed cranial cruciate ligament-deficient canine stifle joint predicted by use of a computer model.

PubMed

Bertocci, Gina E; Brown, Nathan P; Mich, Patrice M

2017-01-01

OBJECTIVE To evaluate effects of an orthosis on biomechanics of a cranial cruciate ligament (CrCL)-deficient canine stifle joint by use of a 3-D quasistatic rigid-body pelvic limb computer model simulating the stance phase of gait and to investigate influences of orthosis hinge stiffness (durometer). SAMPLE A previously developed computer simulation model for a healthy 33-kg 5-year-old neutered Golden Retriever. PROCEDURES A custom stifle joint orthosis was implemented in the CrCL-deficient pelvic limb computer simulation model. Ligament loads, relative tibial translation, and relative tibial rotation in the orthosis-stabilized stifle joint (baseline scenario; high-durometer hinge]) were determined and compared with values for CrCL-intact and CrCL-deficient stifle joints. Sensitivity analysis was conducted to evaluate the influence of orthosis hinge stiffness on model outcome measures. RESULTS The orthosis decreased loads placed on the caudal cruciate and lateral collateral ligaments and increased load placed on the medial collateral ligament, compared with loads for the CrCL-intact stifle joint. Ligament loads were decreased in the orthosis-managed CrCL-deficient stifle joint, compared with loads for the CrCL-deficient stifle joint. Relative tibial translation and rotation decreased but were not eliminated after orthosis management. Increased orthosis hinge stiffness reduced tibial translation and rotation, whereas decreased hinge stiffness increased internal tibial rotation, compared with values for the baseline scenario. CONCLUSIONS AND CLINICAL RELEVANCE Stifle joint biomechanics were improved following orthosis implementation, compared with biomechanics of the CrCL-deficient stifle joint. Orthosis hinge stiffness influenced stifle joint biomechanics. An orthosis may be a viable option to stabilize a CrCL-deficient canine stifle joint.

Radiographic landmarks for locating the femoral origin of the superficial medial collateral ligament.

PubMed

Hartshorn, Timothy; Otarodifard, Karimdad; White, Eric A; Hatch, George F Rick

2013-11-01

Little has been written about the use of radiographic landmarks for locating the origin of the superficial medial collateral ligament (sMCL). A standardized radiographic landmark for the sMCL origin using intraoperative fluoroscopic imaging may be of value in aiding the surgeon in accurate femoral tunnel placement in the setting of extensive soft tissue disruption and bony attrition. To determine a reproducible radiographic landmark that will assist in correct femoral tunnel placement in sMCL repair and reconstruction. Descriptive laboratory study. Ten fresh-frozen unmatched human cadaveric knees were dissected, and the origin of the sMCL was exposed. A 2-mm metallic marker was then placed at the center of the femoral origin of the sMCL. True lateral fluoroscopically assisted digital radiographs were obtained of the knee with the posterior and distal femoral condyles overlapping in a standardized fashion. With the use of computer software, reference lines were drawn on the images, creating 4 quadrants. Two independent examiners performed quantitative measurements of the sMCL origin in relation to this axis and to the Blumensaat line. Mean measurements showed the sMCL origin to be closely related to the intersection point of the Blumensaat line and a line drawn distally from the posterior femoral cortex on a true lateral radiograph. The sMCL origin was found at a mean point 1.6 ± 4.3 mm posterior and 4.9 ± 2.1 mm proximal to the intersection of a line paralleling the posterior femoral cortex and a line drawn perpendicular to the posterior femoral cortical line, where it intersects the Blumensaat line. In 5 of 10 specimens, the center of the sMCL origin fell precisely on the Blumensaat line. The remaining specimens had sMCL origins anterior to the Blumensaat line. The femoral origin of the sMCL was found in the proximal and posterior quadrants in 8 of 10 specimens. With a relatively small amount of deviation, the sMCL origin can be consistently identified on a true

Opening the medial tibiofemoral compartment by pie-crusting the superficial medial collateral ligament at its tibial insertion: a cadaver study.

PubMed

Roussignol, X; Gauthe, R; Rahali, S; Mandereau, C; Courage, O; Duparc, F

2015-09-01

Arthroscopic treatment of tears in the middle and posterior parts of the medial meniscus can be difficult when the medial tibiofemoral compartment is tight. Passage of the instruments may damage the cartilage. The primary objective of this cadaver study was to perform an arthroscopic evaluation of medial tibiofemoral compartment opening after pie-crusting release (PCR) of the superficial medial collateral ligament (sMCL) at its distal insertion on the tibia. The secondary objective was to describe the anatomic relationships at the site of PCR (saphenous nerve, medial saphenous vein). We studied 10 cadaver knees with no history of invasive procedures. The femur was held in a vise with the knee flexed at 45°, and the medial aspect of the knee was dissected. PCR of the sMCL was performed under arthroscopic vision, in the anteroposterior direction, at the distal tibial insertion of the sMCL, along the lower edge of the tibial insertion of the semi-tendinosus tendon. Continuous 300-N valgus stress was applied to the ankle. Opening of the medial tibiofemoral compartment was measured arthroscopically using graduated palpation hooks after sequential PCR of the sMCL. The compartment opened by 1mm after release of the anterior third, 2.3mm after release of the anterior two-thirds, and 3.9mm after subtotal release. A femoral fracture occurred in 1 case, after completion of all measurements. Both the saphenous nerve and the medial saphenous vein were located at a distance from the PCR site in all 10 knees. PCR of the sMCL is chiefly described as a ligament-balancing method during total knee arthroplasty. This procedure is usually performed at the joint line, where it opens the compartment by 4-6mm at the most, with some degree of unpredictability. PCR of the sMCL at its distal tibial insertion provides gradual opening of the compartment, to a maximum value similar to that obtained with PCR at the joint space. The lower edge of the semi-tendinosus tendon is a valuable landmark

Median Arcuate Ligament Syndrome: A Single-Center Experience with 23 Patients

DOE Office of Scientific and Technical Information (OSTI.GOV)

Nasr, Layla A.; Faraj, Walid G.; Al-Kutoubi, Aghiad

BackgroundMedian arcuate ligament syndrome (MALS) is a rare entity that occurs when the median arcuate ligament of the diaphragm is low-lying, causing a compression to the underlying celiac trunk. We reviewed the vascular changes associated with MALS in an effort to emphasize the seriousness of this disease and the complications that may result.MethodsThis is a retrospective descriptive analysis of 23 consecutive patients diagnosed with MALS between January 1, 2012 and December 31, 2015 at a tertiary medical center. Computed tomographic (CT) scans, medical records, and patient follow-up were reviewed.ResultsThe number of patients included herein was 23. The median age wasmore » 56 years (17–83). Sixteen patients (69.6%) had a significant arterial collateral circulation. Eleven patients (47.8%) were found to have visceral artery aneurysms; 4 patients (36.4%) bled secondary to aneurysm rupture. All ruptured aneurysms were treated with endovascular approach. The severity of the hemodynamic changes appears to be greater with complete occlusion,ConclusionsMALS causes pathological hemodynamic changes within the abdominal vasculature. Follow-up is advised for patients who develop a collateral circulation. Resulting aneurysms should preferably be treated when the size ratio approaches three. Treatment of these aneurysms can be done via an endovascular approach coupled with possible celiac artery decompression to restore physiologic blood flow.« less

Does joint line elevation after revision knee arthroplasty affect tibio-femoral kinematics, contact pressure or collateral ligament lengths? An in vitro analysis

PubMed Central

Kowalczewski, Jacek B.; Chevalier, Yan; Okon, Tomasz; Innocenti, Bernardo; Bellemans, Johan

2015-01-01

Introduction Correct restoration of the joint line is generally considered as crucial when performing total knee arthroplasty (TKA). During revision knee arthroplasty however, elevation of the joint line occurs frequently. The general belief is that this negatively affects the clinical outcome, but the reasons are still not well understood. Material and methods In this cadaveric in vitro study the biomechanical consequences of joint line elevation were investigated using a previously validated cadaver model simulating active deep knee squats and passive flexion-extension cycles. Knee specimens were sequentially tested after total knee arthroplasty with joint line restoration and after 4 mm joint line elevation. Results The tibia rotated internally with increasing knee flexion during both passive and squatting motion (range: 17° and 7° respectively). Joint line elevation of 4 mm did not make a statistically significant difference. During passive motion, the tibia tended to become slightly more adducted with increasing knee flexion (range: 2°), while it went into slighlty less adduction during squatting (range: –2°). Neither of both trends was influenced by joint line elevation. Also anteroposterior translation of the femoral condyle centres was not affected by joint line elevation, although there was a tendency for a small posterior shift (of about 3 mm) during squatting after joint line elevation. In terms of kinetics, ligaments lengths and length changes, tibiofemoral contact pressures and quadriceps forces all showed the same patterns before and joint line elevation. No statistically significant changes could be detected. Conclusions Our study suggests that joint line elevation by 4 mm in revision total knee arthroplasty does not cause significant kinematic and kinetic differences during passive flexion/extension movement and squatting in the tibio-femoral joint, nor does it affect the elongation patterns of collateral ligaments. Therefore, clinical

Conservative treatment of an acute traumatic extensor carpi ulnaris tendon subluxation in a collegiate basketball player: a case report.

PubMed

Patterson, Steve M; Picconatto, William J; Alexander, Julie A; Johnson, Rachel L

2011-01-01

To present the case of an acute traumatic extensor carpi ulnaris (ECU) subluxation in a National Collegiate Athletic Association Division II female basketball player. The ECU tendon is stabilized in the ulnar groove by a subsheath located inferior to the extensor retinaculum. The subsheath can be injured with forced supination, ulnar deviation, and wrist flexion, resulting in the ECU tendon subluxing in the palmar and ulnar directions during wrist circumduction. Several methods of intervention exist, but controversy remains on how to best treat this condition. Distal ulnar fracture, ulnar collateral ligament sprain, triangular fibrocartilage complex lesion, lunotriquetral instability, distal radioulnar joint injury, pisotriquetral joint injury, ECU tendinopathy or subluxation. The wrist was placed in a short-arm cast in slight extension and radial deviation for 4 weeks. At that time, the patient was still able to actively sublux the ECU tendon, so a long-arm cast was applied with the wrist in slight extension, radial deviation, and pronation for an additional 4 weeks. The ECU tendon was then found to be stable. She wore a rigid wrist brace for 3 more weeks while she pursued rehabilitation. At the final follow-up appointment, the ECU tendon remained stable, and the wrist was asymptomatic. Subluxations of the ECU are rare. If the patient does not improve with conservative measures, surgical intervention is warranted to repair the sixth dorsal compartment. A long-arm cast with the elbow flexed to 90° and the wrist in approximately 30° of extension, radial deviation, and pronation was appropriate treatment for this type of injury.

Quantitative magnetic resonance imaging analysis of the cross-sectional areas of the anconeus epitrochlearis muscle, cubital tunnel, and ulnar nerve with the elbow in extension in patients with and without ulnar neuropathy.

PubMed

Eng, Hing Y; Gunio, Drew A; Benitez, Carlos L

2018-05-10

The purpose of this study was to assess the cross-sectional area of the anconeus epitrochlearis muscle (AEM), cubital tunnel, and ulnar nerve with the elbow in extension in patients with and without ulnar neuropathy. We performed a retrospective, level IV review of elbow magnetic resonance imaging (MRI) studies. Elbow MRI studies of 32 patients with an AEM (26 men and 6 women, aged 18-60 years), 32 randomly selected patients without an AEM (aged 16-71 years), and 32 patients with clinical ulnar neuritis (22 men and 10 women, aged 24-76 years) were reviewed. We evaluated the ulnar nerve cross-sectional area proximal to, within, and distal to the cubital tunnel; AEM cross-sectional area; and cubital tunnel cross-sectional area. We found no significant difference in the nerve caliber between patients with and without an AEM. No correlation was found between the AEM cross-sectional area and ulnar nerve cross-sectional area within the cubital tunnel (r = 0.14). The mean cubital tunnel cross-sectional area was larger in patients with an AEM. Only 4 of the 32 patients with an AEM had findings of ulnar neuritis on MRI. Of the 32 patients with a clinical diagnosis of ulnar neuritis, only 2 had an AEM. With the elbow in extension, the presence or cross-sectional area of an AEM does not correlate with the area of the ulnar nerve or cubital tunnel. Only a small number of individuals with MRI evidence of an AEM had clinical evidence of ulnar neuropathy. Likewise, MRI evidence of an AEM was found in only a small number of individuals with clinical evidence of ulnar neuropathy. Copyright © 2018 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.

Effect of the Distal Femoral Joint Line on Ligament Tensions in Flexion with Cruciate-Retaining Total Knee Prostheses.

PubMed

Narayanan, Rajkishen; Lenz, Nathaniel; Werner, Jordan Alexander; Cross, Michael B; Hughes, Dean; Laster, Scott; Schwarzkopf, Ran

2018-04-13

Proper ligament tension in knee flexion within cruciate-retaining (CR) total knee arthroplasty has long been associated with clinical success; however, traditional balancing principles have assumed that the distal femoral joint line (DFJL) affects only extension. The purpose of this study was to determine the effect DFJL may have on ligament strains and tibiofemoral kinematics of CR knee designs in flexion. A computational analysis was performed using a musculoskeletal modeling system for two different knee implants, the high-flex CR (HFCR) and guided-motion CR (GMCR). Tibiofemoral kinematics and ligament strain were measured at 90-degree knee flexion while the implants' DFJL was incrementally shifted proximally. Femoral implant position and kinematics were used to determine the femur's anteroposterior position relative to the tibia. The change in the femoral medial condyle position relative to the tibia was 0.33 mm and 0.53 mm more anterior per each 1-mm elevation of the DFJL for HFCR and GMCR, respectively. The change in the lateral condyle position was 0.20 mm more anterior and 0.06 mm more posterior for HFCR and GMCR, respectively. The strain in the lateral and medial collateral ligaments changed minimally with elevation of the DFJL. In both implants, strain increased in the anterior lateral and posterior medial bundles of the posterior collateral ligament with elevation of the DFJL, whereas strain decreased in the iliotibial band and iliotibial patellar band. Our findings suggest that DFJL affects ligament tension at 90-degree knee flexion and therefore flexion balance for CR implants. Elevating the DFJL to address tight extension space in a CR knee while flexion space is well balanced could result in increased flexion tension especially when the flexion-extension mismatch is large. To achieve balanced flexion and extension, the amount of DFJL elevation may need to be reduced. Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.

How Anterior Cruciate Ligament Injury was averted during Knee Collapse in a NBA Point Guard.

PubMed

Schilaty, Nathan D; Bates, Nathaniel A; Krych, Aaron J; Hewett, Timothy E

2017-01-01

Non-contact anterior cruciate ligament (ACL) injuries occur with rapid decelerations and pivoting. A recent injury to a high-level National Basketball Association (NBA) player demonstrated neuromuscular control and injury-sparing mechanisms that resulted in only minor ligament injury to the medial collateral ligament. We analyzed biomechanical mechanisms via publically available orthogonal 2-D video to demonstrate how this potential ACL injury was averted. Analysis of the knee injury mechanism demonstrated that the NBA player experienced low ground reaction force, high sagittal plane flexion, and maintenance of frontal plane stability with neuromuscular control. The outcome of these factors inhibited dynamic valgus collapse of the knee throughout the fall, avoiding ACL injury - a potentially career-altering injury. Many athletes, professional and recreational, will be subjected to similar mechanisms of injury and will have improved outcomes if they can successfully utilize preventive strategies of neuromuscular control to limit injury mechanisms.

Stroke etiology and collaterals: atheroembolic strokes have greater collateral recruitment than cardioembolic strokes.

PubMed

Rebello, L C; Bouslama, M; Haussen, D C; Grossberg, J A; Dehkharghani, S; Anderson, A; Belagaje, S R; Bianchi, N A; Grigoryan, M; Frankel, M R; Nogueira, R G

2017-06-01

Chronic hypoperfusion from athero-stenotic lesions is thought to lead to better collateral recruitment compared to cardioembolic strokes. It was sought to compare collateral flow in stroke patients with atrial fibrillation (AF) versus stroke patients with cervical atherosclerotic steno-occlusive disease (CASOD). This was a retrospective review of a prospectively collected endovascular database. Patients with (i) anterior circulation large vessel occlusion stroke, (ii) pre-treatment computed tomography angiography (CTA) and (iii) intracranial embolism from AF or CASOD were included. CTA collateral patterns were evaluated and categorized into two groups: absent/poor collaterals (CTA collateral score 0-1) versus moderate/good collaterals (CTA collateral score 2-4). CT perfusion was also utilized for baseline core volume and evaluation of infarct growth. A total of 122 patients fitted the inclusion criteria, of whom 88 (72%) had AF and 34 (27%) CASOD. Patients with AF were older (P < 0.01) and less often males or smokers (P = 0.04 and P < 0.01 respectively). Baseline National Institutes of Health Stroke Scale and Alberta Stroke Program Early CT Score were comparable between groups. Collateral scores were lower in the AF group (P = 0.01) with patients having poor collaterals in 28% of cases versus 9% in the CASOD group (P = 0.03). Mortality rates (20% vs. 0%; P = 0.02) were higher in the AF patients whilst rates of any parenchymal hemorrhage (6% vs. 26%; P < 0.01) were higher in the CASOD group. On multivariable analysis, CASOD was an independent predictor of moderate/good collaterals (odds ratio 4.70; 95% confidence interval 1.17-18.79; P = 0.03). Atheroembolic strokes seem to be associated with better collateral flow compared to cardioembolic strokes. This may in part explain the worse outcomes of AF-related stroke. © 2017 EAN.

How does ulnar shortening osteotomy influence morphologic changes in the triangular fibrocartilage complex?

PubMed

Yamanaka, Yoshiaki; Nakamura, Toshiyasu; Sato, Kazuki; Toyama, Yoshiaki

2014-11-01

Ulnar shortening osteotomy often is indicated for treatment of injuries to the triangular fibrocartilage complex (TFCC). However, the effect of ulnar shortening osteotomy on the changes in shape of the TFCC is unclear. In our study, quantitative evaluations were performed using MRI to clarify the effect of ulnar shortening on triangular fibrocartilage (TFC) thickness attributable to disc regeneration of the TFC and TFC angle attributable to the suspension effect of ulnar shortening on the TFC. The purposes of this study were (1) to compare preoperative and postoperative TFC thickness and TFC angle on MR images to quantitatively evaluate the effect of ulnar shortening osteotomy on disc regeneration and the suspension effect on the TFC; and (2) to assess whether changes in TFC thickness and TFC angle correlated with the Mayo wrist score. Between 1995 and 2008, 256 patients underwent ulnar shortening osteotomy for TFCC injuries. The minimum followup was 24 months (mean, 51 months; range, 24-210 months). A total of 79 patients (31%) with complete followup including preoperative and postoperative MR images and the Mayo wrist score was included in this retrospective study. Evaluation of the postoperative MR images and the Mayo wrist score were performed at the final followup. The remaining 177 patients did not undergo postoperative MRI, or they had a previous fracture, large tears of the disc proper, or were lost to followup. Two orthopaedists, one of whom performed the surgeries, measured the TFC thickness and the TFC angle on coronal MR images before and after surgery for each patient. Correlations of the percent change in the TFC thickness and the magnitude of TFC angle change with age, sex, postoperative MR images, extent of ulnar shortening, preoperative ulnar variance, and postoperative Mayo wrist score were assessed. Stepwise regression analysis showed a correlation between the percent change in TFC thickness and preoperative ulnar variance (R2=0.21; β=-0.33; 95

High-Resolution 3T MR Imaging of the Triangular Fibrocartilage Complex

PubMed Central

von Borstel, Donald; Wang, Michael; Small, Kirstin; Nozaki, Taiki; Yoshioka, Hiroshi

2017-01-01

This study is intended as a review of 3Tesla (T) magnetic resonance (MR) imaging of the triangular fibrocartilage complex (TFCC). The recent advances in MR imaging, which includes high field strength magnets, multi-channel coils, and isotropic 3-dimensional (3D) sequences have enabled the visualization of precise TFCC anatomy with high spatial and contrast resolution. In addition to the routine wrist protocol, there are specific techniques used to optimize 3T imaging of the wrist; including driven equilibrium sequence (DRIVE), parallel imaging, and 3D imaging. The coil choice for 3T imaging of the wrist depends on a number of variables, and the proper coil design selection is critical for high-resolution wrist imaging with high signal and contrast-to-noise ratio. The TFCC is a complex structure and is composed of the articular disc (disc proper), the triangular ligament, the dorsal and volar radioulnar ligaments, the meniscus homologue, the ulnar collateral ligament (UCL), the extensor carpi ulnaris (ECU) tendon sheath, and the ulnolunate and ulnotriquetral ligaments. The Palmer classification categorizes TFCC lesions as traumatic (type 1) or degenerative (type 2). In this review article, we present clinical high-resolution MR images of normal TFCC anatomy and TFCC injuries with this classification system. PMID:27535592

High-Resolution 3T MR Imaging of the Triangular Fibrocartilage Complex.

PubMed

von Borstel, Donald; Wang, Michael; Small, Kirstin; Nozaki, Taiki; Yoshioka, Hiroshi

2017-01-10

This study is intended as a review of 3Tesla (T) magnetic resonance (MR) imaging of the triangular fibrocartilage complex (TFCC). The recent advances in MR imaging, which includes high field strength magnets, multi-channel coils, and isotropic 3-dimensional (3D) sequences have enabled the visualization of precise TFCC anatomy with high spatial and contrast resolution. In addition to the routine wrist protocol, there are specific techniques used to optimize 3T imaging of the wrist; including driven equilibrium sequence (DRIVE), parallel imaging, and 3D imaging. The coil choice for 3T imaging of the wrist depends on a number of variables, and the proper coil design selection is critical for high-resolution wrist imaging with high signal and contrast-to-noise ratio. The TFCC is a complex structure and is composed of the articular disc (disc proper), the triangular ligament, the dorsal and volar radioulnar ligaments, the meniscus homologue, the ulnar collateral ligament (UCL), the extensor carpi ulnaris (ECU) tendon sheath, and the ulnolunate and ulnotriquetral ligaments. The Palmer classification categorizes TFCC lesions as traumatic (type 1) or degenerative (type 2). In this review article, we present clinical high-resolution MR images of normal TFCC anatomy and TFCC injuries with this classification system.

An Unusual Log-splitter Injury Leading to Radial Artery Thrombosis, Ulnar Artery Laceration, and Scapholunate Dissociation

PubMed Central

Spock, Christopher R.; Salomon, Jeffrey C.; Narayan, Deepak

2008-01-01

A log splitter is a gasoline- or diesel-powered machine that uses a hydraulic-powered cutting wedge to do the work of an axe. Log-splitter injuries that do not result in amputation of digits or limbs are uncommon and not well described in the literature. We present a unique case of a patient who sustained a log-splitter injury that resulted in thrombosis of the radial artery and avulsion laceration of the ulnar artery leading to acute hand ischemia, in addition to scapholunate ligament disruption leading to a DISI deformity. In this case, thrombolytic therapy was contraindicated and surgical revascularization was the best possible treatment option. Our case illustrates the pitfalls of using this modality in a crush injury, since the use of thrombolytics in this instance would have resulted in severe hemorrhage. An important clinical caveat is the potentially misleading arteriographic diagnosis of thrombosis and/or spasm. PMID:18827886

Ulnar hammer syndrome: a systematic review of the literature.

PubMed

Vartija, Larisa; Cheung, Kevin; Kaur, Manraj; Coroneos, Christopher James; Thoma, Achilleas

2013-11-01

Ulnar hammer syndrome is an uncommon form of arterial insufficiency. Many treatments have been described, and debate continues about the best option. The goal of this systematic review was to determine whether ulnar hammer syndrome has an occupational association, to identify the most reliable diagnostic test, and to determine the best treatment modality. A comprehensive literature search was conducted using the Cochrane Database of Systematic Reviews, the Cochrane Central Register of Controlled Trials, MEDLINE, CINAHL, and EMBASE. Data from articles meeting inclusion criteria were collected in duplicate. Methodological quality of studies was assessed using the Methodological Index for Nonrandomized Studies scale. Thirty studies were included in the systematic review. No randomized controlled trials were identified. There is low-quality evidence suggestive of an association between exposure to repetitive hand trauma and vibration and ulnar hammer syndrome. Various diagnostic investigations were used, but few were compared, making it difficult to determine the most reliable diagnostic test. Numerous nonoperative and operative treatments were reported. With nonoperative treatment, 12 percent had complete resolution and 70 percent had partial resolution of their symptoms. Of patients treated operatively, 42.5 percent had complete resolution and 42.5 percent had partial resolution of their symptoms. The heterogeneity in study design and outcome measures limits definitive conclusions about occupational association, best diagnostic test, and treatment for ulnar hammer syndrome. However, there is low-quality evidence that suggests that most patients with ulnar hammer syndrome will have partial relief of symptoms with nonoperative treatment, and operative treatment results in complete or partial resolution of symptoms in the majority of cases. Therapeutic, IV.

How Anterior Cruciate Ligament Injury was averted during Knee Collapse in a NBA Point Guard

PubMed Central

Schilaty, Nathan D; Bates, Nathaniel A; Krych, Aaron J; Hewett, Timothy E

2017-01-01

Summary Non-contact anterior cruciate ligament (ACL) injuries occur with rapid decelerations and pivoting. A recent injury to a high-level National Basketball Association (NBA) player demonstrated neuromuscular control and injury-sparing mechanisms that resulted in only minor ligament injury to the medial collateral ligament. We analyzed biomechanical mechanisms via publically available orthogonal 2-D video to demonstrate how this potential ACL injury was averted. Analysis of the knee injury mechanism demonstrated that the NBA player experienced low ground reaction force, high sagittal plane flexion, and maintenance of frontal plane stability with neuromuscular control. The outcome of these factors inhibited dynamic valgus collapse of the knee throughout the fall, avoiding ACL injury – a potentially career-altering injury. Many athletes, professional and recreational, will be subjected to similar mechanisms of injury and will have improved outcomes if they can successfully utilize preventive strategies of neuromuscular control to limit injury mechanisms. PMID:28603786

High Ulnar Nerve Injuries: Nerve Transfers to Restore Function.

PubMed

Patterson, Jennifer Megan M

2016-05-01

Peripheral nerve injuries are challenging problems. Nerve transfers are one of many options available to surgeons caring for these patients, although they do not replace tendon transfers, nerve graft, or primary repair in all patients. Distal nerve transfers for the treatment of high ulnar nerve injuries allow for a shorter reinnervation period and improved ulnar intrinsic recovery, which are critical to function of the hand. Copyright © 2016 Elsevier Inc. All rights reserved.

Shear-wave elastography: a new potential method to diagnose ulnar neuropathy at the elbow.

PubMed

Paluch, Łukasz; Noszczyk, Bartłomiej; Nitek, Żaneta; Walecki, Jerzy; Osiak, Katarzyna; Pietruski, Piotr

2018-06-01

The primary aim of this study was to verify if shear-wave elastography (SWE) can be used to diagnose ulnar neuropathy at the elbow (UNE). The secondary objective was to compare the cross-sectional areas (CSA) of the ulnar nerve in the cubital tunnel and to determine a cut-off value for this parameter accurately identifying persons with UNE. The study included 34 patients with UNE (mean age, 59.35 years) and 38 healthy controls (mean age, 57.42 years). Each participant was subjected to SWE of the ulnar nerve at three levels: in the cubital tunnel (CT) and at the distal arm (DA) and mid-arm (MA). The CSA of the ulnar nerve in the cubital tunnel was estimated by means of ultrasonographic imaging. Patients with UNE presented with significantly greater ulnar nerve stiffness in the cubital tunnel than the controls (mean, 96.38 kPa vs. 33.08 kPa, p < 0.001). Ulnar nerve stiffness of 61 kPa, CT to DA stiffness ratio equal 1.68, and CT to MA stiffness ratio of 1.75 provided 100% specificity, sensitivity, positive and negative predictive value in the detection of UNE. Mean CSA of the ulnar nerve in the cubital tunnel turned out to be significantly larger in patients with UNE than in healthy controls (p < 0.001). A weak positive correlation was found in the UNE group between the ulnar nerve CSA and stiffness (R = 0.31, p = 0.008). SWE seems to be a promising, reliable and simple quantitative adjunct test to support the diagnosis of UNE. • SWE enables reliable detection of cubital tunnel syndrome • Significant increase of entrapped ulnar nerve stiffness is observed in UNE • SWE is a perspective screening tool for early detection of compressive neuropathies.

High-resolution 3T Magnetic Resonance Imaging of the Triangular Fibrocartilage Complex in Chinese Wrists: Correlation with Cross-sectional Anatomy.

PubMed

Zhan, Hui-Li; Li, Wen-Ting; Bai, Rong-Jie; Wang, Nai-Li; Qian, Zhan-Hua; Ye, Wei; Yin, Yu-Ming

2017-04-05

The injury of the triangular fibrocartilage complex (TFCC) is a common cause of ulnar-sided wrist pain. The aim of this study was to investigate if the high-resolution 3T magnetic resonance imaging (MRI) could demonstrate the detailed complex anatomy of TFCC in Chinese. Fourteen Chinese cadaveric wrists (from four men and three women; age range at death from 30 to 60 years; mean age at 46 years) and forty healthy Chinese wrists (from 20 healthy volunteers, male/female: 10/10; age range from 21 to 53 years with a mean age of 32 years) in Beijing Jishuitan Hospital from March 2014 to March 2016 were included in this study. All cadavers and volunteers had magnetic resonance (MR) examination of the wrist with coronal T1-weighted and proton density-weighted imaging with fat suppression in three planes, respectively. MR arthrography (MRAr) was performed on one of the cadaveric wrists. Subsequently, all 14 cadaveric wrists were sliced into 2 mm thick slab with band saw (six in coronal plane, four in sagittal plane, and four in axial plane). The MRI features of normal TFCC were analyzed in these specimens and forty healthy wrists. Triangular fibrocartilage, the ulnar collateral ligament, and the meniscal homolog could be best observed on images in coronal plane. The palmar and dorsal radioulnar ligaments were best evaluated in transverse plane. The ulnotriquetral and ulnolunate ligaments were best visualized in sagittal plane. The latter two structures and the volar and dorsal capsules were better demonstrated on MRAr. High-resolution 3T MRI is capable to show the detailed complex anatomy of the TFCC and can provide valuable information for the clinical diagnosis in Chinese.

Prolonged phone-call posture causes changes of ulnar motor nerve conduction across elbow.

PubMed

Padua, Luca; Coraci, Daniele; Erra, Carmen; Doneddu, Pietro Emiliano; Granata, Giuseppe; Rossini, Paolo Maria

2016-08-01

Postures and work-hobby activities may play a role in the origin and progression of ulnar neuropathy at the elbow (UNE), whose occurrence appears to be increasing. The time spent on mobile-phone has increased in the last decades leading to an increased time spent with flexed elbow (prolonged-phone-posture, PPP). We aimed to assess the effect of PPP both in patients with symptoms of UNE and in symptom-free subjects. Patients with pure sensory symptoms of UNE and negative neurophysiological tests (MIN-UNE) and symptom-free subjects were enrolled. We evaluated ulnar motor nerve conduction velocity across elbow at baseline and after 6, 9, 12, 15, and 18min of PPP in both groups. Fifty-six symptom-free subjects and fifty-eight patients were enrolled. Globally 186 ulnar nerves from 114 subjects were studied. Conduction velocity of ulnar nerve across the elbow significantly changed over PPP time in patients with MIN-UNE, showing a different evolution between the two groups. PPP causes a modification of ulnar nerve functionality in patients with MIN-UNE. PPP may cause transient stress of ulnar nerve at elbow. Copyright © 2016 International Federation of Clinical Neurophysiology. Published by Elsevier Ireland Ltd. All rights reserved.

Ulnar Rotation Osteotomy for Congenital Radial Head Dislocation.

PubMed

Liu, Ruiyu; Miao, Wusheng; Mu, Mingchao; Wu, Ge; Qu, Jining; Wu, Yongtao

2015-09-01

To evaluate an ulnar rotation osteotomy for congenital anterior dislocation of the radial head. Nine patients (5 boys and 4 girls aged 6 to 13 years) with congenital anterior dislocation of the radial head were treated with ulnar rotation osteotomy. Magnetic resonance imaging of the elbow showed the proximal radioulnar joint on the anterior-lateral side of the ulna rather than on the lateral side in patients with congenital anterior dislocation of the radial head. On the basis of this finding, we performed an osteotomy on the ulna and laterally rotated the proximal radioulnar joint achieving radial head reduction and restoring the anatomical relationship between the radial head and the capitellum. Clinical and radiographical evaluation of the elbow was performed before surgery and at postoperative follow-up. All patients were followed for 13 to 45 months after surgery. Elbow radiography showed that the radiocapitellar joint was reduced in all patients at the last follow-up visit and that the carrying angle was decreased relative to that in the preoperative condition. Elbow stability and the range of elbow flexion motion were improved at the last follow-up. We did not observe ulnar osteotomy site nonunion or elbow osteoarthritis in these patients. Furthermore, radial head dislocation did not recur. At early follow-up, ulnar rotation osteotomy was a safe and effective method for the treatment of congenital anterior dislocation of the radial head. Therapeutic IV. Copyright © 2015 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.

Visibility of Anterolateral Ligament Tears in Anterior Cruciate Ligament-Deficient Knees With Standard 1.5-Tesla Magnetic Resonance Imaging.

PubMed

Hartigan, David E; Carroll, Kevin W; Kosarek, Frank J; Piasecki, Dana P; Fleischli, James F; D'Alessandro, Donald F

2016-10-01

To attempt to visualize the ligament with standard 1.5-tesla magnetic resonance imaging (MRI) in the acute anterior cruciate ligament (ACL)-torn knee, and if it is visible, attempt to characterize it as torn or intact at its femoral, meniscal, and tibial attachment sites. This was a retrospective MRI study based on arthroscopic findings of a known ACL tear in 72 patients between the years 2006 and 2010. Patients all had hamstring ACL reconstructions, no concomitant lateral collateral ligament, or posterolateral corner injury based on imaging and physical examination, and had a preoperative 1.5-tesla MRI scan with standard sequences performed within 3 weeks of the injury. Two fellowship-trained musculoskeletal radiologists retrospectively reviewed the preoperative MRI for visualization of the anterolateral ligament (ALL) for concomitant tears. Inter- and intraobserver reliability was calculated. Learning effect was analyzed to determine if radiologists' agreement improved as reads progressed. Both radiologists were able to visualize the ALL in 100% of the scans. Overall, ALL tears were noted in 26% by radiologist 1 and in 62% by radiologist 2. The agreement between the ligament being torn or not had a kappa of 0.54 between radiologists. The agreements in torn or not torn between radiologists in the femoral, meniscal, and tibial sites were 0.14, 0.15, and 0.31. The intraobserver reliability by radiologist 1 for femoral, meniscal, and tibial tears was 0.04, 0.57, and 0.54 respectively. For radiologist 2, they were 0.75, 0.61, and 0.55. There was no learning effect noted. ALL tears are currently unable to be reliably identified as torn or intact on standard 1.5-tesla MRI sequences. Proper imaging sequences are of crucial importance to reliably follow these tears to determine their clinical significance. Level IV, therapeutic case series study. Copyright © 2016 Arthroscopy Association of North America. Published by Elsevier Inc. All rights reserved.

Skinfold thickness at 8 common cryotherapy sites in various athletic populations.

PubMed

Jutte, Lisa S; Hawkins, Jeremy; Miller, Kevin C; Long, Blaine C; Knight, Kenneth L

2012-01-01

Researchers have observed slower cooling rates in thigh muscle with greater overlying adipose tissue, suggesting that cryotherapy duration should be based on the adipose thickness of the treatment site. Skinfold data do not exist for other common cryotherapy sites, and no one has reported how those skinfolds might vary because of physical activity level or sex. To determine the variability in skinfold thickness among common cryotherapy sites relative to sex and activity level (National Collegiate Athletic Association Division I athletes, recreationally active college athletes). Descriptive laboratory study. Field. Three hundred eighty-nine college students participated; 196 Division I athletes (157 men, 39 women) were recruited during preseason physicals, and 193 recreationally active college athletes (108 men, 85 women) were recruited from physical education classes. Three skinfold measurements to within 1 mm were taken at 8 sites (inferior angle of the scapula, middle deltoid, ulnar groove, midforearm, midthigh, medial collateral ligament, midcalf, and anterior talofibular ligament [ATF]) using Lange skinfold calipers. Skinfold thickness in millimeters. We noted interactions among sex, activity level, and skinfold site. Male athletes had smaller skinfold measurements than female athletes at all sites except the ATF, scapula, and ulnar groove (F₇,₂₇₀₂ = 69.85, P < .001). Skinfold measurements were greater for recreationally active athletes than their Division I counterparts at all sites except the ATF, deltoid, and ulnar groove (F₇,₂₇₀₂ = 30.79, P < .001). Thigh skinfold measurements of recreationally active female athletes were the largest, and their ATF skinfolds were the smallest. Skinfold thickness at common cryotherapy treatment sites varied based on level of physical activity and sex. Therefore, clinicians should measure skinfold thickness to determine an appropriate cryotherapy duration.

Skinfold Thickness at 8 Common Cryotherapy Sites in Various Athletic Populations

PubMed Central

Jutte, Lisa S.; Hawkins, Jeremy; Miller, Kevin C.; Long, Blaine C.; Knight, Kenneth L.

2012-01-01

Context: Researchers have observed slower cooling rates in thigh muscle with greater overlying adipose tissue, suggesting that cryotherapy duration should be based on the adipose thickness of the treatment site. Skinfold data do not exist for other common cryotherapy sites, and no one has reported how those skinfolds might vary because of physical activity level or sex. Objective: To determine the variability in skinfold thickness among common cryotherapy sites relative to sex and activity level (National Collegiate Athletic Association Division I athletes, recreationally active college athletes). Design: Descriptive laboratory study. Setting: Field. Patients or Other Participants: Three hundred eighty-nine college students participated; 196 Division I athletes (157 men, 39 women) were recruited during preseason physicals, and 193 recreationally active college athletes (108 men, 85 women) were recruited from physical education classes. Intervention(s): Three skinfold measurements to within 1 mm were taken at 8 sites (inferior angle of the scapula, middle deltoid, ulnar groove, midforearm, midthigh, medial collateral ligament, midcalf, and anterior talofibular ligament [ATF]) using Lange skinfold calipers. Main Outcome Measure(s): Skinfold thickness in millimeters. Results: We noted interactions among sex, activity level, and skinfold site. Male athletes had smaller skinfold measurements than female athletes at all sites except the ATF, scapula, and ulnar groove (F7,2702 = 69.85, P < .001). Skinfold measurements were greater for recreationally active athletes than their Division I counterparts at all sites except the ATF, deltoid, and ulnar groove (F7,2702 = 30.79, P < .001). Thigh skinfold measurements of recreationally active female athletes were the largest, and their ATF skinfolds were the smallest. Conclusions: Skinfold thickness at common cryotherapy treatment sites varied based on level of physical activity and sex. Therefore, clinicians should measure

Differential aging of median and ulnar sensory nerve parameters.

PubMed

Werner, Robert A; Franzblau, Alfred; D'Arcy, Hannah J S; Evanoff, Bradley A; Tong, Henry C

2012-01-01

Nerve conduction velocity slows and amplitude declines with aging. Median and ulnar sensory nerves were tested at the annual meetings of the American Dental Association. Seven hundred four subjects had at least two observations. The rate of change in the nerve parameters was estimated while controlling for gender, age, change in hand temperature, baseline body mass index (BMI), and change in BMI. Amplitudes of the median sensory nerve action potentials decreased by 0.58 μV per year, whereas conduction velocity decreased at a rate of 0.41 m/s per year. Corresponding values for the ulnar nerve were 0.89 μV and 0.29 m/s per year. The rates of change in amplitudes did not differ, but the median nerve demonstrated a more rapid loss of conduction velocity. The rate of change for the median conduction velocity was higher than previously reported. The rate of change of median conduction velocity was significantly greater than for the ulnar nerve. Copyright © 2011 Wiley Periodicals, Inc.

Stimulus electrodiagnosis and motor and functional evaluations during ulnar nerve recovery

PubMed Central

Fernandes, Luciane F. R. M.; Oliveira, Nuno M. L.; Pelet, Danyelle C. S.; Cunha, Agnes F. S.; Grecco, Marco A. S.; Souza, Luciane A. P. S.

2016-01-01

BACKGROUND: Distal ulnar nerve injury leads to impairment of hand function due to motor and sensorial changes. Stimulus electrodiagnosis (SE) is a method of assessing and monitoring the development of this type of injury. OBJECTIVE: To identify the most sensitive electrodiagnostic parameters to evaluate ulnar nerve recovery and to correlate these parameters (Rheobase, Chronaxie, and Accommodation) with motor function evaluations. METHOD: A prospective cohort study of ten patients submitted to ulnar neurorrhaphy and evaluated using electrodiagnosis and motor assessment at two moments of neural recovery. A functional evaluation using the DASH questionnaire (Disability of the Arm, Shoulder, and Hand) was conducted at the end to establish the functional status of the upper limb. RESULTS: There was significant reduction only in the Chronaxie values in relation to time of injury and side (with and without lesion), as well as significant correlation of Chronaxie with the motor domain score. CONCLUSION: Chronaxie was the most sensitive SE parameter for detecting differences in neuromuscular responses during the ulnar nerve recovery process and it was the only parameter correlated with the motor assessment. PMID:26786072

Editorial Commentary: The All-Epiphyseal Anterior Cruciate Ligament Distal Femoral Approach: Sockets or Tunnels?

PubMed

Cordasco, Frank A

2018-05-01

I believe that the distal femoral approach for anterior cruciate ligament reconstruction in the skeletally immature athlete with 3 to 6 years of remaining growth is best performed with an all-inside, all-epiphyseal technique using sockets rather than an outside-in approach creating tunnels. A shorter socket rather than a longer tunnel exposes a smaller surface area of the lateral distal femoral physis to potential compromise and resultant valgus malalignment. In addition, exiting the lateral femoral aspect of the epiphysis with a full-diameter tunnel as compared with a smaller diameter drill hole used to prepare a socket places the posterior articular cartilage, the lateral collateral ligament and anterolateral ligament footprints, and the popliteus tendon insertion at risk. My preference for sockets is also related to my belief that they provide a superior biologic milieu for graft incorporation compared with a full-length tunnel with the attendant violation of the lateral femoral cortex of the epiphysis. Copyright © 2018 Arthroscopy Association of North America. Published by Elsevier Inc. All rights reserved.

In vivo axial humero-ulnar rotation in normal and dysplastic canine elbow joints.

PubMed

Rohwedder, Thomas; Fischer, Martin; Böttcher, Peter

2018-04-01

To prospectively compare relative axial (internal-external) humero-ulnar rotation in normal and dysplastic canine elbow joints. Six normal elbows (five dogs) and seven joints (six dogs) with coronoid disease were examined. After implantation of 0.8 mm tantalum beads into humerus and ulna, biplanar x-ray movies of the implanted elbows were taken while dogs were walking on a treadmill. Based on the 2D bead coordinates of the synchronized x-ray movies virtual 3D humero-ulnar animations were calculated. Based on these, relative internal-external humero-ulnar rotation was measured over the first third of stance phase and expressed as maximal rotational amplitude. Amplitudes from three consecutive steps were averaged and groupwise compared using an unpaired t-test. In normal elbow joints mean axial relative humero-ulnar rotation was 2.9° (SD 1.1). Dysplastic joints showed a significantly greater rotational amplitude (5.3°, SD 2.0; p = 0.0229, 95% confidence interval 0.4-4.4). Dysplastic elbow joints show greater relative internal-external humero-ulnar rotation compared to normal elbows, which might reflect rotational joint instability. Increased relative internal-external humero-ulnar rotation might alter physiological joint contact and pressure patterns. Future studies are needed to verify if this plays a role in the pathogenesis of medial coronoid disease. Schattauer GmbH.

Collaterals management during pancreatoduodenectomy in patients with celiac axis stenosis: A systematic review of the literature.

PubMed

Giovanardi, Francesco; Lai, Quirino; Garofalo, Manuela; Arroyo Murillo, Gabriela A; Choppin de Janvry, Eleonore; Hassan, Redan; Larghi Laureiro, Zoe; Consolo, Adriano; Melandro, Fabio; Berloco, Pasquale B

2018-05-15

Celiac axis stenosis (CAS) represents an uncommon and typically innocuous condition. However, when a pancreatic resection is required, a high risk for upper abdominal organs ischemia is observed. In presence of collaterals, such a risk is minimized if their preservation is realized. The aim of the present study is to systematically review the literature with the intent to address the routine management of collateral arteries in the case of CAS patients requiring pancreatoduodenectomy. A systematic search was done in accordance with the PRISMA guidelines, using "celiac axis stenosis" AND "pancreatoduodenectomy" as MeSH terms. Seventy-four articles were initially screened: eventually, 30 articles were identified (n = 87). The main cause of CAS was median arcuate ligament (MAL) (n = 31; 35.6%), followed by atherosclerosis (n = 20; 23.0%). CAS was occasionally discovered during the Whipple procedure in 15 (17.2%) cases. Typically, MAL was divided during surgery (n = 24/31; 77.4%). In the great majority of cases (n = 83; 95.4%), vascular abnormalities involved the pancreatoduodenal arteries (i.e., dilatation, arcade, channels, aneurysms). Collateral arteries were typically preserved, being divided or reconstructed in only 14 (16.1%) cases, respectively. Severe ischemic complications were reported in six (6.9%) patients, 20.0% of whom were reported in patients with preoperatively unknown CAS (p-value 0.06). A correct pre-operative evaluation of anatomical conditions as well as a correct surgical planning represent the paramount targets in CAS patients with arterial collaterals. Vascular flow must be always safeguarded preserving/reconstructing the collaterals or resolving the CAS, with the final intent to avoid dreadful intra- and post-operative complications. Copyright © 2018 IAP and EPC. Published by Elsevier B.V. All rights reserved.

Influence of Medial Collateral Ligament Release for Internal Rotation of Tibia in Posterior-Stabilized Total Knee Arthroplasty: A Cadaveric Study.

PubMed

Wada, Keizo; Hamada, Daisuke; Tamaki, Shunsuke; Higashino, Kosaku; Fukui, Yoshihiro; Sairyo, Koichi

2017-01-01

Previous studies suggested that changes in kinematics in total knee arthroplasty (TKA) affected satisfaction level. The aim of this cadaveric study was to evaluate the effect of medial collateral ligament (MCL) release by multiple needle puncture on knee rotational kinematics in posterior-stabilized TKA. Six fresh, frozen cadaveric knees were included in this study. All TKA procedures were performed with an image-free navigation system using a 10-mm polyethylene insert. Tibial internal rotation was assessed to evaluate intraoperative knee kinematics. Multiple needle puncturing was performed 5, 10, and 15 times for the hard portion of the MCL at 90° knee flexion. Kinematic analysis was performed after every 5 punctures. After performing 15 punctures, a 14-mm polyethylene insert was inserted, and kinematic analysis was performed. The tibial internal rotation angle at maximum knee flexion without multiple needle puncturing was significantly larger (9.42°) than that after 15 punctures (3°). Negative correlation (Pearson r = -0.715, P < .001) between tibial internal rotation angle at maximum knee flexion and frequency of puncture was observed. The tibial internal rotation angle with a 14-mm insert was significantly larger (7.25°) compared with the angle after 15 punctures. Tibial internal rotation during knee flexion was reduced by extensive MCL release using multiple needle puncturing and was recovered by increasing of medial tightness. From the point of view of knee kinematics, medial tightness should be allowed to maintain the internal rotation angle of the tibia during knee flexion which might lead to patient satisfaction. Copyright © 2016 Elsevier Inc. All rights reserved.

Sonoanatomy of sensory branches of the ulnar nerve below the elbow in healthy subjects.

PubMed

Kim, Ki Hoon; Lee, Seok Jun; Park, Byung Kyu; Kim, Dong Hwee

2018-04-01

We identify sensory branches of the ulnar nerve-palmar ulnar cutaneous nerve (PUCN), dorsal ulnar cutaneous nerve (DUCN), and superficial sensory branch-using ultrasonography. In 60 forearms of 30 healthy adult volunteers, the origin and size of the PUCN, DUCN, and superficial sensory branch were measured by ultrasonography. The relative pathway of the DUCN to the ulnar styloid process was also investigated. The PUCN was observed in 47 forearms (78%), and the DUCN was observed in all forearms. Average distances from the pisiform to the origin of the PUCN and DUCN were 11.9 ± 1.4 and 7.0 ± 1.0 cm, respectively. Superficial and deep divisions split 0.9 ± 0.3 cm distal to the pisiform. Cross-sectional areas of the PUCN, DUCN, and superficial sensory branch were 0.3 ± 0.1, 1.5 ± 0.5, and 3.9 ± 1.0 mm 2 , respectively. Sensory branches of the ulnar nerve can be visualized by ultrasonography, helping to differentiate ulnar nerve injury originating at either wrist or elbow. Muscle Nerve 57: 569-573, 2018. © 2017 Wiley Periodicals, Inc.

Influence of recreational activity and muscle strength on ulnar bending stiffness in men

NASA Technical Reports Server (NTRS)

Myburgh, K. H.; Charette, S.; Zhou, L.; Steele, C. R.; Arnaud, S.; Marcus, R.

1993-01-01

Bone bending stiffness (modulus of elasticity [E] x moment of inertia [I]), a measure of bone strength, is related to its mineral content (BMC) and geometry and may be influenced by exercise. We evaluated the relationship of habitual recreational exercise and muscle strength to ulnar EI, width, and BMC in 51 healthy men, 28-61 yr of age. BMC and width were measured by single photon absorptiometry and EI by mechanical resistance tissue analysis. Maximum biceps strength was determined dynamically (1-RM) and grip strength isometrically. Subjects were classified as sedentary (S) (N = 13), moderately (M) (N = 18), or highly active (H) (N = 20) and exercised 0.2 +/- 0.2; 2.2 +/- 1.3; and 6.8 +/- 2.3 h.wk-1 (P < 0.001). H had greater biceps (P < 0.0005) and grip strength (P < 0.05), ulnar BMC (P < 0.05), and ulnar EI (P = 0.01) than M or S, who were similar. Amount of activity correlated with grip and biceps strength (r = 0.47 and 0.49; P < 0.001), but not with bone measurements, whereas muscle strength correlated with both EI and BMC (r = 0.40-0.52, P < 0.005). EI also correlated significantly with both BMC and ulnar width (P < 0.0001). Ulnar width and biceps strength were the only independent predictors of EI (r2 = 0.67, P < 0.0001). We conclude that levels of physical activity sufficient to increase arm strength influence ulnar bending stiffness.

Pentadecapeptide BPC 157 (PL 14736) improves ligament healing in the rat.

PubMed

Cerovecki, Tomislav; Bojanic, Ivan; Brcic, Luka; Radic, Bozo; Vukoja, Ivan; Seiwerth, Sven; Sikiric, Predrag

2010-09-01

We improved medial collateral ligament (MCL) healing throughout 90 days after surgical transection. We introduced intraperitoneal, per-oral (in drinking water) and topical (thin cream layer) peptide therapy always given alone, without a carrier. Previously, as an effective peptide therapy, stable gastric pentadecapeptide BPC 157 (GEPPPGKPADDAGLV, an anti-ulcer peptide effective in inflammatory bowel disease therapy (PL 14736)) particularly improved healing of transected tendon and muscle and wound healing effect including the expression of the early growth response 1 (egr-1) gene. After MCL transection BPC 157 was effective in rats when given once daily intraperitoneally (10 microg or 10 ng/kg) or locally as a thin layer (1.0 microg dissolved in distilled water/g commercial neutral cream) at the site of injury, first application 30 min after surgery and the final application 24 h before sacrifice. Likewise, BPC 157 was effective given per-orally (0.16 microg/ml in the drinking water (12 ml/day/rat)) until sacrifice. Commonly, BPC 157 microg-ng-rats exhibited consistent functional, biomechanical, macroscopic and histological healing improvements. Thus, we suggest BPC 157 improved healing of acute ligament injuries in further ligament therapy. (c) 2010 Orthopaedic Research Society. Published by Wiley Periodicals, Inc.

Anatomy and Histology of the Knee Anterolateral Ligament.

PubMed

Helito, Camilo Partezani; Demange, Marco Kawamura; Bonadio, Marcelo Batista; Tírico, Luis Eduardo Passarelli; Gobbi, Riccardo Gomes; Pécora, José Ricardo; Camanho, Gilberto Luis

2013-12-01

Reconstruction of the anterior cruciate ligament (ACL) is one of the most common procedures in orthopaedic surgery. However, even with advances in surgical techniques and implants, some patients still have residual anterolateral rotatory laxity after reconstruction. A thorough study of the anatomy of the anterolateral region of the knee is needed. To study the anterolateral region and determine the measurements and points of attachments of the anterolateral ligament (ALL). Descriptive laboratory study. Dissections of the anterolateral structures of the knee were performed in 20 human cadavers. After isolating the ALL, its length, thickness, width, and points of attachments were determined. The femoral attachment of the ALL was based on the anterior-posterior and proximal-distal distances from the attachment of the lateral collateral ligament (LCL). The tibial attachment point was based on the distance from the Gerdy tubercle to the fibular head and the distance from the lateral tibial plateau. The ligaments from the first 10 dissections were sent for histological analysis. The ALL was found in all 20 knees. The femoral attachment of the ALL at the lateral epicondyle averaged 3.5 mm distal and 2.2 mm anterior to the attachment of the LCL. Two distal attachments were observed: one inserts into the lateral meniscus, the other between the Gerdy tubercle and the fibular head, approximately 4.4 mm distal to the tibial articular cartilage. The mean measurements for the ligament were 37.3 mm (length), 7.4 mm (width), and 2.7 mm (thickness). The histological analysis of the ligaments revealed dense connective tissue. The ALL is consistently present in the anterolateral region of the knee. Its attachment to the femur is anterior and distal to the attachment of the LCL. Moving distally, it bifurcates at close to half of its length. The ALL features 2 distal attachments, one at the lateral meniscus and the other between the Gerdy tubercle and the fibular head. The ALL may be

Anatomy and Biomechanics of the Finger Proximal Interphalangeal Joint.

PubMed

Pang, Eric Quan; Yao, Jeffrey

2018-05-01

A complete understanding of the normal anatomy and biomechanics of the proximal interphalangeal joint is critical when treating pathology of the joint as well as in the design of new reconstructive treatments. The osseous anatomy dictates the principles of motion at the proximal interphalangeal joint. Subsequently, the joint is stabilized throughout its motion by the surrounding proximal collateral ligament, accessory collateral ligament, and volar plate. The goal of this article is to review the normal anatomy and biomechanics of the proximal interphalangeal joint and its associated structures, most importantly the proper collateral ligament, accessory collateral ligament, and volar plate. Copyright © 2017 Elsevier Inc. All rights reserved.

Three-dimensional analysis of elbow soft tissue footprints and anatomy.

PubMed

Capo, John T; Collins, Christopher; Beutel, Bryan G; Danna, Natalie R; Manigrasso, Michaele; Uko, Linda A; Chen, Linda Y

2014-11-01

Tendinous and ligamentous injuries commonly occur in the elbow. This study characterized the location, surface areas, and origin and insertional footprints of major elbow capsuloligamentous and tendinous structures in relation to bony landmarks with the use of a precision 3-dimensional modeling system. Nine unpaired cadaveric elbow specimens were dissected and mounted on a custom jig. Mapping of the medial collateral ligament (MCL), lateral ulnar collateral ligament (LUCL), triceps, biceps, brachialis, and capsular reflections was then performed with 3-dimensional digitizing technology. The location, surface areas, and footprints of the soft tissues were calculated. The MCL had a mean origin (humeral) footprint of 216 mm(2), insertional footprint of 154 mm(2), and surface area of 421 mm(2). The LUCL had a mean origin footprint of 136 mm(2), an insertional footprint of 142 mm(2), and a surface area of 532 mm(2). Of the tendons, the triceps maintained the largest insertional footprint, followed by the brachialis and the biceps (P < .001-.03). The MCL, LUCL, and biceps footprint locations were consistent, with little variability. The surface areas of the anterior (1251 mm(2)) and posterior (1147 mm(2)) capsular reflections were similar (P = .82), and the anterior capsule extended farther proximally. Restoring the normal anatomy of key elbow capsuloligamentous and tendinous structures is crucial for effective reconstruction after bony or soft tissue trauma. This study provides the upper extremity surgeon with information that may aid in restoring elbow biomechanics and preserving range of motion in these patients. Copyright © 2014 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.

The impact of extended electrodiagnostic studies in Ulnar Neuropathy at the elbow

PubMed Central

Todnem, Kari; Michler, Ralf Peter; Wader, Tony Eugen; Engstrøm, Morten; Sand, Trond

2009-01-01

Background This study aimed to explore the value of extended motor nerve conduction studies in patients with ulnar nerve entrapment at the elbow (UNE) in order to find the most sensitive and least time-consuming method. We wanted to evaluate the utility of examining both the sensory branch from the fifth finger and the dorsal branch of the ulnar nerve. Further we intended to study the clinical symptoms and findings, and a possible correlation between the neurophysiological findings and pain. Methods The study was prospective, and 127 UNE patients who were selected consecutively from the list of patients, had a clinical and electrodiagnostic examination. Data from the most symptomatic arm were analysed and compared to the department's reference limits. Student's t - test, chi-square tests and multiple regression models were used. Two-side p-values < 0.05 were considered as significant. Results Ulnar paresthesias (96%) were more common than pain (60%). Reduced ulnar sensitivity (86%) and muscle strength (48%) were the most common clinical findings. Adding a third stimulation site in the elbow mid-sulcus for motor conduction velocity (MCV) to abductor digiti minimi (ADM) increased the electrodiagnostic sensitivity from 80% to 96%. Additional recording of ulnar MCV to the first dorsal interosseus muscle (FDI) increased the sensitivity from 96% to 98%. The ulnar fifth finger and dorsal branch sensory studies were abnormal in 39% and 30% of patients, respectively. Abnormal electromyography in FDI was found in 49% of the patients. Patients with and without pain had generally similar conduction velocity parameter means. Conclusion We recommend three stimulation sites at the elbow for MCV to ADM. Recording from FDI is not routinely indicated. Sensory studies and electromyography do not contribute much to the sensitivity of the electrodiagnostic evaluation, but they are useful to document axonal degeneration. Most conduction parameters are unrelated to the presence of pain

Evaluation of the Morphology and Function of Medial Collateral Ligament afterTotal Knee Arthroplasty with High-frequency Ultrasound.

PubMed

Jiang, Ling; Liu, Yan-Qing; Cui, Li-Gang; Meng, Ying; Tian, Hua; Zhang, Ke; Wang, Jin-Rui

2016-10-10

Objective To explore the feasibility and clinical value of ultrasonography in evaluating the morphology and function of medial collateral ligaments (MCL) after total knee arthroplasty (TKA). Methods Totally 38 patients undergoing routine KTA (group A) and 22 patients undergoing constrained condylar knee arthroplasty KTA with MCL injury (group B) were included. Long axis views of MCL were taken and the MCL thickness was measured on femur side and tibial side 1 cm away from the joint line, respectively. The thicknesses were compared between the two groups. Subsequently, the gap between the metal part of the femoral prosthesis and the spacer after dynamic valgus stress was measured. The distribution and composition of the gap between the two groups were compared. Results High-frequency ultrasound clearly showed the prosthesis and MCL after TKA. MCL fiber structures of both groups were intact. The MCL thickness on the tibial side in group B was (0.25±0.06)cm, which was significantly thinner than group A [(0.32±0.14)cm] (t=2.12, P=0.040).For the femur side, there was no significant difference (t=1.65, P=0.110) between these two groups [(0.37±0.09) cm in group B versus (0.42±0.12)cm in group A]. Under the condition of valgus stress, the gaps between the metal part of the femoral prosthesis and the spacer could be found in 11 cases in group B but only in 1 case in group A. The proportion of gaps in group B was significantly higher than that in group A (Fisher's exact test, P=0.000). Conclusions High-frequency ultrasound can clearly show the prosthesis and MCL after TKA. The injured MCL can be well joined but the thickness is thinner. Under the condition of valgus stress of the knee, the stability of the TKA can be evaluated according to the gap between the prosthesis and the spacer.

Cooling modifies mixed median and ulnar palmar studies in carpal tunnel syndrome.

PubMed

Araújo, Rogério Gayer Machado de; Kouyoumdjian, João Aris

2007-09-01

Temperature is an important and common variable that modifies nerve conduction study parameters in practice. Here we compare the effect of cooling on the mixed palmar median to ulnar negative peak-latency difference (PMU) in electrodiagnosis of carpal tunnel syndrome (CTS). Controls were 22 subjects (19 women, mean age 42.1 years, 44 hands). Patients were diagnosed with mild symptomatic CTS (25 women, mean age 46.6 years, 34 hands). PMU was obtained at the usual temperature, >32 degrees C, and after wrist/hand cooling to <27 degrees C in ice water. After cooling, there was a significantly greater increase in PMU and mixed ulnar palmar latency in patients versus controls. We concluded that cooling significantly modifies the PMU. We propose that the latencies of compressed nerve overreact to cooling and that this response could be a useful tool for incipient CTS electrodiagnosis. There was a significant latency overreaction of the ulnar nerve to cooling in CTS patients. We hypothesize that subclinical ulnar nerve compression is associated with CTS.

Algorithmic pie-crusting of the medial collateral ligament guided by sensing technology affects the use of constrained inserts during total knee arthroplasty.

PubMed

Amundsen, Spencer; Lee, Yuo-Yu; González Della Valle, Alejandro

2017-06-01

Intra-operative sensing technology is an alternative to standard techniques in total knee arthroplasty (TKA) for determining balance by providing quantitative analysis of loads and point of contact throughout a range of motion. We used intra-operative sensing (VERASENSE-OrthoSensor, Inc.) to examine pie-crusting release of the medial collateral ligament in knees with varus deformity (study group) in comparison to a control group where balance was obtained using a classic release technique and assessed using laminar spreaders, spacer blocks, manual stress, and a ruler. The surgery was performed by a single surgeon utilizing measured resection and posterior-stabilized, cemented implants. Seventy-five study TKAs were matched 1:3 with 225 control TKAs. Outcome variables included the use of a constrained insert, functional- and knee-specific Knee Society score (KSS) at six weeks, four months, and one year post-operatively. Outcomes were analyzed in a multivariate model controlling for age, sex, BMI, and severity of deformity. The use of a constrained insert was significantly lower in the study group (5.3 vs. 13.8%; p = 0.049). The use of increased constraint was not significant between groups with increasing deformity. There was no difference in functional KSS and knee-specific KSS between groups at any follow-up interval. An algorithmic pie-crusting technique guided by intra-operative sensing is associated with decreased use of constrained inserts in TKA patients with a pre-operative varus deformity. This may cause a positive shift in value and cost savings.

High-resolution 3T Magnetic Resonance Imaging of the Triangular Fibrocartilage Complex in Chinese Wrists: Correlation with Cross-sectional Anatomy

PubMed Central

Zhan, Hui-Li; Li, Wen-Ting; Bai, Rong-Jie; Wang, Nai-Li; Qian, Zhan-Hua; Ye, Wei; Yin, Yu-Ming

2017-01-01

Background: The injury of the triangular fibrocartilage complex (TFCC) is a common cause of ulnar-sided wrist pain. The aim of this study was to investigate if the high-resolution 3T magnetic resonance imaging (MRI) could demonstrate the detailed complex anatomy of TFCC in Chinese. Methods: Fourteen Chinese cadaveric wrists (from four men and three women; age range at death from 30 to 60 years; mean age at 46 years) and forty healthy Chinese wrists (from 20 healthy volunteers, male/female: 10/10; age range from 21 to 53 years with a mean age of 32 years) in Beijing Jishuitan Hospital from March 2014 to March 2016 were included in this study. All cadavers and volunteers had magnetic resonance (MR) examination of the wrist with coronal T1-weighted and proton density-weighted imaging with fat suppression in three planes, respectively. MR arthrography (MRAr) was performed on one of the cadaveric wrists. Subsequently, all 14 cadaveric wrists were sliced into 2 mm thick slab with band saw (six in coronal plane, four in sagittal plane, and four in axial plane). The MRI features of normal TFCC were analyzed in these specimens and forty healthy wrists. Results: Triangular fibrocartilage, the ulnar collateral ligament, and the meniscal homolog could be best observed on images in coronal plane. The palmar and dorsal radioulnar ligaments were best evaluated in transverse plane. The ulnotriquetral and ulnolunate ligaments were best visualized in sagittal plane. The latter two structures and the volar and dorsal capsules were better demonstrated on MRAr. Conclusion: High-resolution 3T MRI is capable to show the detailed complex anatomy of the TFCC and can provide valuable information for the clinical diagnosis in Chinese. PMID:28345546

The pie-crusting technique using a blade knife for medial collateral ligament release is unreliable in varus total knee arthroplasty.

PubMed

Kwak, Dai-Soon; In, Yong; Kim, Tae Kyun; Cho, Han Suk; Koh, In Jun

2016-01-01

Despite the documented clinical efficacy of the pie-crusting technique for medial collateral ligament (MCL) release in varus total knee arthroplasty, its quantitative effects on medial gaps and safety remain unclear. This study was undertaken to determine the efficacy (quantitative effect and consistency of the number of punctures) and the safety (frequency of early over-release) of the pie-crusting technique for MCL release. From ten pairs of cadaveric knees, one knee from each pair was randomly assigned to undergo pie crusting in extension (group E) or in flexion (group F). Pie crusting was performed in the superficial MCL using a blade until over-release occurred. After every puncture, the incremental medial gap increase was recorded, and the number of punctures required for 2- or 4-mm gap increases was assessed. In group E, the extension gap increased from 0.8 to 5.0 mm and the flexion gap increased from 0.8 to 3.0 mm. In group F, the extension gap increased from 1.0 to 3.0 mm and the flexion gap increased from 2.6 to 6.0 mm. However, the gap increments were inconsistent with those that followed the preceding blade punctures, and the number of punctures required to increase the gaps by 2 or 4 mm was variable. The number of punctures leading to over-release in group E and group F was 6 ± 1 and 3 ± 1 punctures, respectively. Overall, 70% of over-release occurred earlier than the average number of punctures leading to over-release. Pie crusting led to unpredictable gap increments and to frequent early over-release. Surgeons should decide carefully before using the pie-crusting technique for MCL release and should be cautious of performing throughout the procedure, especially when performing in a flexed knee. Therapeutic study, Level I.

12 CFR 614.4245 - Collateral evaluation policies.

Code of Federal Regulations, 2010 CFR

2010-01-01

... 12 Banks and Banking 6 2010-01-01 2010-01-01 false Collateral evaluation policies. 614.4245... OPERATIONS Collateral Evaluation Requirements § 614.4245 Collateral evaluation policies. (a) The board of... shall adopt well-defined and effective collateral evaluation policies and standards, that comply with...

Investigating the relationship between internal tibial torsion and medial collateral ligament injury in patients undergoing knee arthroscopy due to tears in the posterior one third of the medial meniscus.

PubMed

Guler, Olcay; Isyar, Mehmet; Karataş, Dilek; Ormeci, Tugrul; Cerci, Halis; Mahirogulları, Mahir

2016-08-01

To evaluate the relationship between medial collateral ligament (MCL) injury and degree of internal tibial torsion in patients who had undergone arthroscopic resection due to tears in the posterior one third of the medial meniscus. Seventy-one patients were allocated into two groups with respect to foot femur angle (FFA) and transmalleolar angle (TMA) (Group 1 31 patients with FFA<8° and Group 2 40 patients with FFA≥8°). The groups were compared in terms of valgus instability, Lysholm score, magnetic resonance view, FFA, and TMA, both before and after the operation. Lysholm scores were higher in Group 2 at both postoperative week 1 (p<0.001) and month 1 (p=0.045) relative to Group 1. Preoperative cartilage injury was encountered more frequently in Group 1 (p=0.037) than in Group 2. MCL injury was detected more frequently in Group 1 compared to Group 2 postoperatively at week 1 (p=0.001). We conclude that FFA and TFA, indicators of internal tibial torsion, may serve as markers for foreseeing clinical improvement and complications following arthroscopic surgery. level III retrospective comparative study. Copyright © 2015 Elsevier B.V. All rights reserved.

7 CFR 4287.113 - Release of collateral.

Code of Federal Regulations, 2010 CFR

2010-01-01

... Loans § 4287.113 Release of collateral. (a) All releases of collateral with a value exceeding $100,000... loan. The Agency may, at its discretion, require an appraisal of the remaining collateral in cases... (a) of this section, lenders may, over the life of the loan, release collateral (other than personal...

25 CFR 502.5 - Collateral agreement.

Code of Federal Regulations, 2012 CFR

2012-04-01

... 25 Indians 2 2012-04-01 2012-04-01 false Collateral agreement. 502.5 Section 502.5 Indians NATIONAL INDIAN GAMING COMMISSION, DEPARTMENT OF THE INTERIOR GENERAL PROVISIONS DEFINITIONS OF THIS CHAPTER § 502.5 Collateral agreement. Collateral agreement means any contract, whether or not in writing...

25 CFR 502.5 - Collateral agreement.

Code of Federal Regulations, 2013 CFR

2013-04-01

... 25 Indians 2 2013-04-01 2013-04-01 false Collateral agreement. 502.5 Section 502.5 Indians NATIONAL INDIAN GAMING COMMISSION, DEPARTMENT OF THE INTERIOR GENERAL PROVISIONS DEFINITIONS OF THIS CHAPTER § 502.5 Collateral agreement. Collateral agreement means any contract, whether or not in writing...

25 CFR 502.5 - Collateral agreement.

Code of Federal Regulations, 2011 CFR

2011-04-01

... 25 Indians 2 2011-04-01 2011-04-01 false Collateral agreement. 502.5 Section 502.5 Indians NATIONAL INDIAN GAMING COMMISSION, DEPARTMENT OF THE INTERIOR GENERAL PROVISIONS DEFINITIONS OF THIS CHAPTER § 502.5 Collateral agreement. Collateral agreement means any contract, whether or not in writing...

25 CFR 502.5 - Collateral agreement.

Code of Federal Regulations, 2010 CFR

2010-04-01

... 25 Indians 2 2010-04-01 2010-04-01 false Collateral agreement. 502.5 Section 502.5 Indians NATIONAL INDIAN GAMING COMMISSION, DEPARTMENT OF THE INTERIOR GENERAL PROVISIONS DEFINITIONS OF THIS CHAPTER § 502.5 Collateral agreement. Collateral agreement means any contract, whether or not in writing...

Comparative responsiveness and minimal clinically important differences for idiopathic ulnar impaction syndrome.

PubMed

Kim, Jae Kwang; Park, Eun Soo

2013-05-01

Patient-reported questionnaires have been widely used to predict symptom severity and functional disability in musculoskeletal disease. Importantly, questionnaires can detect clinical changes in patients; however, this impact has not been determined for ulnar impaction syndrome. We asked (1) which of Patient-Rated Wrist Evaluation (PRWE), DASH, and other physical measures was more responsive to clinical improvements, and (2) what was the minimal clinically important difference for the PRWE and DASH after ulnar shortening osteotomy for idiopathic ulnar impaction syndrome. All patients who underwent ulnar shortening osteotomy between March 2008 and February 2011 for idiopathic ulnar impaction syndrome were enrolled in this study. All patients completed the PRWE and DASH questionnaires, and all were evaluated for grip strength and wrist ROM, preoperatively and 12 months postoperatively. We compared the effect sizes observed by each of these instruments. Effect size is calculated by dividing the mean change in a score of each instrument during a specified interval by the standard deviation of the baseline score. In addition, patient-perceived overall improvement was used as the anchor to determine the minimal clinically important differences on the PRWE and DASH 12 months after surgery. The average score of each item except for wrist flexion and supination improved after surgery. The PRWE was more sensitive than the DASH or than physical measurements in detecting clinical changes. The effect sizes and standardized response means of the outcome measures were as follows: PRWE (1.51, 1.64), DASH (1.12, 1.24), grip strength (0.59, 0.68), wrist pronation (0.33, 0.41), and wrist extension (0.28, 0.36). Patient-perceived overall improvement and score changes of the PRWE and DASH correlated significantly. Minimal clinically important differences were 17 points (of a possible 100) for the PRWE and 13.5 for the DASH (also of 100), and minimal detectable changes were 7.7 points

Ulnar nerve entrapment in a French horn player.

PubMed

Hoppmann, R A

1997-10-01

Nerve entrapment syndromes are frequent among musicians. Because of the demands on the musculoskeletal system and the great agility needed to per-form, musicians often present with vague complaints early in the course of entrapment, which makes the diagnosis a challenge for the clinician. Presented here is such a case of ulnar nerve entrapment at the left elbow of a French horn player. This case points out some of the difficulties in establishing a diagnosis of nerve entrapment in musicians. It also supports the theory that prolonged elbow flexion and repetitive finger movement contribute to the development of ulnar entrapment at the elbow. Although surgery is not required for most of the musculoskeletal problems of musicians, release of an entrapped nerve refractory to conservative therapy may be career-saving for the musician.

Two unusual anatomic variations create a diagnostic dilemma in distal ulnar nerve compression.

PubMed

Kiehn, Mark W; Derrick, Allison J; Iskandar, Bermans J

2008-09-01

Diagnosis of peripheral neuropathies is based upon patterns of functional deficits and electrodiagnostic testing. However, anatomic variations can lead to confounding patterns of physical and electrodiagnostic findings. Authors present a case of ulnar nerve compression due to a rare combination of anatomic variations, aberrant branching pattern, and FCU insertion at the wrist, which posed a diagnostic and therapeutic dilemma. The literature related to isolated distal ulnar motor neuropathy and anatomic variations of the ulnar nerve and adjacent structures is also reviewed. This case demonstrates how anatomic variations can complicate the interpretation of clinical and electrodiagnostic findings and underscores the importance of thorough exploration of the nerve in consideration for possible variations. (c) 2008 Wiley-Liss, Inc.

Tendon Transfers Part II: Transfers for Ulnar Nerve Palsy and Median Nerve Palsy

PubMed Central

Sammer, Douglas M.; Chung, Kevin C.

2009-01-01

Objectives After reading this article (part II of II), the participant should be able to: 1. Describe the anatomy and function of the median and ulnar nerves in the forearm and hand. 2. Describe the clinical deficits associated with injury to each nerve. 3. Describe the indications, benefits, and drawbacks for various tendon transfer procedures used to treat median and ulnar nerve palsy.4. Describe the treatment of combined nerve injuries. 5. Describe postoperative care and possible complications associated with these tendon transfer procedures. Summary This article discusses the use of tendon transfer procedures for treatment of median and ulnar nerve palsy as well as combined nerve palsies. Postoperative management and potential complications are also discussed. PMID:19730287

The reverse Segond fracture: not associated with knee dislocation and rarely with posterior cruciate ligament tear.

PubMed

Peltola, Erno K; Lindahl, Jan; Koskinen, Seppo K

2014-06-01

The aims of this study were to assess the incidence of reverse Segond fracture, to examine the associated ligamentous injuries, and to examine how often reverse Segond fracture coexists with a knee dislocation. At a level 1 trauma center, an 11-year period of emergency department multidetector-row computed tomography (MDCT) examinations for knee trauma was evaluated for reverse Segond and Segond fractures. Surgical findings served as the reference standard for intra-articular injuries. The hospital discharge register was searched for the diagnosis of knee dislocation from August 2000 through the end of August 2011. A total of 1,553 knee MDCT examinations were evaluated. Ten patients with a reverse Segond fracture were found, comprising 0.64 % of emergency room acute knee trauma MDCT examinations. Seven patients who had a reverse Segond fracture were operated: Three had an avulsion fracture of the anterior cruciate ligament, one had an avulsion fracture of posterior cruciate ligament, two had a lateral meniscal tear, and two had a medial collateral ligament tear. The ratio of reverse Segond fractures to Segond fractures was 1:4. None of the 71 knee dislocation patients had a reverse Segond fracture. Reverse Segond fracture is a rare finding even in a level 1 trauma center. Cruciate ligament injuries appear to be associated with avulsion fracture, but every patient does not have PCL injury, as previously reported. Our results do not support the association of knee dislocation with reverse Segond fracture.

A New Technique for Volar Capsulodesis for Isolated Palmar Scapholunate Interosseous Ligament Injuries: A Cadaveric Study and Case Report.

PubMed

van Kampen, Robert J; Bayne, Christopher O; Moran, Steven L

2015-11-01

Introduction Most surgical techniques for scapholunate interosseous ligament (SLIL) repair address only the dorsal component of the ligament, potentially leading to high surgical failure rates. We introduce a new technique to reconstruct the volar SLIL using a portion of the long radiolunate ligament (LRL). A biomechanical evaluation was performed to evaluate the rupture strength of this repair, and a subsequent anatomic study was performed to verify that this repair would not compromise the blood supply to either the scaphoid or the lunate. Methods A reconstruction of the volar SLIL was developed utilizing a lunate-based strip of the LRL. Fourteen cadaver arms were injected with red-colored epoxide and latex. The blood supply of the volar wrist capsule was dissected. The vascular supply to the ligaments, scaphoid, and lunate were investigated. The biomechanical strength of this reconstruction was tested on five cadaver arms by potting the scaphoid, lunate, and radius and subjecting the repair to a tensile load using a servohydraulic vertical displacement testing machine. Results In all arms, a branch of the radial artery or radiocarpal arch supplied the radioscapholunate ligament at the medial border of the LRL. The proximal half of the scaphoid was supplied by dorsal branches of the radial artery. In all cases, a vessel entered the lunate on its ulnar volar side, away from the repair. The average strength of the intact LRL strip was 97.4 N, and the average strength of the ligament-suture interface used for the capsulodesis was 43.5 N. Conclusion This volar approach to the SLIL does not compromise the vascularity of the scaphoid or the lunate. This approach allows the possibility of repairing or augmenting the volar SLIL. The strength of this repair appears to be less than the strength of the native SLIL. Further clinical studies are warranted.

31 CFR 202.6 - Collateral security.

Code of Federal Regulations, 2012 CFR

2012-07-01

... 31 Money and Finance:Treasury 2 2012-07-01 2012-07-01 false Collateral security. 202.6 Section 202... GOVERNMENT 1 § 202.6 Collateral security. (a) Requirement. Prior to receiving deposits of public money, a depositary authorized to perform services under § 202.3(b) must pledge collateral security in the amount...

31 CFR 202.6 - Collateral security.

Code of Federal Regulations, 2013 CFR

2013-07-01

... 31 Money and Finance:Treasury 2 2013-07-01 2013-07-01 false Collateral security. 202.6 Section 202... GOVERNMENT 1 § 202.6 Collateral security. (a) Requirement. Prior to receiving deposits of public money, a depositary authorized to perform services under § 202.3(b) must pledge collateral security in the amount...

31 CFR 202.6 - Collateral security.

Code of Federal Regulations, 2011 CFR

2011-07-01

... 31 Money and Finance:Treasury 2 2011-07-01 2011-07-01 false Collateral security. 202.6 Section 202... GOVERNMENT 1 § 202.6 Collateral security. (a) Requirement. Prior to receiving deposits of public money, a depositary authorized to perform services under § 202.3(b) must pledge collateral security in the amount...

A reliable technique for ultrasound-guided perineural injection in ulnar neuropathy at the elbow.

PubMed

Hamscha, Ulrike M; Tinhofer, Ines; Heber, Stefan; Grisold, Wolfgang; Weninger, Wolfgang J; Meng, Stefan

2017-08-01

Ulnar neuropathy at the elbow (UNE) is a common peripheral compression neuropathy and, in most cases, occurs at 2 sites, the retroepicondylar groove or the cubital tunnel. With regard to a potential therapeutic approach with perineural corticosteroid injection, the aim of this study was to evaluate the distribution of injection fluid applied at a standard site. We performed ultrasound-guided (US-guided) perineural injections to the ulnar nerve halfway between the olecranon and the medial epicondyle in 21 upper limbs from 11 non-embalmed cadavers. In anatomic dissection we investigated the spread of injected ink. Ink was successfully injected into the perineural sheath of the ulnar nerve in all 21 cases (cubital tunnel: 21 of 21; retroepicondylar groove: 19 of 21). US-guided injection between the olecranon and the medial epicondyle is a feasible and safe method to reach the most common sites of ulnar nerve entrapment. Muscle Nerve 56: 237-241, 2017. © 2016 Wiley Periodicals, Inc.

Complete dislocation of the ulnar nerve at the elbow: a protective effect against neuropathy?

PubMed

Leis, A Arturo; Smith, Benn E; Kosiorek, Heidi E; Omejec, Gregor; Podnar, Simon

2017-08-01

Recurrent complete ulnar nerve dislocation has been perceived as a risk factor for development of ulnar neuropathy at the elbow (UNE). However, the role of dislocation in the pathogenesis of UNE remains uncertain. We studied 133 patients with complete ulnar nerve dislocation to determine whether this condition is a risk factor for UNE. In all, the nerve was palpated as it rolled over the medial epicondyle during elbow flexion. Of 56 elbows with unilateral dislocation, UNE localized contralaterally in 17 elbows (30.4%) and ipsilaterally in 10 elbows (17.9%). Of 154 elbows with bilateral dislocation, 26 had UNE (16.9%). Complete dislocation decreased the odds of having UNE by 44% (odds ratio = 0.475; P =  0.028), and was associated with less severe UNE (P = 0.045). UNE occurs less frequently and is less severe on the side of complete dislocation. Complete dislocation may have a protective effect on the ulnar nerve. Muscle Nerve 56: 242-246, 2017. © 2016 Wiley Periodicals, Inc.

Complete vs partial-thickness tears of the posterior cruciate ligament: MR findings.

PubMed

Patten, R M; Richardson, M L; Zink-Brody, G; Rolfe, B A

1994-01-01

We sought to define the MRI appearance of both complete and partial-thickness tears of the posterior cruciate ligament (PCL) and to describe patterns of injury and associated MRI findings. Three radiologists retrospectively reviewed MR images and medical records on 32 patients with PCL tears (15 complete, 17 partial) and correlated MRI findings to results of clinical testing and surgery. The PCL had indistinct margins in 27 (84%) of 32 patients and was abnormally thick in 25 (78%) patients. In 31 (97%) patients, the torn PCL showed increased signal intensity on both T1- and T2-weighted pulse sequences. Although there was no statistically significant difference between patients with complete tears and those with partial tears with regard to thickness, margination, and signal intensity of the PCL, MR images in patients with complete tears were more likely to show focal areas of ligamentous discontinuity (10 of 15 cases) (p = 0.01). Associated knee injuries were seen in 21 (66%) patients and were seen more frequently in patients with complete PCL tears (p = 0.015). Bony injury (n = 11, 34%) and tears of the medial collateral ligament (n = 13, 41%) and menisci (n = 10, 31%) were common. No specific pattern of bony injury was found. Posterior cruciate ligament tears can be diagnosed readily by multiplanar MRI using both morphological and signal intensity characteristics. Although differentiation between complete and partial-thickness PCL tears by MRI criteria alone is more problematic, complete tears are more likely to show focal areas of discontinuity and partial tears are more likely to show at least some intact fibers.

Defining ulnar variance in the adolescent wrist: measurement technique and interobserver reliability.

PubMed

Goldfarb, Charles A; Strauss, Nicole L; Wall, Lindley B; Calfee, Ryan P

2011-02-01

The measurement technique for ulnar variance in the adolescent population has not been well established. The purpose of this study was to assess the reliability of a standard ulnar variance assessment in the adolescent population. Four orthopedic surgeons measured 138 adolescent wrist radiographs for ulnar variance using a standard technique. There were 62 male and 76 female radiographs obtained in a standardized fashion for subjects aged 12 to 18 years. Skeletal age was used for analysis. We determined mean variance and assessed for differences related to age and gender. We also determined the interrater reliability. The mean variance was -0.7 mm for boys and -0.4 mm for girls; there was no significant difference between the 2 groups overall. When subdivided by age and gender, the younger group (≤ 15 y of age) was significantly less negative for girls (boys, -0.8 mm and girls, -0.3 mm, p < .05). There was no significant difference between boys and girls in the older group. The greatest difference between any 2 raters was 1 mm; exact agreement was obtained in 72 subjects. Correlations between raters were high (r(p) 0.87-0.97 in boys and 0.82-0.96 for girls). Interrater reliability was excellent (Cronbach's alpha, 0.97-0.98). Standard assessment techniques for ulnar variance are reliable in the adolescent population. Open growth plates did not interfere with this assessment. Young adolescent boys demonstrated a greater degree of negative ulnar variance compared with young adolescent girls. Copyright © 2011 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.

The potential complications of open carpal tunnel release surgery to the ulnar neurovascular bundle and its branches: A cadaveric study.

PubMed

Boughton, O; Adds, P J; Jayasinghe, J A P

2010-07-01

This study investigated the ulnar artery and the ulnar nerve and its branches in the palm to assess how frequently they may be at risk of damage during open carpal tunnel release surgery. Twenty-one formalin-embalmed cadaveric hands were dissected, and the proximity of the ulnar neurovascular bundle to two different lines of incision, the 3rd and 4th interdigital web space axis and the ring finger axis, was assessed and compared. It was found that an incision in the latter (ring finger) axis put the ulnar artery at risk in 12 of 21 specimens, whereas an incision in the former axis (3rd/4th interdigital web space) put the ulnar artery at risk in only two specimens. In 15 hands at least one structure (the ulnar artery or a branch of the ulnar nerve) was at risk in the ring finger axis compared to only seven hands in the axis of the 3rd/4th interdigital web space. We conclude that the ulnar artery and branches of the ulnar nerve are at increased risk of damage with an incision in the axis of the ring finger. The importance of using a blunt dissection technique under direct vision during surgery to identify and preserve these structures and median nerve branches is emphasized. (c) 2010 Wiley-Liss, Inc.

Clinical effects of internal fixation for ulnar styloid fractures associated with distal radius fractures: A matched case-control study.

PubMed

Sawada, Hideyoshi; Shinohara, Takaaki; Natsume, Tadahiro; Hirata, Hitoshi

2016-11-01

Ulnar styloid fractures are often associated with distal radius fractures. However, controversy exists regarding whether to treat ulnar styloid fractures. This study aimed to evaluate clinical effects of internal fixation for ulnar styloid fractures after distal radius fractures were treated with the volar locking plate system. We used prospectively collected data of distal radius fractures. 111 patients were enrolled in this study. A matched case-control study design was used. We selected patients who underwent fixation for ulnar styloid fractures (case group). Three control patients for each patient of the case group were matched on the basis of age, sex, and fracture type of distal radius fractures from among patients who did not undergo fixation for ulnar styloid fractures (control group). The case group included 16 patients (7 men, 9 women; mean age: 52.6 years; classification of ulnar styloid fractures: center, 3; base, 11; and proximal, 2). The control group included 48 patients (15 men, 33 women; mean age: 61.1 years; classification of ulnar styloid fractures: center, 10; base, 31; and proximal, 7). For radiographic examination, the volar tilt angle, radial inclination angle, and ulnar variance length were measured, and the union of ulnar styloid fractures was judged. For clinical examination, the range of motions, grip strength, Hand20 score, and Numeric Rating Scale score were evaluated. There was little correction loss for each radiological parameter of fracture reduction, and these parameters were not significantly different between the groups. The bone-healing rate of ulnar styloid fractures was significantly higher in the case group than in the control group, but the clinical results were not significantly different. We revealed that there was no need to fix ulnar styloid fractures when distal radius fractures were treated via open reduction and internal fixation with a volar locking plate system. Copyright © 2016 The Japanese Orthopaedic Association

The Influence of Component Alignment and Ligament Properties on Tibiofemoral Contact Forces in Total Knee Replacement.

PubMed

Smith, Colin R; Vignos, Michael F; Lenhart, Rachel L; Kaiser, Jarred; Thelen, Darryl G

2016-02-01

The study objective was to investigate the influence of coronal plane alignment and ligament properties on total knee replacement (TKR) contact loads during walking. We created a subject-specific knee model of an 83-year-old male who had an instrumented TKR. The knee model was incorporated into a lower extremity musculoskeletal model and included deformable contact, ligamentous structures, and six degrees-of-freedom (DOF) tibiofemoral and patellofemoral joints. A novel numerical optimization technique was used to simultaneously predict muscle forces, secondary knee kinematics, ligament forces, and joint contact pressures from standard gait analysis data collected on the subject. The nominal knee model predictions of medial, lateral, and total contact forces during gait agreed well with TKR measures, with root-mean-square (rms) errors of 0.23, 0.22, and 0.33 body weight (BW), respectively. Coronal plane component alignment did not affect total knee contact loads, but did alter the medial-lateral load distribution, with 4 deg varus and 4 deg valgus rotations in component alignment inducing +17% and -23% changes in the first peak medial tibiofemoral contact forces, respectively. A Monte Carlo analysis showed that uncertainties in ligament stiffness and reference strains induce ±0.2 BW uncertainty in tibiofemoral force estimates over the gait cycle. Ligament properties had substantial influence on the TKR load distributions, with the medial collateral ligament and iliotibial band (ITB) properties having the largest effects on medial and lateral compartment loading, respectively. The computational framework provides a viable approach for virtually designing TKR components, considering parametric uncertainty and predicting the effects of joint alignment and soft tissue balancing procedures on TKR function during movement.

The Influence of Component Alignment and Ligament Properties on Tibiofemoral Contact Forces in Total Knee Replacement

PubMed Central

Smith, Colin R.; Vignos, Michael F.; Lenhart, Rachel L.; Kaiser, Jarred; Thelen, Darryl G.

2016-01-01

The study objective was to investigate the influence of coronal plane alignment and ligament properties on total knee replacement (TKR) contact loads during walking. We created a subject-specific knee model of an 83-year-old male who had an instrumented TKR. The knee model was incorporated into a lower extremity musculoskeletal model and included deformable contact, ligamentous structures, and six degrees-of-freedom (DOF) tibiofemoral and patellofemoral joints. A novel numerical optimization technique was used to simultaneously predict muscle forces, secondary knee kinematics, ligament forces, and joint contact pressures from standard gait analysis data collected on the subject. The nominal knee model predictions of medial, lateral, and total contact forces during gait agreed well with TKR measures, with root-mean-square (rms) errors of 0.23, 0.22, and 0.33 body weight (BW), respectively. Coronal plane component alignment did not affect total knee contact loads, but did alter the medial–lateral load distribution, with 4 deg varus and 4 deg valgus rotations in component alignment inducing +17% and −23% changes in the first peak medial tibiofemoral contact forces, respectively. A Monte Carlo analysis showed that uncertainties in ligament stiffness and reference strains induce ±0.2 BW uncertainty in tibiofemoral force estimates over the gait cycle. Ligament properties had substantial influence on the TKR load distributions, with the medial collateral ligament and iliotibial band (ITB) properties having the largest effects on medial and lateral compartment loading, respectively. The computational framework provides a viable approach for virtually designing TKR components, considering parametric uncertainty and predicting the effects of joint alignment and soft tissue balancing procedures on TKR function during movement. PMID:26769446

Radial and ulnar bursae of the wrist: cadaveric investigation of regional anatomy with ultrasonographic-guided tenography and MR imaging.

PubMed

Aguiar, Rodrigo O C; Gasparetto, Emerson L; Escuissato, Dante L; Marchiori, Edson; Trudell, Debbie J; Haghighi, Parviz; Resnick, Donald

2006-11-01

To demonstrate the anatomy of the radial and ulnar bursae of the wrist using MR and US images. Ultrasonographic-guided tenography of the tendon sheath of flexor pollicis longus (FPL) and the common tendon sheath of the flexor digitorum of the fifth digit (FD5) of ten cadaveric hands was performed, followed by magnetic resonance imaging and gross anatomic correlation. Patterns of communication were observed between these tendon sheaths and the radial and ulnar bursae of the wrist. The tendon sheath of the FPL communicated with the radial bursa in 100% (10/10) of cases, and the tendon sheath of the FD5 communicated with the ulnar bursa in 80% (8/10). Communication of the radial and ulnar bursae was evident in 100% (10/10), and presented an "hourglass" configuration in the longitudinal plane. The ulnar and radial bursae often communicate. The radial bursa communicates with the FPL tendon sheath, and the ulnar bursa may communicate with the FD5 tendon sheath.

Use of locking compression plates in ulnar fractures of 18 horses.

PubMed

Jacobs, Carrie C; Levine, David G; Richardson, Dean W

2017-02-01

To describe the outcome, clinical findings, and complications associated with the use of the locking compression plate (LCP) for various types of ulnar fractures in horses. Retrospective case series. Client owned horses (n = 18). Medical records, radiographs, and follow-up for horses having an ulnar fracture repaired using at least 1 LCP were reviewed. Fifteen of 18 horses had fractures of the ulna only, and 3 horses had fractures of the ulna and proximal radius. All 18 horses were discharged from the hospital. Complications occurred in 5 horses; incisional infection (n = 4, 22%), implant-associated infection (n = 2, 11%), and colic (n = 1, 6%). Follow-up was available for all horses at a range of 13-120 months and 15 horses (83%) were sound for their intended purpose and 3 horses (17%) were euthanatized. One horse was euthanatized for complications associated with original injury and surgery. The LCP is a viable method of internal fixation for various types of ulnar fractures, with most horses in this series returning to soundness. © 2017 The American College of Veterinary Surgeons.

Electrodiagnosis of ulnar neuropathy at the elbow (Une): a Bayesian approach.

PubMed

Logigian, Eric L; Villanueva, Raissa; Twydell, Paul T; Myers, Bennett; Downs, Marlene; Preston, David C; Kothari, Milind J; Herrmann, David N

2014-03-01

In ulnar neuropathy at the elbow (UNE), we determined how electrodiagnostic cutoffs [across-elbow ulnar motor conduction velocity slowing (AECV-slowing), drop in across-elbow vs. forearm CV (AECV-drop)] depend on pretest probability (PreTP). Fifty clinically defined UNE patients and 50 controls underwent ulnar conduction testing recording abductor digiti minimi (ADM) and first dorsal interosseous (FDI), stimulating wrist, below-elbow, and 6-, 8-, and 10-cm more proximally. For various PreTPs of UNE, the cutoffs required to confirm UNE (defined as posttest probability = 95%) were determined with receiver operator characteristic (ROC) curves and Bayes Theorem. On ROC and Bayesian analyses, the ADM 10-cm montage was optimal. For PreTP = 0.25, the confirmatory cutoffs were >23 m/s (AECV-drop), and <38 m/s (AECV-slowing); for PreTP = 0.75, they were much less conservative: >14 m/s, and <47 m/s, respectively. (1) In UNE, electrodiagnostic cutoffs are critically dependent on PreTP; rigid cutoffs are problematic. (2) AE distances should be standardized and at least 10 cm. Copyright © 2013 Wiley Periodicals, Inc.

An improved OpenSim gait model with multiple degrees of freedom knee joint and knee ligaments.

PubMed

Xu, Hang; Bloswick, Donald; Merryweather, Andrew

2015-08-01

Musculoskeletal models are widely used to investigate joint kinematics and predict muscle force during gait. However, the knee is usually simplified as a one degree of freedom joint and knee ligaments are neglected. The aim of this study was to develop an OpenSim gait model with enhanced knee structures. The knee joint in this study included three rotations and three translations. The three knee rotations and mediolateral translation were independent, with proximodistal and anteroposterior translations occurring as a function of knee flexion/extension. Ten elastic elements described the geometrical and mechanical properties of the anterior and posterior cruciate ligaments (ACL and PCL), and the medial and lateral collateral ligaments (MCL and LCL). The three independent knee rotations were evaluated using OpenSim to observe ligament function. The results showed that the anterior and posterior bundles of ACL and PCL (aACL, pACL and aPCL, pPCL) intersected during knee flexion. The aACL and pACL mainly provided force during knee flexion and adduction, respectively. The aPCL was slack throughout the range of three knee rotations; however, the pPCL was utilised for knee abduction and internal rotation. The LCL was employed for knee adduction and rotation, but was slack beyond 20° of knee flexion. The MCL bundles were mainly used during knee adduction and external rotation. All these results suggest that the functions of knee ligaments in this model approximated the behaviour of the physical knee and the enhanced knee structures can improve the ability to investigate knee joint biomechanics during various gait activities.

22 CFR 213.17 - Liquidation of collateral.

Code of Federal Regulations, 2010 CFR

2010-04-01

... Liquidation of collateral. Where the CFO holds a security instrument with a power of sale or has physical possession of collateral, he may liquidate the security or collateral and apply the proceeds to the overdue... circumstances require judicial foreclosure. However, collection from other businesses, including liquidation of...

Role of biomechanics in the understanding of normal, injured, and healing ligaments and tendons

PubMed Central

Jung, Ho-Joong; Fisher, Matthew B; Woo, Savio L-Y

2009-01-01

Ligaments and tendons are soft connective tissues which serve essential roles for biomechanical function of the musculoskeletal system by stabilizing and guiding the motion of diarthrodial joints. Nevertheless, these tissues are frequently injured due to repetition and overuse as well as quick cutting motions that involve acceleration and deceleration. These injuries often upset this balance between mobility and stability of the joint which causes damage to other soft tissues manifested as pain and other morbidity, such as osteoarthritis. The healing of ligament and tendon injuries varies from tissue to tissue. Tendinopathies are ubiquitous and can take up to 12 months for the pain to subside before one could return to normal activity. A ruptured medial collateral ligament (MCL) can generally heal spontaneously; however, its remodeling process takes years and its biomechanical properties remain inferior when compared to the normal MCL. It is also known that a midsubstance anterior cruciate ligament (ACL) tear has limited healing capability, and reconstruction by soft tissue grafts has been regularly performed to regain knee function. However, long term follow-up studies have revealed that 20–25% of patients experience unsatisfactory results. Thus, a better understanding of the function of ligaments and tendons, together with knowledge on their healing potential, may help investigators to develop novel strategies to accelerate and improve the healing process of ligaments and tendons. With thousands of new papers published in the last ten years that involve biomechanics of ligaments and tendons, there is an increasing appreciation of this subject area. Such attention has positively impacted clinical practice. On the other hand, biomechanical data are complex in nature, and there is a danger of misinterpreting them. Thus, in these review, we will provide the readers with a brief overview of ligaments and tendons and refer them to appropriate methodologies used to

40 CFR 13.16 - Liquidation of collateral.

Code of Federal Regulations, 2010 CFR

2010-07-01

... STANDARDS Collection § 13.16 Liquidation of collateral. Where the Administrator holds a security instrument with a power of sale or has physical possession of collateral, he may liquidate the security or... businesses, including liquidation of security or collateral, is not a prerequisite to requiring payment by a...

Ulnar nerve lesion at the wrist and sport: A report of 8 cases compared with 45 non-sport cases.

PubMed

Seror, P

2015-04-01

Reporting clinical and electrodiagnostic characteristics of sport-related ulnar neuropathies at the wrist. Eight sport-related and 45 non-sport-related cases from 53 ulnar neuropathies at the wrist cases over 14 years. Sport-related ulnar neuropathies at the wrist cases were due to cycling (5 cases), kayaking (2 cases), and big-game fishing (1 case). No patient had sensory complaints in ulnar digits, and all had motor impairment. Conduction across the wrist with recording on the first dorsal interosseous muscle was impaired in all cases, with conduction block in 5. Two cyclists showed bilateral ulnar neuropathies at the wrist. All cases recovered within 2 to 6 months with sport discontinuation. Distal lesions of the deep motor branch were more frequent in sport- than non-sport-related cases. The 8 sport-related ulnar neuropathies at the wrist cases involved the deep motor branch. Conduction study to the first dorsal interosseous muscle across the wrist is the key to electrodiagnostics. Bilateral cases in cyclists does not require wrist imaging. Copyright © 2015 Elsevier Masson SAS. All rights reserved.

Cranial cruciate ligament injury in the dog: pathophysiology, diagnosis and treatment.

PubMed

Jerram, R M; Walker, A M

2003-08-01

Cranial cruciate ligament (CCL) disease in the dog is a multifactorial complex problem that requires a thorough understanding of the biomechanics of the stifle joint to be understood. Successful treatment of rupture of the CCL should be based on managing underlying anatomical and conformational abnormalities rather than attempting to eliminate the tibial cranial drawer sign. The cranial and caudal cruciate ligaments, the patella ligament and quadriceps mechanism, the medial and lateral collateral ligaments, the medial and lateral menisci and the joint capsule provide stability of the joint and load-sharing. The function of the stifle is also significantly influenced by the musculature of the pelvic limb. An active model of biomechanics of the stifle has been described that incorporates not only the ligamentous structures of the stifle but also the forces created by weight-bearing and the musculature of the pelvic limb. This model recognises a force called cranial tibial thrust, which occurs during weight-bearing, and causes compression of the femoral condyles against the tibial plateau. In middle-aged, large-breed dogs, forces acting on the CCL together with conformation-related mild hyperextension of the stifle and slightly increased tibial plateau slopes are suspected to cause progressive degeneration of the ligament. Palpation of craniolateral stifle laxity has become pathognomonic for CCL rupture; however, chronic periarticular fibrosis, a partial CCL rupture, and a tense patient, may make evaluation of instability of the stifle difficult. Surgical treatment is broadly separated into three groups: intracapsular, extracapsular, and tibial osteotomy techniques. Tibial osteotomy techniques do not serve to provide stability of the stifle but rather alter the geometry of the joint to eliminate cranial tibial thrust such that functional joint stability is achieved during weight-bearing. Visualisation of both menisci is a critical aspect of CCL surgery, irrespective

13 CFR 120.343 - Collateral.

Code of Federal Regulations, 2010 CFR

2010-01-01

... 13 Business Credit and Assistance 1 2010-01-01 2010-01-01 false Collateral. 120.343 Section 120.343 Business Credit and Assistance SMALL BUSINESS ADMINISTRATION BUSINESS LOANS Special Purpose Loans Export Working Capital Program (ewcp) § 120.343 Collateral. A Borrower must give SBA a first security...

Anatomical considerations of fascial release in ulnar nerve transposition: a concept revisited.

PubMed

Mahan, Mark A; Gasco, Jaime; Mokhtee, David B; Brown, Justin M

2015-11-01

Surgical transposition of the ulnar nerve to alleviate entrapment may cause otherwise normal structures to become new sources of nerve compression. Recurrent or persistent neuropathy after anterior transposition is commonly attributable to a new distal compression. The authors sought to clarify the anatomical relationship of the ulnar nerve to the common aponeurosis of the humeral head of the flexor carpi ulnaris (FCU) and flexor digitorum superficialis (FDS) muscles following anterior transposition of the nerve. The intermuscular septa of the proximal forearm were explored in 26 fresh cadaveric specimens. The fibrous septa and common aponeurotic insertions of the flexor-pronator muscle mass were evaluated in relation to the ulnar nerve, with particular attention to the effect of transposition upon the nerve in this region. An intermuscular aponeurosis associated with the FCU and FDS muscles was present in all specimens. Transposition consistently resulted in angulation of the nerve during elbow flexion when this fascial septum was not released. The proximal site at which the nerve began to traverse this fascial structure was found to be an average of 3.9 cm (SD 0.7 cm) from the medial epicondyle. The common aponeurosis encountered between the FDS and FCU muscles represents a potential site of posttransposition entrapment, which may account for a subset of failed anterior transpositions. Exploration of this region with release of this structure is recommended to provide an unconstrained distal course for a transposed ulnar nerve.

Forearm Flexor Injuries Among Major League Baseball Players: Epidemiology, Performance, and Associated Injuries.

PubMed

Hodgins, Justin L; Trofa, David P; Donohue, Steve; Littlefield, Mark; Schuk, Michael; Ahmad, Christopher S

2018-06-01

Despite evidence highlighting the importance of the forearm flexor muscles of elite baseball players, no studies have reported on the epidemiology of flexor strains and their associated outcomes. To examine the incidence, associated injuries, and outcomes associated with forearm flexor injuries among major and minor league baseball players. Cohort study; Level of evidence, 3. Injury data attributed to forearm flexor injuries among Major League Baseball (MLB) and minor league teams between 2010 and 2014 were obtained from the professional baseball Health and Injury Tracking System. This analysis included the number of players injured, seasonal timing of injury, days spent on the disabled list (DL), preinjury performance data, and subsequent injuries. A total of 134 and 629 forearm flexor injuries occurred in MLB and the minor leagues, respectively. The mean player age was 28.6 and 22.8 years in the MLB and minor leagues, respectively. The mean time spent on the DL for MLB players was 117.0 days, as opposed to 93.9 days in the minor leagues ( P = .272). Interestingly, pitcher performance declined in all categories examined leading up to the season of injury, with significant differences in walks plus hits per inning pitched ( P = .04) and strike percentage ( P = .036). Of MLB players with a forearm injury, subsequent injuries included 50 (37.3%) shoulder, 48 (35.8%) elbow, and 24 (17.9%) forearm injuries. Among injured minor league players, subsequent injuries included 170 (27.0%) shoulder, 156 (24.8%) elbow, and 83 (13.2%) forearm injuries. These rates of subsequent injuries were significantly higher compared with the rates of injuries sustained among players without forearm injuries in both leagues ( P < .001). Finally, 26 (19.4%) MLB and 56 (8.9%) minor league players required an ulnar collateral ligament reconstruction, rates that were significantly higher compared with players without a flexor strain ( P < .001). Flexor-pronator injuries are responsible for

Summative Report on Time Out of Play for Major and Minor League Baseball: An Analysis of 49,955 Injuries From 2011 Through 2016.

PubMed

Camp, Christopher L; Dines, Joshua S; van der List, Jelle P; Conte, Stan; Conway, Justin; Altchek, David W; Coleman, Struan H; Pearle, Andrew D

2018-06-01

Recent epidemiologic reports have demonstrated rising injury rates in Major League Baseball (MLB) and Minor League Baseball (MiLB). Although several studies have recently been published on specific injuries, the majority of injuries have not yet been formally studied. The purpose of this study is to (1) generate a summative analysis of all injuries that occur in MLB and MiLB, (2) identify the 50 most common injuries, and (3) generate focused reports and fact sheets on the characteristics of each of those diagnoses. Case series; Level of evidence, 4. The MLB Health and Injury Tracking System was used to identify injuries occurring in MLB and MiLB players from 2011 to 2016. Injuries were defined as those that occurred during normal baseball activity and resulted in at least 1 day out of play. A multitude of player and injury characteristics were analyzed, and detailed reports of the 50 most commonly occurring injuries were generated. A total of 49,955 injuries occurred during the study period; 45,123 were non-season ending, and they resulted in 722,176 days out of play. The mean (median) days missed per injury was 16 (6) days. Overall, 39.1% of all injuries occurred in pitchers. The upper extremity was involved in 39% of injuries, while 35% occurred in the hip/groin/lower extremity. Surgery was required in 6.5% of cases, and 9.7% of injuries were season ending. Hamstring strains were the most common injury (n = 3337), followed by rotator cuff strain/tear (n = 1874), paralumbar muscle strain (n = 1313), biceps tendinitis (n = 1264), oblique strain (n = 1249), and elbow ulnar collateral ligament injury (n = 1191). The diagnoses that were most likely to end a player's season were elbow ulnar collateral ligament injury (60% season ending) and superior labrum anterior and posterior tear (50.9% season ending). Contrary to prior reports relying on disabled list data, the annual number of injuries in professional baseball remained steady from 2011 to 2016. Similar trends

13 CFR 120.349 - Collateral.

Code of Federal Regulations, 2012 CFR

2012-01-01

... 13 Business Credit and Assistance 1 2012-01-01 2012-01-01 false Collateral. 120.349 Section 120.349 Business Credit and Assistance SMALL BUSINESS ADMINISTRATION BUSINESS LOANS Special Purpose Loans International Trade Loans § 120.349 Collateral. Each IT loan must be secured either by a first lien position or...

Supinator to ulnar nerve transfer via in situ anterior interosseous nerve bridge to restore intrinsic muscle function in combined proximal median and ulnar nerve injury: a novel cadaveric study.

PubMed

Namazi, Hamid; HajiVandi, Shahin

2017-05-01

In cases of high ulnar nerve palsy, result of nerve repair in term of intrinsic muscle recovery is unsatisfactory. Distal nerve transfer can diminish the regeneration time and improve the results. But, there was no perfect distal nerve transfer for restoring intrinsic hand function in combined proximal median and ulnar nerve injuries. This cadaveric study aims to evaluate the possibility and feasibility of supinator nerve transfer to motor branch of ulnar nerve (MUN). Ten cadaveric upper limbs dissected to identify the location of the supinator branch, anterior interosseous nerve (AIN), and MUN. The AIN was cut from its origin and transferred to the supinator branches. Also, the AIN was distally cut and transferred to the MUN. After nerve coaptation, surface area, fascicle count, and axon number were determined by histologic methods. In all limbs, the proximal and distal stumps of AIN reached the supinator branch and the MUN without tension, respectively. The mean of axon number in the supinator, proximal stump of AIN, distal stump of AIN and MUN branches were 32,426, 45,542, 25,288, and 35,426, respectively. This study showed that transfer of the supinator branches to the MUN is possible via the in situ AIN bridge. The axon count data showed a favorable match between the supinator branches, AIN, and MUN. Therefore, it is suggested that this technique can be useful for patients with combined high median and ulnar nerve injuries. Copyright © 2016 Elsevier Inc. All rights reserved.

Ulnar neuropathy at or distal to the wrist: traumatic versus cumulative stress cases.

PubMed

Chiodo, Anthony; Chadd, Edmund

2007-04-01

To identify clinical and electromyographic characteristics of ulnar neuropathy at or below the wrist, comparing those caused by unitary trauma with those caused by suspected cumulative stress. Retrospective case series. University hospital electromyography laboratory. Patients with electrodiagnostic evidence of an ulnar neuropathy at or distal to the wrist over a 3-year period. Forty-seven hands from 42 patients (age range, 20-80y; mean, 52y) were identified and evaluated in this study. Record review of clinical history, physical examination, electromyography, and treatment. Etiology of injury, physical signs and symptoms, and electromyographic testing results. Ulnar neuropathy at or distal to the wrist is commonly mischaracterized because of other mononeuropathies in the upper extremity and because of peripheral polyneuropathy. Ulnar neuropathy because of cumulative stress presents typically with sensory symptoms (63%) and a normal examination (71%), whereas trauma cases present with motor with or without sensory symptoms (92%) with motor abnormalities (92%) confirmed on examination. Traumatic cases are characterized by electromyography by decreased sensory and motor-evoked amplitudes, prolonged motor distal latencies, and abnormal needle examination. The amplitude changes are noted comparing with laboratory norms and comparing side to side. No characteristic pattern of abnormalities on electromyography is noted in the cumulative stress cases. Patients with no motor symptoms, regardless of etiology, are more apt to have sensory distal latency prolongation, whereas those with motor symptoms have motor amplitude and needle examination abnormalities. Traumatic ulnar neuropathy at or distal to the wrist is characterized by motor symptoms and sensory and motor axonal loss by electromyography, whereas cumulative stress cases have sensory symptoms and electromyographic findings that are highly variable and noncharacteristic. Patients with no motor symptoms are more apt

[Transverse radioulnar branch of the dorsal ulnar nerve: anatomic description and arthroscopic implications from 45 cadaveric dissections].

PubMed

Ehlinger, M; Rapp, E; Cognet, J-M; Clavert, P; Bonnomet, F; Kahn, J-L; Kempf, J-F

2005-05-01

We conducted an anatomic study of the transverse branch of the dorsal ulnar nerve to describe its morphology and position in relation to arthroscopic exploration portals. Forty-five non-side-matched anatomic specimens of unknown age and gender were preserved in formol. The dorsal branch of the ulnar nerve was identified and dissected proximally to distally in order to reveal the different terminal branches. The morphometric analysis included measurement of the length and diameter of the transverse branch and measurement of wrist width. We also measured the smallest distance between the transverse branch and the ulnar styloid process, and between the branch and usual arthroscopic portals (4-5, 6R, 6U) in the axis of the forearm. The transverse branch was inconstant. It was found in 12 of the 45 dissection specimens (27%). In two-thirds of the specimens, the branch ran over less than 50% of the wrist width, tangentially to the radiocarpal joint. Mean nerve diameter was 1 mm. It was found 5-6 mm from the ulnar styloid process and was distal to it in 83% of the specimens. The dissections demonstrated two anatomic variants. Type A corresponded to a branch running distally to the ulnar styloid process, parallel to the joint line (10/12 specimens). Type B exhibited a trajectory proximal to the ulnar styloid process, crossing the ulnar head (2/12 specimens). The relations with the arthroscopic portals (4-5, 6R, 6U) showed that the mean distance from the branch to the portal was 3.75 mm for the 4-5 portal (distally in 11/12 specimens), 3.68 mm for the 6R portal (distally in 10/12 specimens), and 4.83 mm for the 6U portal (distally in 7 specimens and proximally in 5). To our knowledge, there has been only one report specifically devoted to this transverse branch. Two other reports simply mention its existence. According to the literature, the transverse branch of the dorsal ulnar nerve occurs in 60-80% of the cases. We found two anatomic variations different than those

Humeral stress edema: an injury in overhead athletes quarterback with humeral "shin" splints-a case report.

PubMed

Alpert, Justin; Flannery, Robert; Epstein, Robert; Monaco, Robert; Prendergast, Nancy

2014-09-01

Stress injury to the distal humerus has been reported as a cause of chronic arm pain among competitive tennis players. As the serve is technically similar to an overhead throwing motion, it is conceivable that this injury could occur in other overhead athletes. Overuse injuries, including rotator cuff tears, ulnar collateral ligament injuries, and joint sprains have routinely been reported in quarterbacks, but there are few reported cases of upper extremity bony stress injuries in these athletes. Magnetic resonance imaging aids in the diagnostic evaluation of an upper extremity injury as it can identify numerous structural injuries and early stress changes within bone. Accurately diagnosing stress reactions helps prevent progression toward stress fracture, which is possible if conservative measures are initiated early in the rehabilitation period. In this article, we report the case of an elite college quarterback who presented with localized elbow pain while throwing.

[The influences upon the passive tensile of the masticatory muscles and ligaments by Herbst appliance under various bite reconstruction--a three dimensional finite element analysis].

PubMed

Song, J; Zhao, Z; Hu, L; Jiang, W; Fan, Y; Chen, J

2001-02-01

This study aimed to provide some biomechanical references for the clinical use and improvement of Herbst appliance. The three-dimensional model of the 'Temporomandibular joint mandible Herbst appliance system' was set up by SUPER SAP software (version 9.3). On this model, the passive tensile in the masticatory muscles and ligaments were analyzed under various bit reconstruction designed according to specified advanced displacement and vertical bite opening. When Herbst appliance drove the mandible forward, there was not any tensile in the medial, lateral pterygoid and the collateral ligament, while the temporalis, the deep paret of masseter, the stylomandibular ligament, and the sphenomandibular ligament were passively drawn. Under various bite reconstruction, the passive tensile in the medial temporalis, the posterior temporalis, the stylomandibular ligament and the sphenomandibular ligament increased with the amount of the advancement of the mandible; The passive tensile in the posterior temporalis and the deep part of masseter increased with the amount of vertical bite opening of the mandible. The StL, SpL, PT and AT played an important role in functional reconstruction of mandible by Herbst. All five group of bite reconstruction (3-7 mm advancement, 4-2 mm vertical bite opening of the mandible) designed by this study can be selected in clinic according to the patient's capability of adaptation, the extent of malocclusion and the potential and direction of growth.

Intrinsic healing response of the human anterior cruciate ligament: an histological study of reattached ACL remnants.

PubMed

Nguyen, Duy Tan; Ramwadhdoebe, Tamara H; van der Hart, Cor P; Blankevoort, Leendert; Tak, Paul Peter; van Dijk, Cornelis Niek

2014-02-01

A reattachment of the tibial remnant of the torn anterior cruciate ligament (ACL) to the posterior cruciate ligament is sometimes observed during surgery and apparently implies that the human ACL does have a healing response. The aim of this study was to investigate whether this reattachment tissue has similar histological characteristics of a healing response as the medial collateral ligament (MCL), which can heal spontaneously. Standard histology and immunostaining of α-smooth muscle actin and collagen type 3 was performed. The results shows that the reattached tissue has typical characteristics of a healing response: there attached ACL remnant could not be released by forceful traction; microscopy showed that the collagen fibers of the reattached tissue were disorganized with no preferred direction; increased neovascularization; the presence of lipid vacuoles; the mean number of cells within the biopsy tissue was 631±269 cells per mm2; and 68±20% was expressing α-SMA; semi-quantitative analysis of collagen type 3 expression showed that collagen type 3 had an high expression with an average score of 3. In conclusion, this study shows that the human proximal 1/3 ACL has an intrinsic healing response with typical histological characteristics similar to the MCL. © 2013 Orthopaedic Research Society. Published by Wiley Periodicals, Inc.

In situ forces and length patterns of the fibular collateral ligament under controlled loading: an in vitro biomechanical study using a robotic system.

PubMed

Liu, Ping; Wang, Jianquan; Xu, Yan; Ao, Yingfang

2015-04-01

The aim of this study was to determine the in situ forces and length patterns of the fibular collateral ligament (FCL) and kinematics of the knee under various loading conditions. Six fresh-frozen cadaveric knees were used (mean age 46 ± 14.4 years; range 20-58). In situ forces and length patterns of FCL and kinematics of the knee were determined under the following loading conditions using a robotic/universal force-moment sensor testing system: no rotation, varus (10 Nm), external rotation (5 Nm), and internal rotation (5 Nm) at 0°, 15°, 30°, 60º, 90°, and 120° of flexion, respectively. Under no rotation loading, the distances between the centres of the FCL attachments decreased as the knee flexed. Under varus loading, the force in FCL peaked at 15° of flexion and decreased with further knee flexion, while distances remained nearly constant and the varus rotation increased with knee flexion. Using external rotation, the force in the FCL also peaked at 15° flexion and decreased with further knee flexion, the distances decreased with flexion, and external rotation increased with knee flexion. Using internal rotation load, the force in the FCL was relatively small across all knee flexion angles, and the distances decreased with flexion; the amount of internal rotation was fairly constant. FCL has a primary role in preventing varus and external rotation at 15° of flexion. The FCL does not perform isometrically following knee flexion during neutral rotation, and tibia rotation has significant effects on the kinematics of the FCL. Varus and external rotation laxity increased following knee flexion. By providing more realistic data about the function and length patterns of the FCL and the kinematics of the intact knee, improved reconstruction and rehabilitation protocols can be developed.

Median and ulnar neuropathies in U.S. Army Medical Command Band members.

PubMed

Shaffer, Scott W; Koreerat, Nicholas R; Gordon, Lindsay B; Santillo, Douglas R; Moore, Josef H; Greathouse, David G

2013-12-01

Musicians have been reported as having a high prevalence of upper-extremity musculoskeletal disorders, including carpal tunnel syndrome. The purpose of this study was to determine the presence of median and ulnar neuropathies in U.S. Army Medical Command (MEDCOM) Band members at Fort Sam Houston, Texas. Thirty-five MEDCOM Band members (30 males, 5 females) volunteered to participate. There were 33 right-handed musicians, and the mean length of time in the MEDCOM Band was 12.2 yrs (range, 1-30 yrs). Subjects completed a history form, were interviewed, and underwent a physical examination of the cervical spine and bilateral upper extremities. Nerve conduction studies of the bilateral median and ulnar nerves were performed. Electrophysiological variables served as the reference standard for median and ulnar neuropathy and included distal sensory latencies, distal motor latencies, amplitudes, conduction velocities, and comparison study latencies. Ten of the 35 subjects (29%) presented with abnormal electrophysiologic values suggestive of an upper extremity mononeuropathy. Nine of the subjects had abnormal median nerve electrophysiologic values at or distal to the wrist; 2 had bilateral abnormal values. One had an abnormal ulnar nerve electrophysiologic assessment at the elbow. Nine of these 10 subjects had clinical examination findings consistent with the electrophysiological findings. The prevalence of mononeuropathies in this sample of band members is similar to that found in previous research involving civilian musicians (20-36%) and far exceeds that reported in the general population. Prospective research investigating screening, examination items, and injury prevention measures in musicians appears to be warranted.

30 CFR 800.21 - Collateral bonds.

Code of Federal Regulations, 2010 CFR

2010-07-01

... INSURANCE REQUIREMENTS FOR SURFACE COAL MINING AND RECLAMATION OPERATIONS BOND AND INSURANCE REQUIREMENTS FOR SURFACE COAL MINING AND RECLAMATION OPERATIONS UNDER REGULATORY PROGRAMS § 800.21 Collateral bonds... subject to the following conditions: (1) The regulatory authority shall keep custody of collateral...

Collateral Circulation in Chronic Total Occlusions - an interventional perspective.

PubMed

Choo, Gim-Hooi

2015-09-09

Human coronary collaterals are inter-coronary communications that are believed to be present from birth. In the presence of chronic total occlusions, recruitment of flow via these collateral anastomoses to the arterial segment distal to occlusion provide an alternative source of blood flow to the myocardial segment at risk. This mitigates the ischemic injury. Clinical outcome of coronary occlusion ie. severity of myocardial infarction/ischemia, impairment of cardiac function and possibly survival depends not only on the acuity of the occlusion, extent of jeopardized myocardium, duration of ischemia but also to the adequacy of collateral circulation. Adequacy of collateral circulation can be assessed by various methods. These coronary collateral channels have been used successfully as a retrograde access route for percutaneous recanalization of chronic total occlusions. Factors that promote angiogenesis and further collateral remodeling ie. arteriogenesis have been identified. Promotion of collateral growth as a therapeutic target in patients with no suitable revascularization option is an exciting proposal.

Development and morphogenesis of human wrist joint during embryonic and early fetal period

PubMed Central

Hita-Contreras, Fidel; Martínez-Amat, Antonio; Ortiz, Raúl; Caba, Octavio; Álvarez, Pablo; Prados, José C; Lomas-Vega, Rafael; Aránega, Antonia; Sánchez-Montesinos, Indalecio; Mérida-Velasco, Juan A

2012-01-01

The development of the human wrist joint has been studied widely, with the main focus on carpal chondrogenesis, ligaments and triangular fibrocartilage. However, there are some discrepancies concerning the origin and morphogenetic time-table of these structures, including nerves, muscles and vascular elements. For this study we used serial sections of 57 human embryonic (n = 30) and fetal (n = 27) specimens from O’Rahilly stages 17–23 and 9–14 weeks, respectively. The following phases in carpal morphogenesis have been established: undifferentiated mesenchyme (stage 17), condensated mesenchyme (stages 18 and 19), pre-chondrogenic (stages 19 and 20) and chondrogenic (stages 21 and over). Carpal chondrification and osteogenic processes are similar, starting with capitate and hamate (stage 19) and ending with pisiform (stage 22). In week 14, a vascular bud penetrates into the lunate cartilaginous mold, early sign of the osteogenic process that will be completed after birth. In stage 18, median, ulnar and radial nerves and thenar eminence appear in the hand plate. In stage 21, there are indications of the interosseous muscles, and in stage 22 flexor digitorum superficialis, flexor digitorum profundus and lumbrical muscles, transverse carpal ligament and collateral ligaments emerge. In stage 23, the articular disc, radiocarpal and ulnocarpal ligaments and deep palmar arterial arch become visible. Radiate carpal and interosseous ligaments appear in week 9, and in week 10, dorsal radiocarpal ligament and articular capsule are evident. Finally, synovial membrane is observed in week 13. We have performed a complete analysis of the morphogenesis of the structures of the human wrist joint. Our results present new data on nervous and arterial elements and provide the basis for further investigations on anatomical pathology, comparative morphology and evolutionary anthropology. PMID:22428933

Trends in primary and revision anterior cruciate ligament reconstruction among National Basketball Association team physicians.

PubMed

Mall, Nathan A; Abrams, Geoffrey D; Azar, Frederick M; Traina, Steve M; Allen, Answorth A; Parker, Richard; Cole, Brian J

2014-06-01

Anterior cruciate ligament (ACL) tears are common in athletes. Techniques and methods of treatment for these injuries continue to vary among surgeons. Thirty National Basketball Association (NBA) team physicians were surveyed during the NBA Pre-Draft Combine. Survey questions involved current and previous practice methods of primary and revision ACL reconstruction, including technique, graft choice, rehabilitation, and treatment of combined ACL and medial collateral ligament injuries. Descriptive parametric statistics, Fisher exact test, and logistic regression were used, and significance was set at α = 0.05. All 30 team physicians completed the survey. Eighty-seven percent indicated they use autograft (81% bone-patellar tendon-bone) for primary ACL reconstruction in NBA athletes, and 43% indicated they use autograft for revision cases. Fourteen surgeons (47%) indicated they use an anteromedial portal (AMP) for femoral tunnel drilling, whereas 5 years earlier only 4 (13%) used this technique. There was a significant (P = .009) positive correlation between fewer years in practice and AMP use. NBA team physicians' use of an AMP for femoral tunnel drilling has increased over the past 5 years.

45 CFR 160.532 - Collateral estoppel.

Code of Federal Regulations, 2010 CFR

2010-10-01

... 45 Public Welfare 1 2010-10-01 2010-10-01 false Collateral estoppel. 160.532 Section 160.532 Public Welfare DEPARTMENT OF HEALTH AND HUMAN SERVICES ADMINISTRATIVE DATA STANDARDS AND RELATED REQUIREMENTS GENERAL ADMINISTRATIVE REQUIREMENTS Procedures for Hearings § 160.532 Collateral estoppel. When a...

12 CFR 725.19 - Collateral requirements.

Code of Federal Regulations, 2010 CFR

2010-01-01

... 12 Banks and Banking 6 2010-01-01 2010-01-01 false Collateral requirements. 725.19 Section 725.19 Banks and Banking NATIONAL CREDIT UNION ADMINISTRATION REGULATIONS AFFECTING CREDIT UNIONS NATIONAL CREDIT UNION ADMINISTRATION CENTRAL LIQUIDITY FACILITY § 725.19 Collateral requirements. (a) Each...

Pleiotrophin levels are associated with improved coronary collateral circulation.

PubMed

Türker Duyuler, Pinar; Duyuler, Serkan; Gök, Murat; Kundi, Harun; Topçuoğlu, Canan; Güray, Ümit

2018-01-01

Elucidation of the underlying mechanisms of angiogenesis and arteriogenesis in coronary collateral formation is necessary for new therapies. Pleiotrophin is a secreted multifunctional cytokine and associated with the formation of functional cardiovascular neovascularization in a series of experimental animal models. We aimed to evaluate the serum levels of pleiotrophin in patients with chronic total coronary artery occlusion and poor or good collateral development. We included 88 consecutive patients (mean age of the entire population: 63.7±12.1 years, 68 male patients) with stable angina pectoris who underwent coronary angiography and had chronic total occlusion in at least one major coronary artery. Collateral grading was performed according to the Rentrop classification. After grading, patients were divided into poor collateral circulation (Rentrop grade 0 and 1) and good collateral circulation (Rentrop grades 2 and 3) groups. Serum pleiotrophin levels were measured using a commercial human ELISA kit. Fifty-eight patients had good and 30 patients had poor coronary collaterals. The good collateral group had higher serum pleiotrophin levels than the poor collateral group (690.1±187.9 vs. 415.3±165.9 ng/ml, P<0.001). Pleiotrophin levels were higher with higher Rentrop grade (P<0.001). In multivariate analysis, increased pleiotrophin was associated independently with good collateral development (odds ratio: 1.007; confidence interval: 1.003-1.012; P=0.002). This study showed that increased serum pleiotrophin levels are associated with better developed coronary collateral circulation. Further studies are needed to better understand the relationship.

12 CFR 615.5050 - Collateral requirements.

Code of Federal Regulations, 2010 CFR

2010-01-01

....5050 Banks and Banking FARM CREDIT ADMINISTRATION FARM CREDIT SYSTEM FUNDING AND FISCAL AFFAIRS, LOAN POLICIES AND OPERATIONS, AND FUNDING OPERATIONS Collateral § 615.5050 Collateral requirements. (a) Each bank shall have on hand at the time of issuance of any notes, bonds, debentures, or other similar...

20 CFR 498.114 - Collateral estoppel.

Code of Federal Regulations, 2010 CFR

2010-04-01

... 20 Employees' Benefits 2 2010-04-01 2010-04-01 false Collateral estoppel. 498.114 Section 498.114 Employees' Benefits SOCIAL SECURITY ADMINISTRATION CIVIL MONETARY PENALTIES, ASSESSMENTS AND RECOMMENDED EXCLUSIONS § 498.114 Collateral estoppel. In a proceeding under section 1129 of the Social Security Act that...

42 CFR 402.15 - Collateral estoppel.

Code of Federal Regulations, 2010 CFR

2010-10-01

... 42 Public Health 2 2010-10-01 2010-10-01 false Collateral estoppel. 402.15 Section 402.15 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES GENERAL PROVISIONS CIVIL MONEY PENALTIES, ASSESSMENTS, AND EXCLUSIONS General Provisions § 402.15 Collateral estoppel...

28 CFR 94.25 - Collateral sources.

Code of Federal Regulations, 2011 CFR

2011-07-01

... 28 Judicial Administration 2 2011-07-01 2011-07-01 false Collateral sources. 94.25 Section 94.25 Judicial Administration DEPARTMENT OF JUSTICE (CONTINUED) CRIME VICTIM SERVICES International Terrorism... collateral source in connection with the same act of international terrorism. In cases in which a claimant...

28 CFR 94.25 - Collateral sources.

Code of Federal Regulations, 2010 CFR

2010-07-01

... 28 Judicial Administration 2 2010-07-01 2010-07-01 false Collateral sources. 94.25 Section 94.25 Judicial Administration DEPARTMENT OF JUSTICE (CONTINUED) CRIME VICTIM SERVICES International Terrorism... collateral source in connection with the same act of international terrorism. In cases in which a claimant...

28 CFR 94.25 - Collateral sources.

Code of Federal Regulations, 2013 CFR

2013-07-01

... 28 Judicial Administration 2 2013-07-01 2013-07-01 false Collateral sources. 94.25 Section 94.25 Judicial Administration DEPARTMENT OF JUSTICE (CONTINUED) CRIME VICTIM SERVICES International Terrorism... collateral source in connection with the same act of international terrorism. In cases in which a claimant...

28 CFR 94.25 - Collateral sources.

Code of Federal Regulations, 2014 CFR

2014-07-01

... 28 Judicial Administration 2 2014-07-01 2014-07-01 false Collateral sources. 94.25 Section 94.25 Judicial Administration DEPARTMENT OF JUSTICE (CONTINUED) CRIME VICTIM SERVICES International Terrorism... collateral source in connection with the same act of international terrorism. In cases in which a claimant...

28 CFR 94.25 - Collateral sources.

Code of Federal Regulations, 2012 CFR

2012-07-01

... 28 Judicial Administration 2 2012-07-01 2012-07-01 false Collateral sources. 94.25 Section 94.25 Judicial Administration DEPARTMENT OF JUSTICE (CONTINUED) CRIME VICTIM SERVICES International Terrorism... collateral source in connection with the same act of international terrorism. In cases in which a claimant...

A tricalcium phosphate/polyether ether ketone anchor bionic fixation device for anterior cruciate ligament reconstruction: Safety and efficacy in a beagle model.

PubMed

Mao, Genwen; Qin, Zili; Li, Zheng; Li, Xiang; Qiu, Yusheng; Bian, Weiguo

2018-05-02

The goal of this study was to develop a bionic fixation device based on the use of a tricalcium phosphate/polyether ether ketone anchor and harvesting of the ulnar carpal flexor muscle tendon for application as a ligament graft in a beagle anterior cruciate ligament (ACL) reconstruction model, with the goal of accelerating the ligament graft-to-bone tunnel healing and providing a robust stability through exploration of this new kind of autologous ligament graft. The safety and efficacy of this fixation device were explored 3 and 6 months after surgery in a beagle ACL reconstruction model using biomechanical tests and comprehensive histological observation. The data were compared using a two-tailed Student's t test and a paired t test. A p value <0.05 was defined as statistically significant. All the models were successfully established. This fixation device possessed the excellent mechanical properties for ACL reconstruction. A comprehensive histological observation revealed that a cartilage layer was visible in the transition zone between the tendon and bone interface at both 3 and 6 months postoperation. The trabecular of the new bone was observed six months after surgery and was found to be similar to a direct connection. This fixation technique provided not only a robust primary mechanical fixation but also a bionic fixation for long-term knee joint stability by accelerating the healing of the tendon to the bone tunnel, showing a high potential for use in clinical practice. © 2018 Wiley Periodicals, Inc. J Biomed Mater Res Part B: Appl Biomater, 2018. © 2018 Wiley Periodicals, Inc.

Relationship between the Ulnar Nerve and the Branches of the Radial Nerve to the Medial Head of the Triceps Brachii Muscle.

PubMed

Sh, Cho; Ih, Chung; Uy, Lee

2018-05-17

One branch of the radial nerve to the medial head of the triceps brachii muscle (MHN) has been described as accompanying or joining the ulnar nerve. Mostly two MHN branches have been reported, with some reports of one; however, the topographical anatomy is not well documented. We dissected 52 upper limbs from adult cadavers and found one, two, and three MHN branches in 9.6%, 80.8%, and 9.6% of cases, respectively. The MHN accompanying the ulnar nerve was always the superior MHN. The relationship between the ulnar nerve and the MHN was classified into four types according to whether the MHN was enveloped along with the ulnar nerve in the connective tissue sheath and whether it was in contact with the ulnar nerve. It contacted the ulnar nerve in 75.0% of cases and accompanied it over a mean distance of 73.6 mm (range 36-116 mm). In all cases in which the connective tissue sheath enveloped the branch of the MHN and the ulnar nerve, removing the sheath confirmed that the MHN branch originated from the radial nerve. The detailed findings and anatomical measurements of the MHN in this study will help in identifying its branches during surgical procedures. This article is protected by copyright. All rights reserved. © 2018 Wiley Periodicals, Inc.

Fasciocutaneous Propeller Flap Based on Perforating Branch of Ulnar Artery for Soft Tissue Reconstruction of the Hand and Wrist.

PubMed

Jang, Hyo Seok; Lee, Young Ho; Kim, Min Bom; Chung, Joo Young; Seok, Hyun Sik; Baek, Goo Hyun

2018-03-01

A skin defect of the hand and wrist is a common manifestation in industrial crushing injuries, traffic accidents or after excision of tumors. We reconstructed a skin defect in the ulnar aspect of the hand and wrist with a perforator-based propeller flap from the ulnar artery. The aims of our study are to evaluate the utility and effectiveness of this flap and to discuss the advantages and disadvantages of the flap in hand and wrist reconstruction with a review of the literature. Between April 2011 and November 2016, five cases of skin defect were reconstructed with a perforator-based propeller flap from the ulnar artery. There were four males and one female. The age of patients ranged from 36 to 73 years. Skin defect sites were on the dorso-ulnar side of the hand in three cases and palmar-ulnar side of the wrist in two cases. The size of the skin defect ranged from 4 × 3 cm to 8 × 5 cm. We evaluated the viability of the flap, postoperative complication and patient's satisfaction. There was no failure of flap in all cases. The size of the flap ranged from 4 × 4 cm to 12 × 4 cm. One patient, who had a burn scar contracture, presented with limited active and passive motion of the wrist after the operation. The other patients had no complications postoperatively. Cosmetic results of the surgery were excellent in one patient, good in three patients, and fair in one patient. The fasciocutaneous propeller flap based on a perforating branch of the ulnar artery is a reliable treatment option for the ulnar side skin defect of the hand and wrist.

42 CFR 1003.114 - Collateral estoppel.

Code of Federal Regulations, 2010 CFR

2010-10-01

... 42 Public Health 5 2010-10-01 2010-10-01 false Collateral estoppel. 1003.114 Section 1003.114 Public Health OFFICE OF INSPECTOR GENERAL-HEALTH CARE, DEPARTMENT OF HEALTH AND HUMAN SERVICES OIG AUTHORITIES CIVIL MONEY PENALTIES, ASSESSMENTS AND EXCLUSIONS § 1003.114 Collateral estoppel. (a) Where a...

42 CFR 3.532 - Collateral estoppel.

Code of Federal Regulations, 2010 CFR

2010-10-01

... 42 Public Health 1 2010-10-01 2010-10-01 false Collateral estoppel. 3.532 Section 3.532 Public Health PUBLIC HEALTH SERVICE, DEPARTMENT OF HEALTH AND HUMAN SERVICES GENERAL PROVISIONS PATIENT SAFETY ORGANIZATIONS AND PATIENT SAFETY WORK PRODUCT Enforcement Program § 3.532 Collateral estoppel. When a final...

Internal Carotid Artery Stenosis and Collateral Recruitment in Stroke Patients.

PubMed

Dankbaar, Jan W; Kerckhoffs, Kelly G P; Horsch, Alexander D; van der Schaaf, Irene C; Kappelle, L Jaap; Velthuis, Birgitta K

2017-04-24

Leptomeningeal collaterals improve outcome in stroke patients. There is great individual variability in their extent. Internal carotid artery (ICA) stenosis may lead to more extensive recruitment of leptomeningeal collaterals. The purpose of this study was to evaluate the association of pre-existing ICA stenosis with leptomeningeal collateral filling visualized with computed tomography perfusion (CTP). From a prospective acute ischemic stroke cohort, patients were included with an M1 middle cerebral artery (MCA) occlusion and absent ipsilateral, extracranial ICA occlusion. ICA stenosis was determined on admission CT angiography (CTA). Leptomeningeal collaterals were graded as good (>50%) or poor (≤50%) collateral filling in the affected MCA territory on CTP-derived vessel images of the admission scan. The association between ipsilateral ICA stenosis ≥70% and extent of collateral filling was analyzed using logistic regression. In a multivariable analysis the odds ratio (OR) of ICA stenosis ≥70% was adjusted for complete circle of Willis, gender and age. We included 188 patients in our analyses, 50 (26.6%) patients were classified as having poor collateral filling and 138 (73.4%) as good. Of the patients 4 with poor collateral filling had an ICA stenosis ≥70% and 14 with good collateral filling. Unadjusted and adjusted ORs of ICA stenosis ≥70% for good collateral filling were 1.30 (0.41-4.15) and 2.67 (0.81-8.77), respectively. Patients with poor collateral filling had a significantly worse outcome (90-day modified Rankin scale 3-6; 80% versus 52%, p = 0.001). No association was found between pre-existing ICA stenosis and extent of CTP derived collateral filling in patients with an M1 occlusion.

Two cases of feline ectromelia: autopodium ectromelia associated with humero-ulnar synostosis and zeugopodium ectromelia.

PubMed

Macrì, Francesco; De Majo, Massimo; Rapisarda, Giuseppe; Mazzullo, Giuseppe

2009-08-01

Congenital limb deformities are rarely reported in cats. This paper describes the radiographic findings of congenital forelimb malformations in two cats. The radiographic changes were suggestive of an autopodium ectromelia associated with humero-ulnar synostosis in one case and zeugopodium ectromelia in the other case. Congenital feline limb deformities are poorly documented and, to the authors' knowledge, this is the first time that humero-ulnar synostosis has been reported in cats.

[Preliminary investigation of treatment of ulnar nerve defect by end-to-side neurorrhaphy].

PubMed

Luo, Y; Wang, T; Fang, H

1997-11-01

In the repair of the defect of peripheral nerve, it was necessary to find an operative method with excellent therapeutic effect but simple technique. Based on the experimental study, one case of old injury of the ulnar nerve was treated by end-to-side neurorraphy with the intact median nerve. In this case the nerve defect was over 3 cm and unable to be sutured directly. The patient was followed up for fourteen months after the operation. The recovery of the sensation and the myodynamia was evaluated. The results showed that: the sensation and the motor function innervated by ulnar nerve were recovered. The function of the hand was almost recovered to be normal. It was proved that the end-to-side neurorraphy between the distal stump with the intact median nerve to repair the defect of the ulnar nerve was a new operative procedure for nerve repair. Clinically it had good effect with little operative difficulty. This would give a bright prospect to repair of peripheral nerve defect in the future.

[EFFECTIVENESS OF ONE-STAGE REPAIR AND RECONSTRUCTION FOR KNEE DISLOCATION WITH MULTIPLE LIGAMENT INJURIES].

PubMed

Sun, Zhengyu; Zhang, Chenghao; Tang, Xin; Chen, Gang; Li, Jian

2016-06-08

To evaluate the surgical procedure and short-term effectiveness of one-stage repair and reconstruction of knee dislocation with multiple ligament injuries (KDMLI). Between September 2010 and April 2014, 9 cases (9 knees) of KDMLI were treated. There were 7 males and 2 females with an average age of 42 years (range, 27-57 years). Injury was caused by traffic accident in 3 cases, heavy-weight crushing in 3 cases, sports sprain in 2 cases, and falling from height in 1 case. The average time from injury to operation was 11 days (range, 3-19 days). The results of posterior drawer test and Lachman test were positive in all patients. The results of varus stress testing were three-degree positive in 4 cases, and the results of valgus stress testing were three-degree positive in 6 cases. The Lysholm score of knee was 27.2±6.3; the International Knee Documentation Committee (IKDC) score was 29.7±6.5; and the range of motion (ROM) was (52.6±12.8)°. All patients suffered from posterior cruciate ligament (PCL) injury and femoral avulsion injury of anterior cruciate ligament (ACL). Combined injuries included medial collateral ligament (MCL) injury in 4 cases (medial meniscus injury in 1 case), lateral collateral ligament (LCL) injury in 2 cases, and MCL and LCL injuries in 2 cases (medial meniscus and lateral meniscus injuries in 1 case). Autologous harmstring tendon was used to reconstruct PCL under arthroscopy combined with limited open in situ suture for repair of femoral avulsion injury of ACL, and repair of MCL, LCL, and other injury in one-stage operation. All incisions healed by first intention. Joint effusion of knee occurred in 1 case and was cured after removal of fluid combined with pressure bandage. All patients were followed up 12-36 months with an average of 22 months. At last follow-up, the result of posterior drawer test was negative in all patients. The results of Lachman test were one-degree positive in 2 cases; the result of varus stress testing was one

Analyzing cost-effectiveness of ulnar and median nerve transfers to regain forearm flexion.

PubMed

Wali, Arvin R; Park, Charlie C; Brown, Justin M; Mandeville, Ross

2017-03-01

OBJECTIVE Peripheral nerve transfers to regain elbow flexion via the ulnar nerve (Oberlin nerve transfer) and median nerves are surgical options that benefit patients. Prior studies have assessed the comparative effectiveness of ulnar and median nerve transfers for upper trunk brachial plexus injury, yet no study has examined the cost-effectiveness of this surgery to improve quality-adjusted life years (QALYs). The authors present a cost-effectiveness model of the Oberlin nerve transfer and median nerve transfer to restore elbow flexion in the adult population with upper brachial plexus injury. METHODS Using a Markov model, the authors simulated ulnar and median nerve transfers and conservative measures in terms of neurological recovery and improvements in quality of life (QOL) for patients with upper brachial plexus injury. Transition probabilities were collected from previous studies that assessed the surgical efficacy of ulnar and median nerve transfers, complication rates associated with comparable surgical interventions, and the natural history of conservative measures. Incremental cost-effectiveness ratios (ICERs), defined as cost in dollars per QALY, were calculated. Incremental cost-effectiveness ratios less than $50,000/QALY were considered cost-effective. One-way and 2-way sensitivity analyses were used to assess parameter uncertainty. Probabilistic sampling was used to assess ranges of outcomes across 100,000 trials. RESULTS The authors' base-case model demonstrated that ulnar and median nerve transfers, with an estimated cost of $5066.19, improved effectiveness by 0.79 QALY over a lifetime compared with conservative management. Without modeling the indirect cost due to loss of income over lifetime associated with elbow function loss, surgical treatment had an ICER of $6453.41/QALY gained. Factoring in the loss of income as indirect cost, surgical treatment had an ICER of -$96,755.42/QALY gained, demonstrating an overall lifetime cost savings due to

Ulnar neuropathy and medial elbow pain in women's fastpitch softball pitchers: a report of 6 cases.

PubMed

Smith, Adam M; Butler, Thomas H; Dolan, Michael S

2017-12-01

Elite-level women's fastpitch softball players place substantial biomechanical strains on the elbow that can result in medial elbow pain and ulnar neuropathic symptoms. There is scant literature reporting the expected outcomes of the treatment of these injuries. This study examined the results of treatment in a series of these patients. We identified 6 female softball pitchers (4 high school and 2 collegiate) with medial elbow pain and ulnar neuropathic symptoms. Trials of conservative care failed in all 6, and they underwent surgical treatment with subcutaneous ulnar nerve transposition. These patients were subsequently monitored postoperatively to determine outcome. All 6 female pitchers had early resolution of elbow pain and neuropathic symptoms after surgical treatment. Long-term follow-up demonstrated that 1 patient quit playing softball because of other injuries but no longer reported elbow pain or paresthesias. One player was able to return to pitching at the high school level but had recurrent forearm pain and neuritis 1 year later while playing a different sport and subsequently stopped playing competitive sports. Four patients continued to play at the collegiate level without further symptoms. Medial elbow pain in women's softball pitchers caused by ulnar neuropathy can be treated effectively with subcutaneous ulnar nerve transposition if nonsurgical options fail. Further study is necessary to examine the role of overuse, proper training techniques, and whether pitching limits may be necessary to avoid these injuries. Copyright © 2017 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.

Continuing to work with a sterile thumb splint: A case report.

PubMed

Roner, S; Fürnstahl, P; Schweizer, A; Wieser, K

2018-05-17

Nonoperative treatment of an injured ulnar collateral ligament of the thumb metacarpophalangeal (MCP) joint (skier's thumb without a Stener lesion) is managed by immobilization. A splint is applied on the radial side with the thumb in slight flexion to immobilize the MCP joint and allow motion in the interphalangeal joint. Thermoplastic splints are mainly used for daily activities with the advantage of custom fabrication for optimal comfort. To immobilize the thumb during surgical procedures performed by an orthopedic surgeon, splints made of sterilizable materials are needed but not yet available to our knowledge. We present the case of a 36-year-old orthopedic surgeon diagnosed with skier's thumb, and the development and application of a reusable, patient-specific (i.e., the orthopedic surgeon) splint to immobilize the thumb MCP joint in a sterile environment so the surgeon could continue working. Copyright © 2018 SFCM. Published by Elsevier Masson SAS. All rights reserved.

Elbow arthroscopy: valgus extension overload.

PubMed

Ahmad, Christopher S; Conway, John E

2011-01-01

Valgus torque combined with deceleration produces high compression and shear forces acting on the posteromedial olecranon and the posteromedial trochlea. This valgus extension overload process may cause posteromedial trochlea chondromalacia, chondral flap formation, osteochondrosis, subchondral erosion, a subchondral insufficiency fracture, and marginal exostosis formation. Olecranon pathologies include proximal stress reaction, a posteromedial tip stress fracture, a transverse proximal process stress fracture, exostosis formation, exostosis fragmentation, and intra-articular loose bodies. Symptoms include posteromedial elbow pain during the deceleration phase of the throwing motion. The extension impingement test reproduces posterior or posteromedial pain similar to that experienced while throwing. Special radiographic techniques and CT scans can show loose bodies and osteophyte fragmentation. Surgical treatment is indicated when symptoms persist despite nonsurgical management. Based on clinical and basic science research, all patients with valgus extension overload should be comprehensively evaluated for medial ulnar collateral ligament insufficiency. Surgical treatment is limited to the resection of osteophytes only; normal olecranon should not be resected.

ANALYSIS OF THE PATTERN AND MECHANISM OF ELBOW INJURIES RELATED TO ARMBAR-TYPE ARMLOCKS IN JIU-JITSU FIGHTERS.

PubMed

Almeida, Thiago Bernardo Carvalho DE; Dobashi, Eiffel Tsuyoshi; Nishimi, Alexandre Yukio; Almeida, Eduardo Bernardo DE; Pascarelli, Luciano; Rodrigues, Luciano Miller Reis

2017-01-01

The objective of this study was to analyze elbow injuries and their probable mechanism in Jiu-Jitsu fighters resulting from the armbar-type armlock. We evaluated 5 high-performance Jiu-Jitsu fighters from the Gracie Elite gym who were injured during a tournament. All were healthy males with a mean age of 28.8 years. The right arm was involved in three patients (60%). The athletes were followed for approximately 4.6 months, and pain was present in all cases. Clinical examination of the elbow was performed immediately after the injury and when magnetic resonance imaging (MRI) was performed. The radiography showed no changes. Clinical examination detected specific tender points on the medial and anterior topography of the elbows, but no ligamentous instability of the elbow was seen during dynamic testing. The main MRI findings were injury to the common flexor tendon and the ulnar collateral ligament, bone contusion of the distal humerus and olecranon, and joint effusion. The main pattern of injury indicated by the MRI in the athletes was injury to the medial elbow complex. The primary mechanism that determined the injury was most likely elbow hyperextension applied with the forearm in neutral position of forearm. Level of Evidence IV, Case Series.

ANALYSIS OF THE PATTERN AND MECHANISM OF ELBOW INJURIES RELATED TO ARMBAR-TYPE ARMLOCKS IN JIU-JITSU FIGHTERS

PubMed Central

ALMEIDA, THIAGO BERNARDO CARVALHO DE; DOBASHI, EIFFEL TSUYOSHI; NISHIMI, ALEXANDRE YUKIO; ALMEIDA, EDUARDO BERNARDO DE; PASCARELLI, LUCIANO; RODRIGUES, LUCIANO MILLER REIS

2017-01-01

ABSTRACT Objective: The objective of this study was to analyze elbow injuries and their probable mechanism in Jiu-Jitsu fighters resulting from the armbar-type armlock. Methods: We evaluated 5 high-performance Jiu-Jitsu fighters from the Gracie Elite gym who were injured during a tournament. All were healthy males with a mean age of 28.8 years. The right arm was involved in three patients (60%). The athletes were followed for approximately 4.6 months, and pain was present in all cases. Clinical examination of the elbow was performed immediately after the injury and when magnetic resonance imaging (MRI) was performed. The radiography showed no changes. Clinical examination detected specific tender points on the medial and anterior topography of the elbows, but no ligamentous instability of the elbow was seen during dynamic testing. Results: The main MRI findings were injury to the common flexor tendon and the ulnar collateral ligament, bone contusion of the distal humerus and olecranon, and joint effusion. Conclusion: The main pattern of injury indicated by the MRI in the athletes was injury to the medial elbow complex. The primary mechanism that determined the injury was most likely elbow hyperextension applied with the forearm in neutral position of forearm. Level of Evidence IV, Case Series. PMID:29081707

Zinc release from Schaffer collaterals and its significance.

PubMed

Takeda, Atsushi; Nakajima, Satoko; Fuke, Sayuri; Sakurada, Naomi; Minami, Akira; Oku, Naoto

2006-02-15

On the basis of the evidence that approximately 45% of Schaffer collateral boutons are zinc-positive, zinc release from Schaffer collaterals and its action were examined in hippocampal slices. When zinc release from Schaffer collaterals was examined using ZnAF-2, a membrane-impermeable zinc indicator, ZnAF-2 signal in the stratum radiatum of the CA1 was increased by tetanic stimuli at 100 Hz for 1s, suggesting that zinc is released from Schaffer collaterals in a calcium- and impulse-dependent manner. An in vivo microdialysis experiment indicated that the perfusion with 10 microM zinc significantly decreases extracellular glutamate concentration in the CA1. When tetanic stimuli at 100 Hz for 5s were delivered to the dentate granule cells, the increase in calcium signal in the stratum radiatum of the CA1, as well as in the stratum lucidum of the CA3, was attenuated by addition of 10 microM zinc, while enhanced by addition of 1mM CaEDTA, a membrane-impermeable zinc chelator. The increase in calcium signal in the CA1, in which Schaffer collateral synapses exist, during delivery of tetanic stimuli at 100 Hz for 1s to the Schaffer collateral-commissural pathway was also significantly enhanced by addition of 1mM CaEDTA. These results suggest that zinc released from Schaffer collaterals suppressively modulates presynaptic and postsynaptic calcium signaling in the CA1, followed by the suppression of glutamate release.

A review of the anterolateral ligament of the knee: current knowledge regarding its incidence, anatomy, biomechanics, and surgical dissection.

PubMed

Pomajzl, Ryan; Maerz, Tristan; Shams, Christienne; Guettler, Joseph; Bicos, James

2015-03-01

To systematically review current literature on the anterolateral ligament (ALL) of the knee. We searched the PubMed/Medline database for publications specifically addressing the ALL. We excluded studies not written in English, studies not using human cadavers or subjects, and studies not specifically addressing the ALL. Data extraction related to the incidence, anatomy, morphometry, biomechanics, and histology of the ALL and its relation to the Segond fracture was performed. The incidence of the ALL ranged from 83% to 100%, and this range occurs because of small discrepancies in the definition of the ALL's bony insertions. The ALL originates anterior and distal to the femoral attachment of the lateral collateral ligament. It spans the joint in an oblique fashion and inserts between the fibular head and Gerdy tubercle on the tibia. Exact anatomic and morphometric descriptions vary in the literature, and there are discrepancies regarding the ALL's attachment to the capsule and lateral meniscus. The ALL is a contributor to tibial internal rotation stability, and histologically, it exhibits parallel, crimped fibers consistent with a ligamentous microstructure. The footprint of the ALL has been shown to be at the exact location of the Segond fracture. The ALL is a distinct ligamentous structure at the anterolateral aspect of the knee, and it is likely involved in tibial internal rotation stability and the Segond fracture. Level IV, systematic review of anatomic and imaging studies. Copyright © 2015 Arthroscopy Association of North America. Published by Elsevier Inc. All rights reserved.

A History of Anterior Cruciate Ligament Reconstruction at the National Football League Combine Results in Inferior Early National Football League Career Participation.

PubMed

Provencher, Matthew T; Bradley, James P; Chahla, Jorge; Sanchez, Anthony; Beaulieu-Jones, Brendin R; Arner, Justin W; Kennedy, Nicholas I; Sanchez, George; Kennedy, Mitchell I; Moatshe, Gilbert; Cinque, Mark E; LaPrade, Robert F

2018-05-19

To evaluate whether players with a history of an anterior cruciate ligament reconstruction (ACLR) before the National Football League (NFL) Combine played or started fewer games and/or participated in fewer eligible snaps compared with NFL Combine participants without a history of knee injury or surgery. We performed a retrospective review of all players who participated in the NFL Combine between 2009 and 2015 and who had a history of an ACLR. NFL Combine participants were included if they had a previous ACLR or combined anterior cruciate ligament (ACL) injury and nonoperatively managed medial collateral ligament injury. The number of games started, number of games played, draft number, overall draft pick, and snap percentage for each position were determined. The mean value of each outcome metric was compared between case and control players. We identified 110 players who had an ACL injury (n = 76) or a combined ACL and medial collateral ligament injury (n = 34). Players in the ACLR group had a significantly worse mean draft pick number (difference of 30.2, P = .002) and mean draft round (difference of 0.8, P = .019) versus controls. Compared with control players, players in the ACLR group started and played significantly fewer games in both season 1 (difference of 2.7 games started, P < .001; difference of 2.7 games played, P < .001) and season 2 (difference of 7.4 games started, P < .001; difference of 3.0 games played, P = .003) and had a significantly lower snap percentage in both season 1 (difference of 23.1%, P < .001) and season 2 (difference of 24.0%, P < .001). Athletes at the NFL Combine who previously underwent an ACLR had significantly lower early-career NFL player metrics, including fewer games started, fewer games played, and a lower snap percentage, than uninjured controls. Defensive linemen, defensive backs, and linebackers were the 3 most affected positions. Players with a prior ACLR and combined meniscal-chondral pathology had

The superficial medial collateral ligament is the primary medial restraint to knee laxity after cruciate-retaining or posterior-stabilised total knee arthroplasty: effects of implant type and partial release.

PubMed

Athwal, Kiron K; Daou, Hadi El; Kittl, Christoph; Davies, Andrew J; Deehan, David J; Amis, Andrew A

2016-08-01

The aim of this study was to quantify the contributions of medial soft tissues to stability following cruciate-retaining (CR) or posterior-stabilised (PS) total knee arthroplasty (TKA). Using a robotic system, eight cadaveric knees were subjected to ±90-N anterior-posterior force, ±5-Nm internal-external and ±8-Nm varus-valgus torques at various flexion angles. The knees were tested intact and then with CR and PS implants, and successive cuts of the deep and superficial medial collateral ligaments (dMCL, sMCL) and posteromedial capsule (PMC) quantified the percentage contributions of each structure to restraining the applied loads. In implanted knees, the sMCL restrained valgus rotation (62 % across flexion angles), anterior-posterior drawer (24 and 10 %, respectively) and internal-external rotation (22 and 37 %). Changing from CR TKA to PS TKA increased the load on the sMCL when resisting valgus loads. The dMCL restrained 11 % of external and 13 % of valgus rotations, and the PMC was significant at low flexion angles. This work has shown that medial release in the varus knee should be minimised, as it may inadvertently result in a combined laxity pattern. There is increasing interest in preserving constitutional varus in TKA, and this work argues for preservation of the sMCL to afford the surgeon consistent restraint and maintain a balanced knee for the patient.

Reliability, reference values and predictor variables of the ulnar sensory nerve in disease free adults.

PubMed

Ruediger, T M; Allison, S C; Moore, J M; Wainner, R S

2014-09-01

The purposes of this descriptive and exploratory study were to examine electrophysiological measures of ulnar sensory nerve function in disease free adults to determine reliability, determine reference values computed with appropriate statistical methods, and examine predictive ability of anthropometric variables. Antidromic sensory nerve conduction studies of the ulnar nerve using surface electrodes were performed on 100 volunteers. Reference values were computed from optimally transformed data. Reliability was computed from 30 subjects. Multiple linear regression models were constructed from four predictor variables. Reliability was greater than 0.85 for all paired measures. Responses were elicited in all subjects; reference values for sensory nerve action potential (SNAP) amplitude from above elbow stimulation are 3.3 μV and decrement across-elbow less than 46%. No single predictor variable accounted for more than 15% of the variance in the response. Electrophysiologic measures of the ulnar sensory nerve are reliable. Absent SNAP responses are inconsistent with disease free individuals. Reference values recommended in this report are based on appropriate transformations of non-normally distributed data. No strong statistical model of prediction could be derived from the limited set of predictor variables. Reliability analyses combined with relatively low level of measurement error suggest that ulnar sensory reference values may be used with confidence. Copyright © 2014 Elsevier Masson SAS. All rights reserved.

MRI appearance of surgically proven abnormal accessory anterior-inferior tibiofibular ligament (Bassett's ligament).

PubMed

Subhas, Naveen; Vinson, Emily N; Cothran, R Lee; Santangelo, James R; Nunley, James A; Helms, Clyde A

2008-01-01

A thickened accessory anterior-inferior tibiofibular ligament (Bassett's ligament) of the ankle can be a cause of ankle impingement. Its imaging appearance is not well described. The purpose of this study was to determine if the ligament could be identified on magnetic resonance imaging (MRI), to determine associated abnormalities, and to determine if MRI could be used to differentiate normal from abnormal. Eighteen patients with a preoperative ankle MRI and an abnormal Bassett's ligament reported at surgery were found retrospectively. A separate cohort of 18 patients was selected as a control population. The presence of Bassett's ligament and its thickness were noted. The integrity and appearance of the lateral ankle ligaments, talar dome cartilage, and anterolateral gutter were also noted. In 34 of the 36 cases (94%), Bassett's ligament was identified on MRI. The ligament was seen in all three imaging planes and most frequently in the axial plane. The mean thickness of the ligament in the surgically abnormal cases was 2.37 mm, compared with 1.87 mm in the control with a p value=0.015 (t test). Nine of the 18 abnormal cases (50%) had talar dome cartilage lesions as a result of contact with the ligament at surgery, with only 3 cases of high-grade defects seen on MRI. Fourteen of the 18 abnormal cases (78%) had of synovitis or scarring in the lateral gutter at surgery, with only 5 cases with scarring seen on MRI. The anterior-inferior tibiofibular ligament was abnormal or torn in 8 of the 18 abnormal cases (44%) by MRI and confirmed in only 3 cases at surgery. Bassett's ligament can be routinely identified on MRI and was significantly thicker in patients who had it resected at surgery. An abnormal Bassett's ligament is often present in the setting of a normal anterior-inferior tibiofibular ligament. The cartilage abnormalities and synovitis associated with an abnormal Bassett's ligament are poorly detected by conventional MRI.

48 CFR 2448.104-3 - Sharing collateral savings.

Code of Federal Regulations, 2011 CFR

2011-10-01

... DEVELOPMENT CONTRACT MANAGEMENT VALUE ENGINEERING 2448.104-3 Sharing collateral savings. (a) The authority of the HCA to determine that the cost of calculating and tracking collateral savings will exceed the...

48 CFR 2448.104-3 - Sharing collateral savings.

Code of Federal Regulations, 2013 CFR

2013-10-01

... DEVELOPMENT CONTRACT MANAGEMENT VALUE ENGINEERING 2448.104-3 Sharing collateral savings. (a) The authority of the HCA to determine that the cost of calculating and tracking collateral savings will exceed the...

48 CFR 2448.104-3 - Sharing collateral savings.

Code of Federal Regulations, 2012 CFR

2012-10-01

... DEVELOPMENT CONTRACT MANAGEMENT VALUE ENGINEERING 2448.104-3 Sharing collateral savings. (a) The authority of the HCA to determine that the cost of calculating and tracking collateral savings will exceed the...

10 CFR 1015.210 - Liquidation of collateral.

Code of Federal Regulations, 2010 CFR

2010-01-01

... States. Collection from other sources, including liquidation of security or collateral, is not a... Energy DEPARTMENT OF ENERGY (GENERAL PROVISIONS) COLLECTION OF CLAIMS OWED THE UNITED STATES Standards... liquidate security or collateral through the exercise of a power of sale in the security instrument or a...

Handlebar palsy--a compression syndrome of the deep terminal (motor) branch of the ulnar nerve in biking.

PubMed

Capitani, Daniel; Beer, Serafin

2002-10-01

We describe 3 patients who developed a severe palsy of the intrinsic ulnar supplied hand muscles after bicycle riding. Clinically and electrophysiologically all showed an isolated lesion of the deep terminal motor branch of the ulnar nerve leaving the hypothenar muscle and the distal sensory branch intact. This type of lesion at the canal of Guyon is quite unusual, caused in the majority of cases by chronic external pressure over the ulnar palm. In earlier reports describing this lesion in bicycle riders, most patients experienced this lesion after a long distance ride. Due to the change of riding position and shape of handlebars (horn handle) in recent years, however, even a single bicycle ride may be sufficient to cause a lesion of this ulnar branch. Especially in downhill riding, a large part of the body weight is supported by the hand on the corner of the handlebar leading to a high load at Guyon's canal. As no sensory fibres are affected, the patients are not aware of the ongoing nerve compression until a severe lesion develops. Individual adaptation of the handlebar and riding position seems to be crucial for prevention of this type of nerve lesion.

13 CFR 120.1850 - Will the Collateral be held by SBA?

Code of Federal Regulations, 2010 CFR

2010-01-01

... Loan Program) § 120.1850 Will the Collateral be held by SBA? Yes, SBA or its expressly authorized agent... all Collateral for SISMBD Loans in a custodial account. Certificates held as Collateral must be in... 13 Business Credit and Assistance 1 2010-01-01 2010-01-01 false Will the Collateral be held by SBA...

27 CFR 72.25 - Deposit of collateral.

Code of Federal Regulations, 2010 CFR

2010-04-01

... be pledged and deposited by claimants as collateral security in lieu of corporate sureties in... treasurers' checks may be furnished by claimants as collateral security in lieu of corporate sureties. (b..., Notes or Other Obligations Issued or Guaranteed by the United States as Security in Lieu of Surety or...

27 CFR 72.25 - Deposit of collateral.

Code of Federal Regulations, 2012 CFR

2012-04-01

... be pledged and deposited by claimants as collateral security in lieu of corporate sureties in... treasurers' checks may be furnished by claimants as collateral security in lieu of corporate sureties. (b..., Notes or Other Obligations Issued or Guaranteed by the United States as Security in Lieu of Surety or...

27 CFR 72.25 - Deposit of collateral.

Code of Federal Regulations, 2013 CFR

2013-04-01

... be pledged and deposited by claimants as collateral security in lieu of corporate sureties in... treasurers' checks may be furnished by claimants as collateral security in lieu of corporate sureties. (b..., Notes or Other Obligations Issued or Guaranteed by the United States as Security in Lieu of Surety or...

27 CFR 72.25 - Deposit of collateral.

Code of Federal Regulations, 2014 CFR

2014-04-01

... be pledged and deposited by claimants as collateral security in lieu of corporate sureties in... treasurers' checks may be furnished by claimants as collateral security in lieu of corporate sureties. (b..., Notes or Other Obligations Issued or Guaranteed by the United States as Security in Lieu of Surety or...

27 CFR 72.25 - Deposit of collateral.

Code of Federal Regulations, 2011 CFR

2011-04-01

... be pledged and deposited by claimants as collateral security in lieu of corporate sureties in... treasurers' checks may be furnished by claimants as collateral security in lieu of corporate sureties. (b..., Notes or Other Obligations Issued or Guaranteed by the United States as Security in Lieu of Surety or...

Coronary Collateral Growth—Back to the Future

PubMed Central

Chilian, William M.; Penn, Marc S.; Pung, Yuh Fen; Dong, Feng; Mayorga, Maritza; Ohanyan, Vahagn; Logan, Suzanna; Yin, Liya

2012-01-01

The coronary collateral circulation is critically important as an adaptation of the heart to prevent the damage from ischemic insults. In their native state, collaterals in the heart would be classified as part of the microcirculation, existing as arterial-arterial anastomotic connections in the range of 30 to 100 μM in diameter. However, these vessels also show a propensity to remodel into components of the macrocirculation and can become arteries larger than a 1000 μM in diameter. This process of outward remodelling is critically important in the adaptation of the heart to ischemia because the resistance to blood flow is inversely related to the fourth power of the diameter of the vessel. Thus, an expansion of a vessel from 100 to 1000 μM would reduce resistance (in this part of the circuit) to a negligible amount and enable delivery of flow to the region at risk. Our goal in this review is to highlight the voids in understanding this adaptation to ischemia—the growth of the coronary collateral circulation. In doing so we discuss the controversies and unknown aspects of the causal factors that stimulate growth of the collateral circulation, the role of genetics, and the role of endogenous stem and progenitor cells in the context of the normal, physiological situation and under more pathological conditions of ischemic heart disease or with some of the underlying risk factors, e.g., diabetes. The major conclusion of this review is that there are many gaps in our knowledge of coronary collateral growth and this knowledge is critical before the potential of stimulating collateralization in the hearts of patients can be realized. PMID:22210280

Status of systemic to pulmonary arterial collateral flow after the fontan procedure.

PubMed

Whitehead, Kevin K; Harris, Matthew A; Glatz, Andrew C; Gillespie, Matthew J; DiMaria, Michael V; Harrison, Neil E; Dori, Yoav; Keller, Marc S; Rome, Jonathan J; Fogel, Mark A

2015-06-15

The investigators recently validated a method of quantifying systemic-to-pulmonary arterial collateral flow using phase-contrast magnetic resonance imaging velocity mapping. Cross-sectional data suggest decreased collateral flow in patients with total cavopulmonary connections (TCPCs) compared with those with superior cavopulmonary connections (SCPCs). However, no studies have examined serial changes in collateral flow from SCPCs to TCPCs in the same patients. The aim of this study was to examine differences in collateral flow between patients with SCPCs and those with TCPCs. Collateral flow was quantified by 2 independent measures from 250 single-ventricle studies in 219 different patients (115 SCPC and 135 TCPC studies, 31 patients with both) and 18 controls, during routine studies using through-plane phase-contrast magnetic resonance imaging. Collateral flow was indexed to body surface area, aortic flow, and pulmonary venous flow. Regardless of indexing method, SCPC patients had significantly higher collateral flow than TCPC patients (1.64 ± 0.8 vs 1.03 ± 0.8 L/min/m(2), p <0.001). In 31 patients who underwent serial examinations, collateral flow as a fraction of aortic flow increased early after TCPC completion. In TCPC patients, indexed collateral flow demonstrated a significant negative correlation with time from TCPC. In conclusion, SCPC and TCPC patients demonstrate substantial collateral flow, with SCPC patients having higher collateral flow than TCPC patients overall. On the basis of the paired subset analysis, collateral flow does not decrease in the short term after TCPC completion and trends toward an increase. In the long term, however, collateral flow decreases over time after TCPC completion. Copyright © 2015 Elsevier Inc. All rights reserved.

Varying whole body vibration amplitude differentially affects tendon and ligament structural and material properties

PubMed Central

Keller, Benjamin V.; Davis, Matthew L.; Thompson, William R.; Dahners, Laurence E.; Weinhold, Paul S.

2014-01-01

Whole Body Vibration (WBV) is becoming increasingly popular for helping to maintain bone mass and strengthening muscle. Vibration regimens optimized for bone maintenance often operate at hypogravity levels (<1 G) and regimens for muscle strengthening often employ hypergravity (>1 G) vibrations. The effect of vibratory loads on tendon and ligament properties is unclear though excessive vibrations may be injurious. Our objective was to evaluate how tendon gene expression and the mechanical/histological properties of tendon and ligament were affected in response to WBV in the following groups: no vibration, low vibration (0.3 G peak-to-peak), and high vibration (2 G peak-to-peak). Rats were vibrated for 20 min a day, 5 days a week, for 5 weeks. Upon sacrifice, the medial collateral ligament (MCL), patellar tendon (PT), and the Achilles Tendon (AT) were isolated with insertion sites intact. All tissues were tensile tested to determine structural and material properties or used for histology. Patellar tendon was also subjected to quantitative RT-PCR to evaluate expression of anabolic and catabolic genes. No differences in biomechanical data between the control and the low vibration groups were found. There was evidence of significant weakness in the MCL with high vibration, but no significant effect on the PT or AT. Histology of the MCL and PT showed a hypercellular tissue response and some fiber disorganization with high vibration. High vibration caused an increase in collagen expression and a trend for an increase in IGF-1 expression suggesting a potential anabolic response to prevent tendon overuse injury. PMID:23623311

Artificial Ligaments: Promise or Panacea?

ERIC Educational Resources Information Center

Lubell, Adele

1987-01-01

The Food and Drug Administration has approved a prosthetic ligament for limited use in persons with damaged anterior cruciate ligaments (ACL). This article addresses ligament repair, ACL tears, current treatment, development of the Gore-Tex artificial ligament, other artificial ligaments in process, and arguments for and against their use.…

Knee arthroscopy

MedlinePlus

... remove it. Torn or damaged anterior cruciate ligament (ACL) or posterior cruciate ligament (PCL). Torn or damaged ... surgery; Meniscus - arthroscopy; Collateral ligament - arthroscopy Patient Instructions ACL reconstruction - discharge Getting your home ready - knee or ...

Knee pain

MedlinePlus

... the kneecap. Torn ligament. An anterior cruciate ligament (ACL) injury, or medial collateral ligament (MCL) injury may ... need surgery. Alternative Names Pain - knee Patient Instructions ACL reconstruction - discharge Hip or knee replacement - after - what ...

Outcomes of coronoid-first repair in terrible triad injuries of the elbow.

PubMed

Zhang, Junren; Tan, Mark; Kwek, Ernest Beng Kee

2017-09-01

Clinical outcomes of terrible triad injuries (TTIs) of the elbow are historically poor. To date, it is still debatable whether the coronoid needs to be fixed and if so, how and in which sequence. Between 2010 and 2013, 13 patients were treated surgically for acute TTIs of the elbow at a Tertiary Level 1 Trauma Centre by a single surgeon, using a standardized protocol, which included coronoid-brachialis complex fixation via pull-through trans-osseous sutures, radial head fixation or prosthetic replacement and a repair of the lateral ulnar collateral ligament. Repair of the medial collateral ligament (MCL) was done if valgus-stress test demonstrated persistent instability. Patients were then followed-up with clinical and radiological evaluation by the senior author until fracture union and elbow range of motion reached a plateau. Outcomes measured were range of motion, DASH scores and MEPS, as well as surgical complications. Intraoperative stability was achieved in all 13 cases, MCL repair was required in 3 cases and application of external fixation was not required in any case. Patients were followed-up for an average length of 27.7 months and the minimum follow-up period was 12 months. The average age of patients was 46.4 years (range 35-79 years old) at the time of trauma. This included eight Regan-Morrey Type I and five Regan-Morrey Type II coronoid fractures, with ten Mason Type I/II and three Mason Type III radial head fractures. The average arc of ulno-humeral motion was 105.0° (range 80°-135°). The average flexion contracture was 15.0° (range 0°-40°). The average supination-pronation arc was 114.9° (range 0°-180°). The average MEPS was 85 of 100 (range 45-100) and the average DASH score was 21.2 of 100 (range 1.7-61.2). A single case of radio-ulnar synostosis, heterotropic ossification and two cases of recurrent elbow instability were noted. The coronoid-first surgical approach, using a suture-lasso fixation method, has technical benefits for us

Morphological patterns of the collateral sulcus in the human brain.

PubMed

Huntgeburth, Sonja C; Petrides, Michael

2012-04-01

The collateral sulcal complex is an important landmark on the medial surface of the temporal lobe. Anteriorly, it delineates the limbic regions of the parahippocampal gyrus from the visual-processing areas of the fusiform gyrus. Posteriorly, it continues into the occipital lobe, bearing no relationship to the memory-related limbic regions. Given the considerable extent of the sulcus and functional heterogeneity of the surrounding cortex, an investigation of the morphology of this sulcus was carried out to examine whether it is continuous or a series of sulcal parts, i.e. independent sulci classified together under the name collateral sulcus. We investigated the collateral sulcal complex using magnetic resonance images taking into account the three-dimensional nature of the brain. Our examination demonstrated three separate sulcal segments: (i) an anterior segment, the rhinal sulcus, delineating the uncus from the adjacent temporal neocortex, (ii) a middle segment, the collateral sulcus proper, forming the lateral border of the posterior parahippocampal cortex, and (iii) a caudal segment, the occipital extent of the collateral sulcus, within the occipital lobe. Three relationships exist between the rhinal sulcus and collateral sulcus proper, only one being clearly identifiable from the surface. Posteriorly, the collateral sulcus proper and the occipital collateral sulcus, although appearing continuous on the brain surface, can be separated in the depth of the sulcus in all cases. These results provide quantification of the location and variability within standard stereotaxic space for the three collateral sulcus segments that could be used to aid accurate identification of functional activation peaks derived from neuroimaging studies. © 2012 The Authors. European Journal of Neuroscience © 2012 Federation of European Neuroscience Societies and Blackwell Publishing Ltd.

Factors Influencing Outcomes after Ulnar Nerve Stability-Based Surgery for Cubital Tunnel Syndrome: A Prospective Cohort Study

PubMed Central

Kang, Ho Jung; Oh, Won Taek; Koh, Il Hyun; Kim, Sungmin

2016-01-01

Purpose Simple decompression of the ulnar nerve has outcomes similar to anterior transposition for cubital tunnel syndrome; however, there is no consensus on the proper technique for patients with an unstable ulnar nerve. We hypothesized that 1) simple decompression or anterior ulnar nerve transposition, depending on nerve stability, would be effective for cubital tunnel syndrome and that 2) there would be determining factors of the clinical outcome at two years. Materials and Methods Forty-one patients with cubital tunnel syndrome underwent simple decompression (n=30) or anterior transposition (n=11) according to an assessment of intra-operative ulnar nerve stability. Clinical outcome was assessed using grip and pinch strength, two-point discrimination, the mean of the disabilities of arm, shoulder, and hand (DASH) survey, and the modified Bishop Scale. Results Preoperatively, two patients were rated as mild, another 20 as moderate, and the remaining 19 as severe according to the Dellon Scale. At 2 years after operation, mean grip/pinch strength increased significantly from 19.4/3.2 kg to 31.1/4.1 kg, respectively. Two-point discrimination improved from 6.0 mm to 3.2 mm. The DASH score improved from 31.0 to 14.5. All but one patient scored good or excellent according to the modified Bishop Scale. Correlations were found between the DASH score at two years and age, pre-operative grip strength, and two-point discrimination. Conclusion An ulnar nerve stability-based approach to surgery selection for cubital tunnel syndrome was effective based on 2-year follow-up data. Older age, worse preoperative grip strength, and worse two-point discrimination were associated with worse outcomes at 2 years. PMID:26847300

The Impact of Osseous Malalignment and Realignment Procedures in Knee Ligament Surgery: A Systematic Review of the Clinical Evidence.

PubMed

Tischer, Thomas; Paul, Jochen; Pape, Dietrich; Hirschmann, Michael T; Imhoff, Andreas B; Hinterwimmer, Stefan; Feucht, Matthias J

2017-03-01

Failure rates of knee ligament surgery may be high, and the impact of osseous alignment on surgical outcome remains controversial. Basic science studies have demonstrated that osseous malalignment can negatively affect ligament strain and that realignment procedures may improve knee joint stability. The purpose of this review was to summarize the clinical evidence concerning the impact of osseous malalignment and realignment procedures in knee ligament surgery. The hypotheses were that lower extremity malalignment would be an important contributor to knee ligament surgery failure and that realignment surgery would contribute to increased knee stability and improved outcome in select cases. Systematic review; Level of evidence, 4. According to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, a systematic electronic search of the PubMed database was performed in November 2015 to identify clinical studies investigating (A) the influence of osseous alignment on postoperative stability and/or failure rates after knee ligament surgery and (B) the impact of osseous realignment procedures in unstable knees with or without additional knee ligament surgery on postoperative knee function and stability. Methodological quality of the studies was assessed using the Oxford Centre for Evidence-Based Medicine Levels of Evidence and the Coleman Methodological Score (CMS). Of the 1466 potentially relevant articles, 28 studies fulfilled the inclusion and exclusion criteria. Average study quality was poor (CMS, 40). For part A, studies showed increased rerupture rate after anterior cruciate ligament (ACL) replacement in patients with increased tibial slope. Concerning the posterior cruciate ligament (PCL)/posterolateral corner (PLC)/lateral collateral ligament (LCL), varus malalignment was considered a significant risk factor for failure. For part B, studies showed decreased anterior tibial translation after slope-decreasing high tibial

The Impact of Osseous Malalignment and Realignment Procedures in Knee Ligament Surgery: A Systematic Review of the Clinical Evidence

PubMed Central

Tischer, Thomas; Paul, Jochen; Pape, Dietrich; Hirschmann, Michael T.; Imhoff, Andreas B.; Hinterwimmer, Stefan; Feucht, Matthias J.

2017-01-01

Background: Failure rates of knee ligament surgery may be high, and the impact of osseous alignment on surgical outcome remains controversial. Basic science studies have demonstrated that osseous malalignment can negatively affect ligament strain and that realignment procedures may improve knee joint stability. Hypothesis/Purpose: The purpose of this review was to summarize the clinical evidence concerning the impact of osseous malalignment and realignment procedures in knee ligament surgery. The hypotheses were that lower extremity malalignment would be an important contributor to knee ligament surgery failure and that realignment surgery would contribute to increased knee stability and improved outcome in select cases. Study Design: Systematic review; Level of evidence, 4. Methods: According to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, a systematic electronic search of the PubMed database was performed in November 2015 to identify clinical studies investigating (A) the influence of osseous alignment on postoperative stability and/or failure rates after knee ligament surgery and (B) the impact of osseous realignment procedures in unstable knees with or without additional knee ligament surgery on postoperative knee function and stability. Methodological quality of the studies was assessed using the Oxford Centre for Evidence-Based Medicine Levels of Evidence and the Coleman Methodological Score (CMS). Results: Of the 1466 potentially relevant articles, 28 studies fulfilled the inclusion and exclusion criteria. Average study quality was poor (CMS, 40). For part A, studies showed increased rerupture rate after anterior cruciate ligament (ACL) replacement in patients with increased tibial slope. Concerning the posterior cruciate ligament (PCL)/posterolateral corner (PLC)/lateral collateral ligament (LCL), varus malalignment was considered a significant risk factor for failure. For part B, studies showed decreased

Reversed Palmaris Longus Muscle Causing Volar Forearm Pain and Ulnar Nerve Paresthesia.

PubMed

Bhashyam, Abhiram R; Harper, Carl M; Iorio, Matthew L

2017-04-01

A case of volar forearm pain associated with ulnar nerve paresthesia caused by a reversed palmaris longus muscle is described. The patient, an otherwise healthy 46-year-old male laborer, presented after a previous unsuccessful forearm fasciotomy for complaints of exercise exacerbated pain affecting the volar forearm associated with paresthesia in the ulnar nerve distribution. A second decompressive fasciotomy was performed revealing an anomalous "reversed" palmaris longus, with the muscle belly located distally. Resection of the anomalous muscle was performed with full relief of pain and sensory symptoms. Copyright © 2017 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.

41 CFR 105-55.014 - Liquidation of collateral.

Code of Federal Regulations, 2010 CFR

2010-07-01

... Management Regulations System (Continued) GENERAL SERVICES ADMINISTRATION Regional Offices-General Services Administration 55-COLLECTION OF CLAIMS OWED THE UNITED STATES § 105-55.014 Liquidation of collateral. (a) The General Services Administration (GSA) will liquidate security or collateral through the exercise of a...

Inducible nitric oxide synthase inhibits oxygen consumption in collateral-dependent myocardium

PubMed Central

Chen, Yingjie; Zhang, Ping; Li, Jingxin; Xu, Xin

2013-01-01

Following coronary artery occlusion growth of collateral vessels can provide an effective blood supply to the dependent myocardium. The ischemia, which results in growth of collateral vessels, recruits an inflammatory response with expression of cytokines and growth factors, upregulation of endothelial nitric oxide (NO) synthase (eNOS) in vascular endothelial cells, and expression of inducible nitric oxide synthase (iNOS) in both vessels and cardiac myocytes. Because NO is a potent collateral vessel dilator, this study examined whether NO derived from iNOS or constitutive NOS regulates myocardial blood flow (MBF) in the collateral region. Nonselective NOS inhibition with NG-nitro-l-arginine (LNA) caused vasoconstriction with a significant decrease in MBF to the collateral region during exercise. In contrast, the highly selective iNOS inhibitor 1400W caused a 21 ± 5% increase of MBF in the collateral region. This increase in MBF following selective iNOS blockade was proportionate to an increase in myocardial O2 consumption (MV̇o2). The results suggest that NO produced by iNOS inhibits MV̇o2 in the collateralized region, so that the increase in MBF following iNOS blockade was the result of metabolic vasodilation secondary to an increase in MV̇o2. Thus the coordinated expression of iNOS to restrain MV̇o2 and eNOS to maintain collateral vasodilation act to optimize the O2 supply-demand relationship and protect the collateralized myocardium from ischemia. PMID:24322607

Inducible nitric oxide synthase inhibits oxygen consumption in collateral-dependent myocardium.

PubMed

Chen, Yingjie; Zhang, Ping; Li, Jingxin; Xu, Xin; Bache, Robert J

2014-02-01

Following coronary artery occlusion growth of collateral vessels can provide an effective blood supply to the dependent myocardium. The ischemia, which results in growth of collateral vessels, recruits an inflammatory response with expression of cytokines and growth factors, upregulation of endothelial nitric oxide (NO) synthase (eNOS) in vascular endothelial cells, and expression of inducible nitric oxide synthase (iNOS) in both vessels and cardiac myocytes. Because NO is a potent collateral vessel dilator, this study examined whether NO derived from iNOS or constitutive NOS regulates myocardial blood flow (MBF) in the collateral region. Nonselective NOS inhibition with N(G)-nitro-l-arginine (LNA) caused vasoconstriction with a significant decrease in MBF to the collateral region during exercise. In contrast, the highly selective iNOS inhibitor 1400W caused a 21 ± 5% increase of MBF in the collateral region. This increase in MBF following selective iNOS blockade was proportionate to an increase in myocardial O2 consumption (MVo2). The results suggest that NO produced by iNOS inhibits MVo2 in the collateralized region, so that the increase in MBF following iNOS blockade was the result of metabolic vasodilation secondary to an increase in MVo2. Thus the coordinated expression of iNOS to restrain MVo2 and eNOS to maintain collateral vasodilation act to optimize the O2 supply-demand relationship and protect the collateralized myocardium from ischemia.

Cervical extraforaminal ligaments: an anatomical study.

PubMed

Arslan, Mehmet; Açar, Halil İbrahim; Cömert, Ayhan

2017-12-01

The purpose of this study was to elucidate the anatomy and clinical importance of extraforaminal ligaments in the cervical region. This study was performed on eight embalmed cadavers. The existence and types of extraforaminal ligaments were identified. The morphology, quantity, origin, insertion, and orientation of the extraforaminal ligaments in the cervical region were observed. Extraforaminal ligaments could be divided into two types: transforaminal ligaments and radiating ligaments. It was observed that during their course, transforaminal ligaments cross the intervertebral foramen ventrally. They usually originate from the anteroinferior margin of the anterior tubercle of the cranial transverse process and insert into the superior margin of the anterior tubercle of the caudal transverse process. The dorsal aspect of the transforaminal ligaments adhere loosely to the spinal nerve sheath. The length, width and thickness of these ligaments increased from the cranial to the caudal direction. A single intervertebral foramen contained at least one transforaminal ligament. A total of 98 ligaments in 96 intervertebral foramina were found. The spinal nerves were extraforaminally attached to neighboring anterior and posterior tubercle of the cervical transverse process by the radiating ligaments. The radiating ligaments consisted of the ventral superior, ventral, ventral inferior, dorsal superior and dorsal inferior radiating ligaments. Radiating ligaments originated from the adjacent transverse processes and inserted into the nerve root sheath. The spinal nerve was held like the hub of a wheel by a series of radiating ligaments. The dorsal ligaments were the thickest. From C2-3 to C6-7 at the cervical spine, radiating ligaments were observed. They developed particularly at the level of the C5-C6 intervertebral foramen. This anatomic study may provide a better understanding of the relationship of the extraforaminal ligaments to the cervical nerve root.

[Dynamic radioulnar convergence after Darrach operation, soft tissue stabilizing operations of the distal ulna and ulnar head prosthesis implantation--an experimental biomechanical study].

PubMed

Sauerbier, M; Hahn, M E; Fujita, M; Neale, P G; Germann, G; An, K N; Berger, R A

2002-08-01

The most common method of treating the arthrotic distal radioulnar joint (DRUJ) is resection of the entire ulnar head (Darrach procedure). Complications related to instability of the distal forearm resulting from loss of the ulnar head are usually manifested by pain and weak grip strength and have remained the drawbacks of this procedure. In an attempt to mechanically stabilize the distal forearm, an endoprosthesis was developed to replace the ulnar head after Darrach resection. The purpose of this study was to: 1) evaluate the dynamic effects of the Darrach procedure on radioulnar convergence; and 2) evaluate the mechanical efficacy of two soft tissue stabilizing techniques (Pronator quadratus advancement flap and ECU/FCU tenodesis) for the unstable distal ulnar stump and 3) the stability after the implantation of an ulnar head endoprosthesis following a Darrach resection on radioulnar convergence. With a dynamic PC-controled forearm simulator the rotation of 7 fresh-frozen cadaver upper extremities was actively and passively performed while loading relevant muscles. Resultant total forearm torque and the 3-dimensional kinematics of the ulna, radius and third metacarpal were recorded simultaneously. The implantation of the ulnar head endoprosthesis effectively restored the stability of the DRUJ. There were significantly better results after the implantation of the prosthesis compared with the Darrach and the soft tissue stabilization procedures. This study provides laboratory validity to the option of implanting an ulnar head endoprosthesis as an attempt to stabilize the distal forearm after Darrach resection in lieu of performing soft tissue stabilization techniques.

Replacement of the anterior cruciate ligament with a bone-ligament-bone anterior cruciate ligament allograft in dogs.

PubMed

Vasseur, P B; Rodrigo, J J; Stevenson, S; Clark, G; Sharkey, N

1987-06-01

Acute replacement of the canine anterior cruciate ligament (ACL) with a frozen, bone-ligament-bone anterior cruciate ligament preparation was studied using biochemical, immunologic, and biomechanical testing methods. Nine dogs were used for the study, six dogs received allografts and three received autografts. No tissue antigen matching was performed. All nine dogs were killed nine months after surgery. Necropsy examination revealed that the ACL was not present in three joints (one autograft, two allografts). The two autograft and four allograft ligaments available for mechanical testing sustained mean maximum loads that were 10% and 14%, respectively, of the mean maximum loads sustained by the contralateral ACL. Autoradiography indicated that cellular activity was more pronounced in the autograft specimens. Hydroxyproline uptake was 200% and 45% of normal in the autograft and allograft ligaments, respectively. Both autograft and allograft specimens were producing Type I collagen at the time of killing. Antidonor dog leukocyte antigen (DLA) antibody was detected in the synovial fluid taken at the time of killing from six of six dogs that received allografts and in zero of three dogs that received autografts.

Supercharged end-to-side anterior interosseous to ulnar motor nerve transfer for intrinsic musculature reinnervation.

PubMed

Barbour, John; Yee, Andrew; Kahn, Lorna C; Mackinnon, Susan E

2012-10-01

Functional motor recovery after peripheral nerve injury is predominantly determined by the time to motor end plate reinnervation and the absolute number of regenerated motor axons that reach target. Experimental models have shown that axonal regeneration occurs across a supercharged end-to-side (SETS) nerve coaptation. In patients with a recovering proximal ulnar nerve injury, a SETS nerve transfer conceptually is useful to protect and preserve distal motor end plates until the native axons fully regenerate. In addition, for nerve injuries in which incomplete regeneration is anticipated, a SETS nerve transfer may be useful to augment the regenerating nerve with additional axons and to more quickly reinnervate target muscle. We describe our technique for a SETS nerve transfer of the terminal anterior interosseous nerve (AIN) to the pronator quadratus muscle (PQ) end-to-side to the deep motor fascicle of the ulnar nerve in the distal forearm. In addition, we describe our postoperative therapy regimen for these transfers and an evaluation tool for monitoring progressive muscle reinnervation. Although the AIN-to-ulnar motor group SETS nerve transfer was specifically designed for ulnar nerve injuries, we believe that the SETS procedure might have broad clinical utility for second- and third-degree axonotmetic nerve injuries, to augment partial recovery and/or "babysit" motor end plates until the native parent axons regenerate to target. We would consider all donor nerves currently utilized in end-to-end nerve transfers for neurotmetic injuries as candidates for this SETS technique. Copyright © 2012 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.

Role of "Sural Sparing" Pattern (Absent/Abnormal Median and Ulnar with Present Sural SNAP) Compared to Absent/Abnormal Median or Ulnar with Normal Sural SNAP in Acute Inflammatory Demyelinating Polyneuropathy.

PubMed

Surpur, Spurthi Sunil; Govindarajan, Raghav

2017-01-01

Sural sparing defined as absent/abnormal median sensory nerve action potential (SNAP) amplitude or absent/abnormal ulnar SNAP amplitude with a normal sural SNAP amplitude is thought to be a marker for inflammatory demyelinating polyneuropathies. If sural sparing pattern specifically defined as absent/abnormal median and ulnar SNAP amplitude with normal sural SNAP amplitude (AMUNS) is sensitive and specific when compared with either absent/abnormal median and normal sural (AMNS) or absent/abnormal ulnar and normal sural (AUNS) for acute inflammatory demyelinating polyneuropathy (AIDP), chronic inflammatory demyelinating polyneuropathy (CIDP), select non-diabetic axonopathies (AXPs), and diabetic neuropathies (DNs). Retrospective analysis from 2001 to 2010 on all newly diagnosed AIDP, CIDP, select non-diabetic AXP, and DN. There were 20 AIDP and 23 CIDP. Twenty AXP and 50 DN patients between 2009 and 2010 were included as controls. AMUNS was seen in 65% of AIDP, 39% CIDP compared with 10% of AXP and 6% for DN with sensitivity of 51%, specificity of 92%, whereas the specificity of AMNS/AUNS was 73% and its sensitivity was 58%. If a patient has AMUNS they are >12 times more likely to have AIDP ( p  < 0.001). Sural sparing is highly specific but not sensitive when compared with either AMNS or AUNS in AIDP but does not add to sensitivity or specificity in CIDP.

7 CFR 762.142 - Servicing related to collateral.

Code of Federal Regulations, 2014 CFR

2014-01-01

... 7 Agriculture 7 2014-01-01 2014-01-01 false Servicing related to collateral. 762.142 Section 762.142 Agriculture Regulations of the Department of Agriculture (Continued) FARM SERVICE AGENCY, DEPARTMENT OF AGRICULTURE SPECIAL PROGRAMS GUARANTEED FARM LOANS § 762.142 Servicing related to collateral...

48 CFR 48.104-3 - Sharing collateral savings.

Code of Federal Regulations, 2010 CFR

2010-10-01

... 48 Federal Acquisition Regulations System 1 2010-10-01 2010-10-01 false Sharing collateral savings. 48.104-3 Section 48.104-3 Federal Acquisition Regulations System FEDERAL ACQUISITION REGULATION CONTRACT MANAGEMENT VALUE ENGINEERING Policies and Procedures 48.104-3 Sharing collateral savings. (a) The...

Enhanced Fibroblast Cellular Ligamentization Process to Polyethylene Terepthalate Artificial Ligament by Silk Fibroin Coating.

PubMed

Jiang, Jia; Ai, Chengchong; Zhan, Zufeng; Zhang, Peng; Wan, Fang; Chen, Jun; Hao, Wei; Wang, Yaxian; Yao, Jinrong; Shao, Zhengzhong; Chen, Tianwu; Zhou, Liang; Chen, Shiyi

2016-04-01

Artificial ligaments utilized in reconstruction of anterior cruciate ligament (ACL) are usually made of polyethylene terepthalate (PET) because of its good mechanical properties in vivo. However, it was found that the deficiencies in hydrophilicity and biocompatibility of PET hindered the process of ligamentization. Therefore, surface modification of the PET is deemed as a solution in resolving such problem. Silk fibroin (SF), which is characterized by good biocompatibility and low immunogenicity in clinical applications, was utilized to prepare a coating on the PET ligament (PET+SF) in this work. At first, decrease of hydrophobicity and appearance of amino groups were found on the surface of artificial PET ligament after coating with SF. Second, mouse fibroblasts were cultured on the two different kinds of ligament in order to clarify the possible effect of SF coating. It was proved that mouse fibroblasts display better adhesion and proliferation on PET+SF than PET ligament according to the results of several technical methods including SEM observation, cell adhesive force and spread area test, and mRNA analysis. Meanwhile, methylthiazolyldiphenyl-tetrazolium bromide and DNA content tests showed that biocompatibility of PET+SF is better than PET ligament. In addition, collagen deposition tests also indicated that the quantity of collagen in PET+SF is higher than PET ligament. Based on these results, it can be concluded that SF coating is suggested to be an effective approach to modify the surface of PET ligament and enhance the "ligamentization" process in vivo accordingly. Copyright © 2015 International Center for Artificial Organs and Transplantation and Wiley Periodicals, Inc.

Analysis of the Papal Benediction Sign: The ulnar neuropathy of St. Peter.

PubMed

Futterman, Bennett

2015-09-01

The origin of the Papal Benediction Sign has been a source of controversy for many generations of medical students. The question has been whether the Papal Benediction Sign posture is the result of an injury to the median nerve or to the ulnar nerve. The increasingly popular use of online "chat rooms" and the vast quantities of information available on the internet has led to an increasing level of confusion. Looking in major anatomy texts, anatomy and board review books as well as numerous internet sites the answer remains unresolved. Through the analysis of functional anatomy of the hand, cultural and religious practices of the early centuries of the Common Era and church art a clear answer emerges. It will become apparent that this hand posture results from an ulnar neuropathy. Copyright © 2015 Wiley Periodicals, Inc.

48 CFR 2448.104-3 - Sharing collateral savings.

Code of Federal Regulations, 2010 CFR

2010-10-01

... 48 Federal Acquisition Regulations System 6 2010-10-01 2010-10-01 true Sharing collateral savings. 2448.104-3 Section 2448.104-3 Federal Acquisition Regulations System DEPARTMENT OF HOUSING AND URBAN DEVELOPMENT CONTRACT MANAGEMENT VALUE ENGINEERING 2448.104-3 Sharing collateral savings. (a) The authority of...

48 CFR 2448.104-3 - Sharing collateral savings.

Code of Federal Regulations, 2014 CFR

2014-10-01

... 48 Federal Acquisition Regulations System 6 2014-10-01 2014-10-01 false Sharing collateral savings. 2448.104-3 Section 2448.104-3 Federal Acquisition Regulations System DEPARTMENT OF HOUSING AND URBAN DEVELOPMENT CONTRACT MANAGEMENT VALUE ENGINEERING 2448.104-3 Sharing collateral savings. (a) The authority of...

Chronic ankle instability and common fibular nerve injury.

PubMed

Benchortane, Michaël; Collado, Hervé; Coudreuse, Jean-Marie; Desnuelle, Claude; Viton, Jean-Michel; Delarque, Alain

2011-03-01

The lateral collateral ligaments of the ankle are often damaged in ankle inversion injuries. Ankle inversion may also cause injury to other structures located around the ankle or further away, such as the common fibular nerve. Few descriptions exist of common fibular nerve injury associated with ankle sprains and chronic ankle instability. We describe the case of a patient who sustained common fibular nerve injury during each of two ankle sprain recurrences involving the lateral collateral ligaments. Our objectives are to illustrate the links between common fibular nerve and lateral collateral ligament injuries and to emphasize the importance of the neurological evaluation in patients seen for ankle sprains or chronic ankle instability. Copyright © 2010 Société française de rhumatologie. Published by Elsevier SAS. All rights reserved.

Pure neuritic leprosy presenting as ulnar nerve neuropathy: a case report of electrodiagnostic, radiographic, and histopathological findings.

PubMed

Payne, Russell; Baccon, Jennifer; Dossett, John; Scollard, David; Byler, Debra; Patel, Akshal; Harbaugh, Kimberly

2015-11-01

Hansen's disease, or leprosy, is a chronic infectious disease with many manifestations. Though still a major health concern and leading cause of peripheral neuropathy in the developing world, it is rare in the United States, with only about 150 cases reported each year. Nevertheless, it is imperative that neurosurgeons consider it in the differential diagnosis of neuropathy. The causative organism is Mycobacterium leprae, which infects and damages Schwann cells in the peripheral nervous system, leading first to sensory and then to motor deficits. A rare presentation of Hansen's disease is pure neuritic leprosy. It is characterized by nerve involvement without the characteristic cutaneous stigmata. The authors of this report describe a case of pure neuritic leprosy presenting as ulnar nerve neuropathy with corresponding radiographic, electrodiagnostic, and histopathological data. This 11-year-old, otherwise healthy male presented with progressive right-hand weakness and numbness with no cutaneous abnormalities. Physical examination and electrodiagnostic testing revealed findings consistent with a severe ulnar neuropathy at the elbow. Magnetic resonance imaging revealed diffuse thickening and enhancement of the ulnar nerve and narrowing at the cubital tunnel. The patient underwent ulnar nerve decompression with biopsy. Pathology revealed acid-fast organisms within the nerve, which was pathognomonic for Hansen's disease. He was started on antibiotic therapy, and on follow-up he had improved strength and sensation in the ulnar nerve distribution. Pure neuritic leprosy, though rare in the United States, should be considered in the differential diagnosis of those presenting with peripheral neuropathy and a history of travel to leprosy-endemic areas. The long incubation period of M. leprae, the ability of leprosy to mimic other conditions, and the low sensitivity of serological tests make clinical, electrodiagnostic, and radiographic evaluation necessary for diagnosis

Negative modulation of presynaptic activity by zinc released from Schaffer collaterals.

PubMed

Takeda, Atsushi; Fuke, Sayuri; Tsutsumi, Wataru; Oku, Naoto

2007-12-01

The role of zinc in excitation of Schaffer collateral-CA1 pyramidal cell synapses is poorly understood. Schaffer collaterals stained with ZnAF-2 or ZnAF-2DA, a membrane-impermeable or a membrane-permeable zinc indicator, respectively, were treated by tetanic stimulation (200 Hz, 1 sec). Extracellular and intracellular ZnAF-2 signals were increased in the stratum radiatum of the CA1, in which Schaffer collateral synapses exist. Both the increases were completely blocked in the presence of 1 mM CaEDAT, a membrane-impermeable zinc chelator, suggesting that 1 mM CaEDTA is effective for chelating zinc released from Schaffer collaterals. The role of Schaffer collateral zinc in presynaptic activity was examined by using FM4-64, a fluorescent indicator for vesicular exocytosis. The decrease in FM4-64 signal during tetanic stimulation (10 Hz, 180 sec) was enhanced in Schaffer collaterals in the presence of 1 mM CaEDTA but suppressed in the presence of 5 microM ZnC1(2), suggesting that zinc released from Schaffer collaterals suppresses presynaptic activity during tetanic stimulation. When Schaffer collateral synapses stained with calcium orange AM, a membrane-permeable calcium indicator, were regionally stimulated with 1 mM glutamate, calcium orange signal was increased in the CA1 pyramidal cell layer. This increase was enhanced in the presence of CaEDTA and attenuated in the presence of zinc. These results suggest that zinc attenuates excitation of Schaffer collateral synapses elicited with glutamate via suppression of presynaptic activity. (c) 2007 Wiley-Liss, Inc.

27 CFR 24.151 - Deposit of collateral security.

Code of Federal Regulations, 2013 CFR

2013-04-01

... pledged and deposited as collateral security in lieu of corporate sureties in accordance with the... furnished as collateral security in lieu of corporate sureties. (b) Treasury Department Circular No. 154 is... security. 24.151 Section 24.151 Alcohol, Tobacco Products and Firearms ALCOHOL AND TOBACCO TAX AND TRADE...

27 CFR 24.151 - Deposit of collateral security.

Code of Federal Regulations, 2010 CFR

2010-04-01

... pledged and deposited as collateral security in lieu of corporate sureties in accordance with the... furnished as collateral security in lieu of corporate sureties. (b) Treasury Department Circular No. 154 is... security. 24.151 Section 24.151 Alcohol, Tobacco Products and Firearms ALCOHOL AND TOBACCO TAX AND TRADE...

27 CFR 24.151 - Deposit of collateral security.

Code of Federal Regulations, 2011 CFR

2011-04-01

... pledged and deposited as collateral security in lieu of corporate sureties in accordance with the... furnished as collateral security in lieu of corporate sureties. (b) Treasury Department Circular No. 154 is... security. 24.151 Section 24.151 Alcohol, Tobacco Products and Firearms ALCOHOL AND TOBACCO TAX AND TRADE...

27 CFR 24.151 - Deposit of collateral security.

Code of Federal Regulations, 2012 CFR

2012-04-01

... pledged and deposited as collateral security in lieu of corporate sureties in accordance with the... furnished as collateral security in lieu of corporate sureties. (b) Treasury Department Circular No. 154 is... security. 24.151 Section 24.151 Alcohol, Tobacco Products and Firearms ALCOHOL AND TOBACCO TAX AND TRADE...

27 CFR 24.151 - Deposit of collateral security.

Code of Federal Regulations, 2014 CFR

2014-04-01

... pledged and deposited as collateral security in lieu of corporate sureties in accordance with the... furnished as collateral security in lieu of corporate sureties. (b) Treasury Department Circular No. 154 is... security. 24.151 Section 24.151 Alcohol, Tobacco Products and Firearms ALCOHOL AND TOBACCO TAX AND TRADE...

12 CFR 615.5335 - Bank net collateral ratio.

Code of Federal Regulations, 2011 CFR

2011-01-01

... 12 Banks and Banking 6 2011-01-01 2011-01-01 false Bank net collateral ratio. 615.5335 Section 615.5335 Banks and Banking FARM CREDIT ADMINISTRATION FARM CREDIT SYSTEM FUNDING AND FISCAL AFFAIRS, LOAN POLICIES AND OPERATIONS, AND FUNDING OPERATIONS Surplus and Collateral Requirements § 615.5335 Bank net...

12 CFR 615.5335 - Bank net collateral ratio.

Code of Federal Regulations, 2010 CFR

2010-01-01

... 12 Banks and Banking 6 2010-01-01 2010-01-01 false Bank net collateral ratio. 615.5335 Section 615.5335 Banks and Banking FARM CREDIT ADMINISTRATION FARM CREDIT SYSTEM FUNDING AND FISCAL AFFAIRS, LOAN POLICIES AND OPERATIONS, AND FUNDING OPERATIONS Surplus and Collateral Requirements § 615.5335 Bank net...

Change in the temporal coordination of the finger joints with ulnar nerve block during different power grips analyzed with a sensor glove.

PubMed

Wachter, N J; Mentzel, M; Häderer, C; Krischak, G D; Gülke, J

2018-02-01

Ulnar nerve injuries can cause deficient hand movement patterns. Their assessment is important for diagnosis and rehabilitation in hand surgery cases. The purpose of this study was to quantify the changes in temporal coordination of the finger joints during different power grips with an ulnar nerve block by means of a sensor glove. In 21 healthy subjects, the onset and end of the active flexion of the 14 finger joints when gripping objects of different diameters was recorded by a sensor glove. The measurement was repeated after an ulnar nerve block was applied in a standardized setting. The change in the temporal coordination of the metacarpophalangeal (MCP), proximal interphalangeal (PIP) and distal interphalangeal (DIP) joints with and without the nerve block was calculated within the same subject. In healthy subjects, the MCP joints started their movement prior to the PIP joints in the middle and ring finger, whereas this occurred in the reverse order at the index and little finger. The DIP joint onset was significantly delayed (P<0.01). With the ulnar nerve block, this coordination shifted towards simultaneous onset of all joints, independent of the grip diameter. The thumb and index finger were affected the least. With an ulnar nerve block, the PIP joints completed their movement prior to the MCP joints when gripping small objects (G1 and G2), whereas the order was reversed with larger objects (G3 and G4). The alterations with ulnar nerve block affected mainly the little finger when gripping small objects. With larger diameter objects, all fingers had a significant delay at the end of the PIP joint movement relative to the MCP and DIP joints, and the PIP and DIP joint sequence was reversed (P<0.01). Based on the significant changes in temporal coordination of finger flexion during different power grips, there are biomechanical effects of loss of function of the intrinsic muscles caused by an ulnar nerve block on the fine motor skills of the hand. This can be

Evaluation of outcome of corrective ulnar osteotomy with bone grafting and annular ligament reconstruction in neglected monteggia fracture dislocation in children.

PubMed

Datta, Tanmay; Chatterjee, Nd; Pal, Ananda Kisor; Das, Sunil Kumar

2014-06-01

Neglected Monteggia fracture dislocation in the paediatric age group constitutes significant disability in respect to pain, stiffness, deformity, neurological compromise and restriction of activities of daily living. A longitudinal prospective study was done on 21 children with old Monteggia fracture-dislocation which included 18 cases of Bado type I and 3 cases of Bado type III at the department of orthopaedics, IPGME&R,SSKM hospital, Kolkata, India between 2007 and 2012. All were treated by modified Hirayama corrective osteotomy of ulna with wedge bone grafting along with restoration of its length and reconstruction of annular ligament using Bell Tawse method and fixation of radial head with transcapitellar Kirschner wire. Average follow up period was 5.5 years. Results were evaluated on the basis of 100 point Mayo Elbow Performance Index, radiology and questionnaire. The mean postoperative increase in Mayo Elbow Performance Index score was 30 with average increase in the range of movement by 30o. In three cases, there was subluxation of radial head and in addition one had transient palsy of posterior interosseous nerve. Three cases showed distortion of the radial head which were insignificant functionally. Results of improvement in mean MEPI were analysed by chi-square test and was significant at 0 .01 level of significance. Study showed good results with modified Hirayama osteotomy with annular ligament reconstruction using Bell Tawse procedure which is a more biological option for restoration of elbow biomechanics.

MR imaging of patients with lateral epicondylitis of the elbow: is the common extensor tendon an isolated lesion?

PubMed

Qi, Liang; Zhu, Zheng-Feng; Li, Feng; Wang, Ren-Fa

2013-01-01

To investigate whether an injury of the common extensor tendon (CET) is associated with other abnormalities in the elbow joint and find the potential relationships between these imaging features by using a high-resolution magnetic resonance imaging (MRI). Twenty-three patients were examined with 3.0 T MR. Two reviewers were recruited for MR images evaluation. Image features were recorded in terms of (1) the injury degree of CET; (2) associated injuries in the elbow joint. Spearman's rank correlation analysis was performed to analyze the relationships between the injury degree of CET and associated abnormalities of the elbow joint, correlations were considered significant at p<0.05. Total 24 elbows in 23 patients were included. Various degrees of injuries were found in total 24 CETs (10 mild, 7 moderate and 7 severe). Associated abnormalities were detected in accompaniments of the elbow joints including ligaments, tendons, saccussynovialis and muscles. A significantly positive correlation (r = 0.877,p<0.01) was found in injuries of CET and lateral ulnar collateral ligament (LUCL). Injury of the CET is not an isolated lesion for lateral picondylitis, which is mostly accompanied with other abnormalities, of which the LUCL injury is the most commonly seen in lateral epicondylitis, and there is a positive correlation between the injury degree in CET and LUCL.

Epidemiology of Ulnar Collateral Ligament Reconstruction in Major and Minor League Baseball Pitchers: Comprehensive Report on 1,313 Cases

PubMed Central

Camp, Christopher L.; Conte, Stan; D’Angelo, John; Fealy, Stephen

2017-01-01

Objectives: Although much as been done to better understand and characterize the epidemic of UCL reconstruction in pitchers, a comprehensive review of all UCL reconstructions performed in professional baseball pitchers is surprisingly lacking. Accordingly, the purpose of this work was to provide an epidemiologic report on every UCL reconstruction ever performed in professional baseball with a special focus on outcomes (return to play rates and time) and overall survivorship. Methods: Three resources (including the Major League Baseball [MLB] injury tracking system) were combined and cross-referenced to identify all professional baseball players who had ever undergone primary UCL reconstruction (1974 to 2015). Variables analyzed included the date of injury, date of surgery, time out of play, geographical region, and revision status. Trends over time were analyzed collectively and based on level of play at the time of surgery. A minimum of 2 years of follow up was required to determine return to play status. Revision free Kaplan-Meier survivor analysis was performed. Results: A total of 1,313 UCL reconstructions were identified. The annual rate of primary and revision UCL reconstructions rose significantly for all levels of play from 1974 to 2015 and from (p<0.001). The overall mean time to return to play (RTP) was 436 days (range 98 to 1,643). The rate of RTP to any level was 93.9% for MLB pitchers vs. 76.3% for MiLB pitchers (p<0.001), and MLB pitchers RTP at the MLB level in 73.1% of cases. The time to RTP was longer (by 54 days) for revisions (p=0.025) compared to primaries, and MLB pitchers RTP from primary surgery 95.6% of the time but only 81.8% for revision surgery (p=0.008). The revision rate was 10.7%, and the percentage of players free of revision and still playing professional baseball was 92% at 2 years, 53% at 5 years, and 17% at 10 years. Survivorship was improved for players undergoing UCL reconstruction before age 25 opposed to after 25. Conclusion: This study represents the most robust epidemiologic report of UCL reconstruction in baseball to date, and a number of novel findings are reported. A number of key differences in MLB and MiLB, as well as primary and revision surgeries, were identified. Although the revision rate (10.7%) is higher than prior reports, 75% of players who had surgery before age of 25 are revision free and still playing professional baseball four years post operative.

Instrument-assisted cross fiber massage increases tissue perfusion and alters microvascular morphology in the vicinity of healing knee ligaments.

PubMed

Loghmani, M Terry; Warden, Stuart J

2013-09-28

Ligament injuries are common clinical problems for which there are few established interventions. Instrument-assisted cross fiber massage (IACFM) was recently shown to accelerate the restoration of biomechanical properties in injured rodent knee medial collateral ligaments (MCL). The current study aimed to investigate the influence of IACFM on regional perfusion and vascularity in the vicinity of healing rodent knee MCL injuries. Bilateral knee MCL injuries were induced in female Sprague-Dawley rats. Commencing 1 week post-injury, 1 minute of IACFM was introduced unilaterally 3 times/week for 3 weeks. The contralateral injured MCL served as an internal control. Regional tissue perfusion was assessed in vivo throughout healing using laser Doppler imaging, whereas regional microvascular morphology was assessed ex vivo via micro-computed tomography of vessels filled with contrast. IACFM had no effect on tissue perfusion when assessed immediately, or at 5, 10, 15 or 20 min following intervention (all p > 0.05). However, IACFM-treated hindlimbs had enhanced tissue perfusion when assessed 1 day following the 4th and 9th (last) treatment sessions (all p < 0.05). IACFM-treated hindlimbs also had greater perfusion when assessed 1 wk following the final treatment session (32 days post-injury) (p < 0.05). Subsequent investigation of microvascular morphology found IACFM to increase the proportion of arteriole-sized blood vessels (5.9 to <41.2 μm) in the tibial third of the ligament (p < 0.05). These findings suggest IACFM alters regional perfusion and vascularity in the vicinity of healing rodent knee MCL injuries. This effect may contribute to the beneficial effect of IACFM observed on the recovery of knee ligament biomechanical properties following injury.

Nerve Transfer Versus Nerve Graft for Reconstruction of High Ulnar Nerve Injuries.

PubMed

Sallam, Asser A; El-Deeb, Mohamed S; Imam, Mohamed A

2017-04-01

To assess the efficacy of nerve transfer versus nerve grafting in restoring motor and sensory hand function in patients with complete, isolated high ulnar nerve injuries. A retrospective chart review was performed, at a minimum 2 years of follow-up, of 52 patients suffering complete, isolated high ulnar nerve injury between January 2006 and June 2013 in one specialized hand surgery unit. Twenty-four patients underwent motor and sensory nerve transfers (NT group). Twenty-eight patients underwent sural nerve grafting (NG group). Motor recovery, return of sensibility and complications were examined as outcome measures. The Medical Research Council scale was applied to evaluate sensory and motor recovery. Grip and pinch strengths of the hand were measured. Twenty of 24 patients (83.33%) in the NT group regained M3 grade or greater for the adductor pollicis, the abductor digiti minimi, and the medial 2 lumbricals and interossei, compared with only 16 of 28 patients (57.14%) in the NG group. Means for percentage recovery of grip strengths compared with the other healthy hand were significantly higher for the NT group than the NG group. Sensory recovery of S3 or greater was achieved in more than half of each group with no significant difference between groups. Nerve transfer is favored over nerve grafting in managing high ulnar nerve injuries because of better improvement of motor power and better restoration of grip functions of the hand. Therapeutic IV. Copyright © 2017 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.

7 CFR 1779.48 - Collateral.

Code of Federal Regulations, 2010 CFR

2010-01-01

... (CONTINUED) WATER AND WASTE DISPOSAL PROGRAMS GUARANTEED LOANS § 1779.48 Collateral. (a) Lender..., water rights, buildings, machinery, equipment, accounts receivable, contracts, cash, or other accounts...

Effect of fascicle composition on ulnar to musculocutaneous nerve transfer (Oberlin transfer) in neonatal brachial plexus palsy.

PubMed

Smith, Brandon W; Chulski, Nicholas J; Little, Ann A; Chang, Kate W C; Yang, Lynda J S

2018-06-01

OBJECTIVE Neonatal brachial plexus palsy (NBPP) continues to be a problematic occurrence impacting approximately 1.5 per 1000 live births in the United States, with 10%-40% of these infants experiencing permanent disability. These children lose elbow flexion, and one surgical option for recovering it is the Oberlin transfer. Published data support the use of the ulnar nerve fascicle that innervates the flexor carpi ulnaris as the donor nerve in adults, but no analogous published data exist for infants. This study investigated the association of ulnar nerve fascicle choice with functional elbow flexion outcome in NBPP. METHODS The authors conducted a retrospective study of 13 cases in which infants underwent ulnar to musculocutaneous nerve transfer for NBPP at a single institution. They collected data on patient demographics, clinical characteristics, active range of motion (AROM), and intraoperative neuromonitoring (IONM) (using 4 ulnar nerve index muscles). Standard statistical analysis compared pre- and postoperative motor function improvement between specific fascicle transfer (1-2 muscles for either wrist flexion or hand intrinsics) and nonspecific fascicle transfer (> 2 muscles for wrist flexion and hand intrinsics) groups. RESULTS The patients' average age at initial clinic visit was 2.9 months, and their average age at surgical intervention was 7.4 months. All NBPPs were unilateral; the majority of patients were female (61%), were Caucasian (69%), had right-sided NBPP (61%), and had Narakas grade I or II injuries (54%). IONM recordings for the fascicular dissection revealed a donor fascicle with nonspecific innervation in 6 (46%) infants and specific innervation in the remaining 7 (54%) patients. At 6-month follow-up, the AROM improvement in elbow flexion in adduction was 38° in the specific fascicle transfer group versus 36° in the nonspecific fascicle transfer group, with no statistically significant difference (p = 0.93). CONCLUSIONS Both specific and

Simultaneous Median and Ulnar Compression Neuropathy Secondary to a Giant Palmar Lipoma: A Case Report and Review of the Literature

PubMed Central

Unal, Melih; Demirayak, Engin; Acar, Baver

2018-01-01

Lipomas are benign tumors that rarely settle in the hand. They usually present with mass, pain, and nerve compression symptoms. Although isolated median or ulnar nerve compression neuropathy secondary to a lipoma of the hand has been widely reported, simultaneous median and ulnar nerve compression neuropathy are exceedingly rare and there are only three reported cases in the current literature to date. Herein, a case of a 50-year-old woman with a giant palmar lipoma that caused median and ulnar compression neuropathy is presented. The removal of the tumor resulted in the complete recovery of the patient’s symptoms. A deep-seated palmar lipoma should be kept in mind in patients with unilateral compression neuropathy symptoms with a palmar mass. PMID:29666776

Tendon and ligament imaging

PubMed Central

Hodgson, R J; O'Connor, P J; Grainger, A J

2012-01-01

MRI and ultrasound are now widely used for the assessment of tendon and ligament abnormalities. Healthy tendons and ligaments contain high levels of collagen with a structured orientation, which gives rise to their characteristic normal imaging appearances as well as causing particular imaging artefacts. Changes to ligaments and tendons as a result of disease and injury can be demonstrated using both ultrasound and MRI. These have been validated against surgical and histological findings. Novel imaging techniques are being developed that may improve the ability of MRI and ultrasound to assess tendon and ligament disease. PMID:22553301

Extrinsic wrist ligaments: prevalence of injury by magnetic resonance imaging and association with intrinsic ligament tears.

PubMed

Taneja, Atul K; Bredella, Miriam A; Chang, Connie Y; Joseph Simeone, F; Kattapuram, Susan V; Torriani, Martin

2013-01-01

The objective of this study was to determine the prevalence of extrinsic wrist ligament injury by magnetic resonance imaging and its association with intrinsic ligament tears. We reviewed conventional magnetic resonance images performed over a 5-year period from adult patients in the setting of wrist trauma. Two musculoskeletal radiologists examined the integrity of wrist ligaments and presence of bone abnormalities. In a cohort of 75 subjects, extrinsic ligament injury was present in 75%, with radiolunotriquetral being most frequently affected (45%). Intrinsic ligament injury was present in 60%. Almost half of subjects had combined intrinsic and extrinsic ligament injury. Bone abnormalities were seen in 69%. The rate of extrinsic injury was higher in subjects with bone injury (P = 0.008). There is high prevalence of extrinsic ligament injury in the setting of wrist trauma, especially in the presence of bone abnormalities, with combined injury of intrinsic and extrinsic ligaments in about half of cases.

Anatomical considerations on the discomalleolar ligament

PubMed Central

RODRÍGUEZ-VÁZQUEZ, J. F.; MÉRIDA-VELASCO, J. R.; MÉRIDA-VELASCO, J. A.; JIMÉNEZ-COLLADO, J.

1998-01-01

A study was carried out on the discomalleolar ligament by dissection of adult human cadavers. The ligament corresponds to the most internal portion of the superior lamina of the temporomandibular joint capsule. It extends from the posterointernal portion of the temporomandibular joint disc, penetrates the petrotympanic fissure and reaches the malleus of the middle ear. Because of its morphology and anatomical arrangement the discomalleolar ligament should be considered as an intrinsic ligament of the temporomandibular joint and distinguished from the tympanic portion of the sphenomandibular ligament (anterior ligament of the malleus). PMID:9723988

Comparison between open and arthroscopic-assisted foveal triangular fibrocartilage complex repair for post-traumatic distal radio-ulnar joint instability.

PubMed

Luchetti, R; Atzei, A; Cozzolino, R; Fairplay, T; Badur, N

2014-10-01

The aim of this study was to assess the objective and subjective functional outcomes after foveal reattachment of proximal or complete ulnar-sided triangular fibrocartilage complex lesions by two surgical procedures: an open technique or an arthroscopically assisted repair. The study was done prospectively on 49 wrists affected by post-traumatic distal radio-ulnar joint instability. Twenty-four patients were treated with the open technique (Group 1) and 25 by the arthroscopically assisted technique (Group 2). Magnetic resonance imaging demonstrated a clear foveal detachment of the triangular fibrocartilage complex in 67% of the cases. Arthroscopy showed a positive ulnar-sided detachment of the triangular fibrocartilage complex (positive hook test) in all cases. Distal radio-ulnar joint stability was obtained in all but five patients at a mean follow-up of 6 months. Both groups had improvement of all parameters with significant differences in wrist pain scores, Mayo wrist score, Disability of the Arm, Shoulder and Hand questionnaire and Patient-Rated Wrist/Hand Evaluation questionnaire scores. There were no significant post-operative differences between the two groups in the outcome parameters except for the Disability of the Arm Shoulder and Hand questionnaire score, which was significantly better in Group 2 (p < 0.001). © The Author(s) 2013.

Establishment of a Method to Measure Length of the Ulnar Nerve and Standardize F-wave Values in Clinically Normal Beagles

PubMed Central

HIRASAWA, Shun; SHIMIZU, Miki; MARUI, Yuumi; KISHIMOTO, Miori; OKUNO, Seiichi

2014-01-01

We designed a new method of measuring the length of the ulnar nerve and determining standard values for F-wave parameters of the ulnar nerve in clinically normal beagles. Nerve length must be precisely measured to determine F-wave latency and conduction velocity. The length of the forelimb has served as the length of the ulnar nerve for F-wave assessments, but report indicates that F-wave latency is proportional to the length of the pathway traveled by nerve impulses. Therefore, we measured the surface distance from a stimulus point to the spinous process of the first thoracic vertebra (nerve length 1) and the anterior horn of the scapula (nerve length 2) as landmarks through the olecranon and the shoulder blade acromion. The correlation coefficients between the shortest F-wave latency and the length of nerves 1, 2 or the forelimb were 0.61, 0.7 and 0.58. Nerve length 2 generated the highest value. Furthermore, the anterior horn of the scapula was easily palpated in any dog regardless of well-fed body. We concluded that nerve length 2 was optimal for measuring the length of the ulnar nerve. PMID:25649942

45 CFR 1336.67 - Security and collateral: Responsibilities of the Loan Administrator.

Code of Federal Regulations, 2010 CFR

2010-10-01

...) As a Credit Factor. The availability of collateral security normally is considered an important... 45 Public Welfare 4 2010-10-01 2010-10-01 false Security and collateral: Responsibilities of the... Fund Demonstration Project § 1336.67 Security and collateral: Responsibilities of the Loan...

Surgical treatment of subacute and chronic valgus instability in multiligament-injured knees with superficial medial collateral ligament reconstruction using Achilles allografts: a quantitative analysis with a minimum 2-year follow-up.

PubMed

Liu, Xin; Feng, Hua; Zhang, Hui; Hong, Lei; Wang, Xue Song; Zhang, Jin; Shen, Jie Wei

2013-05-01

Symptomatic medial collateral ligament (MCL) instability is rare, and it is frequently associated with multiligament injuries. Most clinical investigations have failed to clearly define the specific objective outcome measures assessing the stability of the MCL quantitatively before and after the reconstruction procedure. To quantitatively evaluate the early clinical outcomes of patients with valgus instability of knee joints who had undergone superficial MCL reconstruction using Achilles tendon allografts. Case series; Level of evidence, 4. From August 2005 to December 2010, 19 consecutive patients with MCL injuries were included in this study. The inclusion criteria were (1) a subacute or chronic MCL injury, with a time from initial injury to surgery of longer than 3 weeks, and (2) valgus laxity graded C or D according to the International Knee Documentation Committee (IKDC). All patients underwent superficial MCL reconstruction using Achilles tendon allografts. To evaluate the laxity of the MCL preoperatively and postoperatively, valgus stress radiographs using a Telos device were used. Other assessments included the IKDC subjective functional evaluation and Lysholm score estimation. Sixteen of the 19 patients (12 men and 4 women) were available for final follow-up. The median age of the patients was 37 years (range, 19-53 years); mean body mass index (BMI) was 26.4 (range, 21.7-29.4). The mean time from injury to surgery was 15.9 months (range, 24 days to 84 months), and median follow-up period was 34 months (range, 24-67 months). The mean medial knee laxity (side-to-side difference) was 8.9 ± 3.2 mm (range, 6-15.9 mm) preoperatively and 1.1 ± 0.9 mm (range, -1.1 to 3.2 mm) postoperatively (P < .001). The preoperative mean IKDC subjective knee functional score was 49.8 ± 6.9 (range, 31-57.5), while the postoperative functional score was 84.3 ± 6.0 (range, 71.3-93.1) (P < .001). The mean Lysholm score was 69.3 ± 5.9 (range, 55-78) preoperatively and 88.6 �

The Influence of Meniscal and Anterolateral Capsular Injury on Knee Laxity in Patients With Anterior Cruciate Ligament Injuries.

PubMed

Musahl, Volker; Rahnemai-Azar, Ata A; Costello, Joanna; Arner, Justin W; Fu, Freddie H; Hoshino, Yuichi; Lopomo, Nicola; Samuelsson, Kristian; Irrgang, James J

2016-12-01

The role of the anterolateral capsule (ALC) as a secondary restraint to quantitative rotatory laxity of patients with an anterior cruciate ligament (ACL) injury is currently debated. The purpose was to determine the influence of concomitant ALC injuries as well as injuries to other soft tissue structures on rotatory knee laxity in patients with an ACL injury. It was hypothesized that a concomitant ALC injury would be associated with increased rotatory knee laxity as measured during a quantitative pivot-shift test. Cross-sectional study; Level of evidence, 3. Forty-one patients with an ACL injury (average age, 23 ± 6.9 years) were enrolled. Two blinded musculoskeletal radiologists reviewed magnetic resonance imaging (MRI) scans for the presence of ACL injuries and concomitant soft tissue injuries including the ALC, medial collateral ligament, lateral collateral ligament, posterolateral corner, medial meniscus, and lateral meniscus. A standardized pivot-shift test was performed under anesthesia, and rotatory laxity was quantified according to anterior translation of the lateral tibial compartment during the pivot-shift maneuver. The Student t test was used to analyze the data. Statistical significance was set at P < .05. A complete ACL rupture was confirmed in all of the patients. MRI evidence of an ALC injury was observed in 21 (51%) of the patients. Patients with MRI evidence of an ALC injury had significantly higher rotatory knee laxity (3.6 ± 1.5 mm) compared with those without an ALC injury (2.7 ± 1.5 mm; P = .04). Lateral and medial meniscus injuries were detected in 17 (41%) and 19 (46%) patients, respectively. Patients with MRI evidence of either a medial meniscus injury or lateral meniscus injury had significantly higher rotatory knee laxity compared with patients without these injuries (medial meniscus: 3.7 ± 1.4 mm vs 2.7 ± 1.6 mm, respectively; lateral meniscus: 3.7 ± 1.7 mm vs 2.7 ± 1.3 mm, respectively) (P = .03 for both). MRI evidence of a

The in situ force in the calcaneofibular ligament and the contribution of this ligament to ankle joint stability.

PubMed

Kobayashi, Takuma; Yamakawa, Satoshi; Watanabe, Kota; Kimura, Kei; Suzuki, Daisuke; Otsubo, Hidenori; Teramoto, Atsushi; Fujimiya, Mineko; Fujie, Hiromichi; Yamashita, Toshihiko

2016-12-01

Numerous biomechanical studies of the lateral ankle ligaments have been reported; however, the isolated function of the calcaneofibular ligament has not been clarified. We hypothesize that the calcaneofibular ligament would stabilize the ankle joint complex under multidirectional loading, and that the in situ force in the calcaneofibular ligament would change in each flexed position. Using seven fresh frozen cadaveric lower extremities, the motions and forces of the intact ankle under multidirectional loading were recorded using a 6-degree-of-freedom robotic system. On repeating these intact ankle joint complex motions after the calcaneofibular ligament transection, the in situ force in the calcaneofibular ligament and the contribution of the calcaneofibular ligament to ankle joint complex stability were calculated. Finally, the motions of the calcaneofibular ligament-transected ankle joint complex were recorded. Under an inversion load, significant increases of inversion angle were observed in all the flexed positions following calcaneofibular ligament transection, and the calcaneofibular ligament accounted for 50%-70% of ankle joint complex stability during inversion. The in situ forces in the calcaneofibular ligament under an anterior force, inversion moment, and external rotation moment were larger in the dorsiflexed position than in the plantarflexed position. The calcaneofibular ligament plays a role in stabilizing the ankle joint complex to multidirectional loads and the role differs with load directions. The in situ force of the calcaneofibular ligament is larger at the dorsiflexed position. This ligament provides the primary restraint to the inversion ankle stability. Copyright © 2016 Elsevier Ltd. All rights reserved.

[Visualization of Anterolateral Ligament of the Knee Using 3D Reconstructed Variable Refocus Flip Angle-Turbo Spin Echo T2 Weighted Image].

PubMed

Yokosawa, Kenta; Sasaki, Kana; Muramatsu, Koichi; Ono, Tomoya; Izawa, Hiroyuki; Hachiya, Yudo

2016-05-01

Anterolateral ligament (ALL) is one of the lateral structures in the knee that contributes to the internal rotational stability of tibia. ALL has been referred to in some recent reports to re-emphasize its importance. We visualized the ALL on 3D-MRI in 32 knees of 27 healthy volunteers (23 male knees, 4 female knees; mean age: 37 years). 3D-MRIs were performed using 1.5-T scanner [T(2) weighted image (WI), SPACE: Sampling Perfection with Application optimized Contrast using different flip angle Evolutions] in the knee extended positions. The visualization rate of the ALL, the mean angle to the lateral collateral ligament (LCL), and the width and the thickness of the ALL at the joint level were investigated. The visualization rate was 100%. The mean angle to the LCL was 10.6 degrees. The mean width and the mean thickness of the ALL were 6.4 mm and 1.0 mm, respectively. The ALL is a very thin ligament with a somewhat oblique course between the lateral femoral epicondyle and the mid-third area of lateral tibial condyle. Therefore, the slice thickness and the slice angle can easily affect the ALL visualization. 3D-MRI enables acquiring thin-slice imaging data over a relatively short time, and arbitrary sections aligned with the course of the ALL can later be selected.

13 CFR 120.395 - What is SBA's collateral position?

Code of Federal Regulations, 2011 CFR

2011-01-01

... 13 Business Credit and Assistance 1 2011-01-01 2011-01-01 false What is SBA's collateral position? 120.395 Section 120.395 Business Credit and Assistance SMALL BUSINESS ADMINISTRATION BUSINESS LOANS Special Purpose Loans Builders Loan Program § 120.395 What is SBA's collateral position? SBA will require...

13 CFR 120.395 - What is SBA's collateral position?

Code of Federal Regulations, 2013 CFR

2013-01-01

... 13 Business Credit and Assistance 1 2013-01-01 2013-01-01 false What is SBA's collateral position? 120.395 Section 120.395 Business Credit and Assistance SMALL BUSINESS ADMINISTRATION BUSINESS LOANS Special Purpose Loans Builders Loan Program § 120.395 What is SBA's collateral position? SBA will require...

13 CFR 120.395 - What is SBA's collateral position?

Code of Federal Regulations, 2012 CFR

2012-01-01

... 13 Business Credit and Assistance 1 2012-01-01 2012-01-01 false What is SBA's collateral position? 120.395 Section 120.395 Business Credit and Assistance SMALL BUSINESS ADMINISTRATION BUSINESS LOANS Special Purpose Loans Builders Loan Program § 120.395 What is SBA's collateral position? SBA will require...

13 CFR 120.395 - What is SBA's collateral position?

Code of Federal Regulations, 2010 CFR

2010-01-01

... 13 Business Credit and Assistance 1 2010-01-01 2010-01-01 false What is SBA's collateral position? 120.395 Section 120.395 Business Credit and Assistance SMALL BUSINESS ADMINISTRATION BUSINESS LOANS Special Purpose Loans Builders Loan Program § 120.395 What is SBA's collateral position? SBA will require...

13 CFR 120.395 - What is SBA's collateral position?

Code of Federal Regulations, 2014 CFR

2014-01-01

... 13 Business Credit and Assistance 1 2014-01-01 2014-01-01 false What is SBA's collateral position? 120.395 Section 120.395 Business Credit and Assistance SMALL BUSINESS ADMINISTRATION BUSINESS LOANS Special Purpose Loans Builders Loan Program § 120.395 What is SBA's collateral position? SBA will require...

Use of collateral information to improve LANDSAT classification accuracies

NASA Technical Reports Server (NTRS)

Strahler, A. H. (Principal Investigator)

1981-01-01

Methods to improve LANDSAT classification accuracies were investigated including: (1) the use of prior probabilities in maximum likelihood classification as a methodology to integrate discrete collateral data with continuously measured image density variables; (2) the use of the logit classifier as an alternative to multivariate normal classification that permits mixing both continuous and categorical variables in a single model and fits empirical distributions of observations more closely than the multivariate normal density function; and (3) the use of collateral data in a geographic information system as exercised to model a desired output information layer as a function of input layers of raster format collateral and image data base layers.

Rupture of the meniscofibular ligament

PubMed Central

2010-01-01

The meniscofibular ligament is an anatomically defined ligament of the knee in humans. However, there are no data regarding the prognosis following injury to this ligament. Our case was a 42-year-old man who presented at our clinic with pain of the lateral side of his left knee. MRI of his left knee revealed the rupture of the meniscofibular ligament. The mechanism of injury was consistent with anatomical and mechanical studies of the meniscofibular ligament. The patient was treated conservatively for 1 year, but his pain did not resolve completely. A case series of patients with the same injury is required to establish an effective treatment for this rare injury. PMID:20478075

Relationship between haemodynamic impairment and collateral blood flow in carotid artery disease.

PubMed

Hartkamp, Nolan S; Petersen, Esben T; Chappell, Michael A; Okell, Thomas W; Uyttenboogaart, Maarten; Zeebregts, Clark J; Bokkers, Reinoud Ph

2017-01-01

Collateral blood flow plays a pivotal role in steno-occlusive internal carotid artery (ICA) disease to prevent irreversible ischaemic damage. Our aim was to investigate the effect of carotid artery disease upon cerebral perfusion and cerebrovascular reactivity and whether haemodynamic impairment is influenced at brain tissue level by the existence of primary and/or secondary collateral. Eighty-eight patients with steno-occlusive ICA disease and 29 healthy controls underwent MR examination. The presence of collaterals was determined with time-of-flight, two-dimensional phase contrast MRA and territorial arterial spin labeling (ASL) imaging. Cerebral blood flow and cerebrovascular reactivity were assessed with ASL before and after acetazolamide. Cerebral haemodynamics were normal in asymptomatic ICA stenosis patients, as opposed to patients with ICA occlusion, in whom the haemodynamics in both hemispheres were compromised. Haemodynamic impairment in the affected brain region was always present in symptomatic patients. The degree of collateral blood flow was inversely correlated with haemodynamic impairment. Recruitment of secondary collaterals only occurred in symptomatic ICA occlusion patients. In conclusion, both CBF and cerebrovascular reactivity were found to be reduced in symptomatic patients with steno-occlusive ICA disease. The presence of collateral flow is associated with further haemodynamic impairment. Recruitment of secondary collaterals is associated with severe haemodynamic impairment.

Instrument-assisted cross fiber massage increases tissue perfusion and alters microvascular morphology in the vicinity of healing knee ligaments

PubMed Central

2013-01-01

Background Ligament injuries are common clinical problems for which there are few established interventions. Instrument-assisted cross fiber massage (IACFM) was recently shown to accelerate the restoration of biomechanical properties in injured rodent knee medial collateral ligaments (MCL). The current study aimed to investigate the influence of IACFM on regional perfusion and vascularity in the vicinity of healing rodent knee MCL injuries. Methods Bilateral knee MCL injuries were induced in female Sprague–Dawley rats. Commencing 1 week post-injury, 1 minute of IACFM was introduced unilaterally 3 times/week for 3 weeks. The contralateral injured MCL served as an internal control. Regional tissue perfusion was assessed in vivo throughout healing using laser Doppler imaging, whereas regional microvascular morphology was assessed ex vivo via micro-computed tomography of vessels filled with contrast. Results IACFM had no effect on tissue perfusion when assessed immediately, or at 5, 10, 15 or 20 min following intervention (all p > 0.05). However, IACFM-treated hindlimbs had enhanced tissue perfusion when assessed 1 day following the 4th and 9th (last) treatment sessions (all p < 0.05). IACFM-treated hindlimbs also had greater perfusion when assessed 1 wk following the final treatment session (32 days post-injury) (p < 0.05). Subsequent investigation of microvascular morphology found IACFM to increase the proportion of arteriole-sized blood vessels (5.9 to <41.2 μm) in the tibial third of the ligament (p < 0.05). Conclusions These findings suggest IACFM alters regional perfusion and vascularity in the vicinity of healing rodent knee MCL injuries. This effect may contribute to the beneficial effect of IACFM observed on the recovery of knee ligament biomechanical properties following injury. PMID:24073942

Associations Between Collateral Status and Thrombus Characteristics and Their Impact in Anterior Circulation Stroke.

PubMed

Alves, Heitor C; Treurniet, Kilian M; Dutra, Bruna G; Jansen, Ivo G H; Boers, Anna M M; Santos, Emilie M M; Berkhemer, Olvert A; Dippel, Diederik W J; van der Lugt, Aad; van Zwam, Wim H; van Oostenbrugge, Robert J; Lingsma, Hester F; Roos, Yvo B W E M; Yoo, Albert J; Marquering, Henk A; Majoie, Charles B L M

2018-02-01

Thrombus characteristics and collateral score are associated with functional outcome in patients with acute ischemic stroke. It has been suggested that they affect each other. The aim of this study is to evaluate the association between clot burden score, thrombus perviousness, and collateral score and to determine whether collateral score influences the association of thrombus characteristics with functional outcome. Patients with baseline thin-slice noncontrast computed tomography and computed tomographic angiography images from the MR CLEAN trial (Multicenter Randomized Clinical Trial of Endovascular Treatment of Acute Ischemic Stroke in the Netherlands) were included (n=195). Collateral score and clot burden scores were determined on baseline computed tomographic angiography. Thrombus attenuation increase was determined by comparing thrombus density on noncontrast computed tomography and computed tomographic angiography using a semiautomated method. The association of collateral score with clot burden score and thrombus attenuation increase was evaluated with linear regression. Mediation and effect modification analyses were used to assess the influence of collateral score on the association of clot burden score and thrombus attenuation increase with functional outcome. A higher clot burden score (B=0.063; 95% confidence interval, 0.008-0.118) and a higher thrombus attenuation increase (B=0.014; 95% confidence interval, 0.003-0.026) were associated with higher collateral score. Collateral score mediated the association of clot burden score with functional outcome. The association between thrombus attenuation increase and functional outcome was modified by the collateral score, and this association was stronger in patients with moderate and good collaterals. Patients with lower thrombus burden and higher thrombus perviousness scores had higher collateral score. The positive effect of thrombus perviousness on clinical outcome was only present in patients with

Corkscrew collaterals in atherosclerosis obliterans.

PubMed

Fujii, Yuichi; Ueda, Tomohiro; Uchimura, Yuko; Teragawa, Hiroki

2017-12-01

Marked calcifications in the femoral artery obscured imaging of the artery in computed tomography (CT) and duplex ultrasonography. The presence of corkscrew collateral arteries in patients with Atherosclerosis obliterans (ASO) indicates total artery occlusion.

Desensitizing the posterior interosseous nerve alters wrist proprioceptive reflexes.

PubMed

Hagert, Elisabet; Persson, Jonas K E

2010-07-01

The presence of wrist proprioceptive reflexes after stimulation of the dorsal scapholunate interosseous ligament has previously been described. Because this ligament is primarily innervated by the posterior interosseous nerve (PIN) we hypothesized altered ligamento-muscular reflex patterns following desensitization of the PIN. Eight volunteers (3 women, 5 men; mean age, 26 y; range 21-28 y) participated in the study. In the first study on wrist proprioceptive reflexes (study 1), the scapholunate interosseous ligament was stimulated through a fine-wire electrode with 4 1-ms bipolar pulses at 200 Hz, 30 times consecutively, while EMG activity was recorded from the extensor carpi radialis brevis, extensor carpi ulnaris, flexor carpi radialis, and flexor carpi ulnaris, with the wrist in extension, flexion, radial deviation, and ulnar deviation. After completion of study 1, the PIN was anesthetized in the radial aspect of the fourth extensor compartment using 2-mL lidocaine (10 mg/mL) infiltration anesthesia. Ten minutes after desensitization, the experiment was repeated as in study 1. The average EMG results from the 30 consecutive stimulations were rectified and analyzed using Student's t-test. Statistically significant changes in EMG amplitude were plotted along time lines so that the results of study 1 and 2 could be compared. Dramatic alterations in reflex patterns were observed in wrist flexion, radial deviation, and ulnar deviation following desensitization of the PIN, with an average of 72% reduction in excitatory reactions. In ulnar deviation, the inhibitory reactions of the extensor carpi ulnaris were entirely eliminated. In wrist extension, no differences in the reflex patterns were observed. Wrist proprioception through the scapholunate ligament in flexion, radial deviation, and ulnar deviation depends on an intact PIN function. The unchanged reflex patterns in wrist extension suggest an alternate proprioceptive pathway for this position. Routine excision of

Completed Ulnar Shaft Stress Fracture in a Fast-Pitch Softball Pitcher.

PubMed

Wiltfong, Roger E; Carruthers, Katherine H; Popp, James E

2017-03-01

Stress fractures of the upper extremity have been previously described in the literature, yet reports of isolated injury to the ulna diaphysis or olecranon are rare. The authors describe a case involving an 18-year-old fast-pitch softball pitcher. She presented with a long history of elbow and forearm pain, which was exacerbated during a long weekend of pitching. Her initial physician diagnosed her as having forearm tendinitis. She was treated with nonsurgical means including rest, anti-inflammatory medications, therapy, and kinesiology taping. She resumed pitching when allowed and subsequently had an acute event immediately ceasing pitching. She presented to an urgent care clinic that evening and was diagnosed as having a complete ulnar shaft fracture subsequently needing surgical management. This case illustrates the need for a high degree of suspicion for ulnar stress fractures in fast-pitch soft-ball pitchers with an insidious onset of unilateral forearm pain. Through early identification and intervention, physicians may be able to reduce the risk of injury progression and possibly eliminate the need for surgical management. [Orthopedics. 2017; 40(2):e360-e362.]. Copyright 2016, SLACK Incorporated.

Posterolateral rotatory instability from multiple steroids injections for tennis elbow: a case report.

PubMed

Chanlalit, Cholawish; Limsricharoen, Warodom

2013-01-01

This article reports the complication (lateral collateral ligament rupture) arising from improper numbers of steroids injections for the chronic lateral elbow pain (tennis elbow). Clinical sign and investigation with MRI confirmed a diagnosis of LCL rupture. In the present report, we describe the successful outcome of one year results in surgical debridement and lateral collateral ligament (LCL) reconstruction. A discussion of the proper conservative role for the chronic lateral epicondyalgia and the surgical decision to resolve this complication is also included.

7 CFR 1421.106 - Warehouse-stored marketing assistance loan collateral.

Code of Federal Regulations, 2012 CFR

2012-01-01

... 7 Agriculture 10 2012-01-01 2012-01-01 false Warehouse-stored marketing assistance loan collateral... SIMILARLY HANDLED COMMODITIES-MARKETING ASSISTANCE LOANS AND LOAN DEFICIENCY PAYMENTS FOR 2008 THROUGH 2012 Marketing Assistance Loans § 1421.106 Warehouse-stored marketing assistance loan collateral. (a) A commodity...

7 CFR 1421.106 - Warehouse-stored marketing assistance loan collateral.

Code of Federal Regulations, 2013 CFR

2013-01-01

... 7 Agriculture 10 2013-01-01 2013-01-01 false Warehouse-stored marketing assistance loan collateral... SIMILARLY HANDLED COMMODITIES-MARKETING ASSISTANCE LOANS AND LOAN DEFICIENCY PAYMENTS FOR 2008 THROUGH 2012 Marketing Assistance Loans § 1421.106 Warehouse-stored marketing assistance loan collateral. (a) A commodity...

7 CFR 1421.106 - Warehouse-stored marketing assistance loan collateral.

Code of Federal Regulations, 2014 CFR

2014-01-01

... 7 Agriculture 10 2014-01-01 2014-01-01 false Warehouse-stored marketing assistance loan collateral... SIMILARLY HANDLED COMMODITIES-MARKETING ASSISTANCE LOANS AND LOAN DEFICIENCY PAYMENTS FOR 2008 THROUGH 2012 Marketing Assistance Loans § 1421.106 Warehouse-stored marketing assistance loan collateral. (a) A commodity...

10 CFR 609.15 - Default, demand, payment, and collateral liquidation.

Code of Federal Regulations, 2011 CFR

2011-01-01

... 10 Energy 4 2011-01-01 2011-01-01 false Default, demand, payment, and collateral liquidation. 609.15 Section 609.15 Energy DEPARTMENT OF ENERGY (CONTINUED) ASSISTANCE REGULATIONS LOAN GUARANTEES FOR PROJECTS THAT EMPLOY INNOVATIVE TECHNOLOGIES § 609.15 Default, demand, payment, and collateral liquidation...

Acute posterior cruciate ligament injuries: effect of location, severity, and associated injuries on surgical management.

PubMed

Anderson, Mark A; Simeone, F Joseph; Palmer, William E; Chang, Connie Y

2018-06-01

To correlate MRI findings of patients with posterior cruciate ligament (PCL) injury and surgical management. A retrospective search yielded 79 acute PCL injuries (36 ± 16 years old, 21 F, 58 M). Two independent readers graded PCL tear location (proximal, middle, or distal third) and severity (low-grade or high-grade partial/complete) and evaluated injury of other knee structures. When available, operative reports were examined and the performed surgical procedure was compared with injury grade, location, and presence of associated injuries. The most commonly injured knee structures in acute PCL tears were posterolateral corner (58/79, 73%) and anterior cruciate ligament (ACL) (48/79, 61%). Of the 64 patients with treatment information, 31/64 (48%) were managed surgically: 12/31 (39%) had PCL reconstruction, 13/31 (42%) had ACL reconstruction, 10/31 (32%) had posterolateral corner reconstruction, 9/31 (29%) had LCL reconstruction, 8/31 (26%) had meniscectomy, and 8/31 (26%) had fixation of a fracture. Proximal third PCL tear and multiligamentous injury were more commonly associated with surgical management (P < 0.05). Posterolateral and posteromedial corner, ACL, collateral ligament, meniscus, patellar retinaculum, and gastrocnemius muscle injury, and fracture were more likely to result in surgical management (P < 0.05). Patients with high-grade partial/complete PCL tear were more likely to have PCL reconstruction as a portion of surgical management (P < 0.05). Location of PCL tear and presence of other knee injuries were associated with surgical management while high-grade/complete PCL tear grade was associated with PCL reconstruction. MRI reporting of PCL tear location, severity, and of other knee structure injuries is important for guiding clinical management.

Pattern of venous collateral development after splenic vein occlusion in an extended Whipple procedure : comparison with collateral vein pattern in cases of sinistral portal hypertension.

PubMed

Strasberg, Steven M; Bhalla, Sanjeev; Sanchez, Luis A; Linehan, David C

2011-11-01

The risks of developing sinistral portal hypertension as a result of occlusion of the splenic vein close to its termination during a Whipple procedure are unclear. Our purpose was to compare the pattern of venous collateral development after splenic vein ligation in an extended Whipple procedure with the pattern of collateral development in cases of sinistral portal hypertension. Five patients underwent an extended Whipple procedure in which the splenic vein was divided and not reconstructed. Six to eight months later detailed mapping of venous return from the spleen was determined by contrast-enhanced multidetector computed tomography or in one case by 3D contrast-enhanced MRI. Spleen size and length of residual patent splenic vein were also measured. The literature on sinistral portal hypertension was evaluated to ascertain whether the venous collateral pattern in cases of left-sided portal hypertension was similar to the pattern that developed when the splenic vein was ligated at its termination in the Whipple procedure. A length of splenic vein remained patent in all five patients, measuring 4.5 to 11.5 cm from the spleen. Splenomegaly did not develop. Blood returned from the spleen by multiple collaterals including collaterals in the omentum and mesocolon. These types of collaterals do not develop in sinistral portal hypertension, nor is residual patent splenic vein seen. Ligation of the splenic vein close to its termination in five patients resulted in a pattern of venous return different from patients that have developed left-sided portal hypertension.

Bioreactor design for tendon/ligament engineering.

PubMed

Wang, Tao; Gardiner, Bruce S; Lin, Zhen; Rubenson, Jonas; Kirk, Thomas B; Wang, Allan; Xu, Jiake; Smith, David W; Lloyd, David G; Zheng, Ming H

2013-04-01

Tendon and ligament injury is a worldwide health problem, but the treatment options remain limited. Tendon and ligament engineering might provide an alternative tissue source for the surgical replacement of injured tendon. A bioreactor provides a controllable environment enabling the systematic study of specific biological, biochemical, and biomechanical requirements to design and manufacture engineered tendon/ligament tissue. Furthermore, the tendon/ligament bioreactor system can provide a suitable culture environment, which mimics the dynamics of the in vivo environment for tendon/ligament maturation. For clinical settings, bioreactors also have the advantages of less-contamination risk, high reproducibility of cell propagation by minimizing manual operation, and a consistent end product. In this review, we identify the key components, design preferences, and criteria that are required for the development of an ideal bioreactor for engineering tendons and ligaments.

Anatomic ligament consolidation of the superior acromioclavicular ligament and the coracoclavicular ligament complex after acute arthroscopically assisted double coracoclavicular bundle stabilization.

PubMed

Jobmann, S; Buckup, J; Colcuc, C; Roessler, P P; Zimmermann, E; Schüttler, K F; Hoffmann, R; Welsch, F; Stein, T

2017-09-18

The consolidation of the acromioclavicular (AC) and coracoclavicular (CC) ligament complex after arthroscopically assisted stabilization of acute acromioclavicular joint (ACJ) separation is still under consideration. Fifty-five consecutive patients after arthroscopically assisted double-CC-bundle stabilization within 14 days after acute high-grade ACJ separation were studied prospectively. All patients were clinically analysed preoperatively (FU0) and post-operatively (FU1 = 6 months; FU2 = 12 months). The structural MRI assessments were performed at FU0 (injured ACJ) and at FU2 bilateral (radiologic control group) and assessed separately the ligament thickness and length at defined regions for the conoid, trapezoid and the superior AC ligament. Thirty-seven patients were assessed after 6.5 months and after 16.0 months. The 16-month MRI analysis revealed for all patients continuous ligament healing for the CC-complex and the superior AC ligament with in the average hypertrophic consolidation compared to the control side. Separate conoid and trapezoid strands (double-strand configuration) were detected in 27 of 37 (73%) patients, and a single-strand configuration was detected in 10 of 37 (27%) patients; both configurations showed similar CCD data. The ligament healing was not influenced by the point of surgery, age at surgery and heterotopic ossification. The clinical outcome was increased (FU0-FU2): Rowe, 47.7-97.0 pts.; TAFT, 3.9-10.6 pts.; NAS pain , 8.9-1.4 pts. (all P < 0.05). The arthroscopically assisted double-CC-bundle stabilization within 14 days after acute high-grade ACJ separation showed 16 months after surgery sufficient consolidations of the AC and double-CC ligament complex in 73%. III, Case series.

Sonographic measurements of the ulnar nerve at the elbow with different degrees of elbow flexion.

PubMed

Patel, Prutha; Norbury, John W; Fang, Xiangming

2014-05-01

To determine whether there were differences in the cross-sectional area (CSA) and the flattening ratio of the normative ulnar nerve as it passes between the medial epicondyle and the olecranon at 30° of elbow flexion versus 90° of elbow flexion. Bilateral upper extremities of normal healthy adult volunteers were evaluated with ultrasound. The CSA and the flattening ratio of the ulnar nerve at the elbow as it passes between the medial epicondyle and the olecranon were measured, with the elbow flexed at 30° and at 90°, by 2 operators with varying ultrasound scanning experience by using ellipse and direct tracing methods. The results from the 2 different angles of elbow flexion were compared for each individual operator. Finally, intraclass correlations for absolute agreement and consistency between the 2 raters were calculated. An outpatient clinic room at a regional rehabilitation center. Twenty-five normal healthy adult volunteers. The mean CSA and the mean flattening ratio of the ulnar nerve at 30° of elbow flexion and at 90° of elbow flexion. First, for the ellipse method, the mean CSA of the ulnar nerve at 90° (9.93 mm(2)) was slightly larger than at 30° (9.77 mm(2)) for rater 1. However, for rater 2, the mean CSA of the ulnar nerve at 90° (6.80 mm(2)) was slightly smaller than at 30° (7.08 mm(2)). This was found to be statistically insignificant when using a matched pairs t test and the Wilcoxon signed-rank test, with a significance level of .05. Similarly, the difference between the right side and the left side was not statistically significant. The intraclass correlations for absolute agreement between the 2 raters were not very high due to different measurement locations, but the intraclass correlations for consistency were high. Second, for the direct tracing method, the mean CSA at 90° (7.26 mm(2)) was slightly lower than at 30° (7.48 mm(2)). This was found to be statistically nonsignificant when using the matched pairs t test and the

Influence of oxidative stress on the development of collateral circulation in total coronary occlusions.

PubMed

Demirbag, Recep; Gur, Mustafa; Yilmaz, Remzi; Kunt, Alper Sami; Erel, Ozcan; Andac, M Halit

2007-03-02

The purpose of this study was to investigate whether the levels of total antioxidant capacity (TAC), total peroxide and oxidative stress index (OSI) are associated with the development of collaterals in total coronary occlusions. Our study group contained 176 consecutive men patients with single-vessel TCO, 94 of whom had poorly developed coronary collateral, while 82 had well-developed coronary collateral. TAC and total peroxide concentration were measured of plasma. The ratio of TAC to total peroxide was accepted as an indicator of oxidative stress. The values of total peroxide and OSI in the Group I were significantly lower than that in Group II (p<0.001, for both). TAC levels were significantly higher in patients with poorly developed collaterals than in well-developed collateral group (p<0.001). OSI values were also significantly different among the Rentrop class-0, -1, -2 and -3 (ANOVA p<0.001). We found significant correlations between collaterals score and TAC, total peroxide and OSI levels (p<0.001 for all). In multiple linear regression analysis, total peroxide and OSI were independent predictors of collaterals score (p=0.006 and p<0.001 respectively). This study clearly demonstrates that the level of OSI is independently and positively associated with the presence of collateral circulation in total coronary occlusion patients.

12 CFR 615.5090 - Reduction in carrying value of collateral.

Code of Federal Regulations, 2010 CFR

2010-01-01

... 12 Banks and Banking 6 2010-01-01 2010-01-01 false Reduction in carrying value of collateral. 615.5090 Section 615.5090 Banks and Banking FARM CREDIT ADMINISTRATION FARM CREDIT SYSTEM FUNDING AND FISCAL AFFAIRS, LOAN POLICIES AND OPERATIONS, AND FUNDING OPERATIONS Collateral § 615.5090 Reduction in...

Bioreactor Design for Tendon/Ligament Engineering

PubMed Central

Wang, Tao; Gardiner, Bruce S.; Lin, Zhen; Rubenson, Jonas; Kirk, Thomas B.; Wang, Allan; Xu, Jiake

2013-01-01

Tendon and ligament injury is a worldwide health problem, but the treatment options remain limited. Tendon and ligament engineering might provide an alternative tissue source for the surgical replacement of injured tendon. A bioreactor provides a controllable environment enabling the systematic study of specific biological, biochemical, and biomechanical requirements to design and manufacture engineered tendon/ligament tissue. Furthermore, the tendon/ligament bioreactor system can provide a suitable culture environment, which mimics the dynamics of the in vivo environment for tendon/ligament maturation. For clinical settings, bioreactors also have the advantages of less-contamination risk, high reproducibility of cell propagation by minimizing manual operation, and a consistent end product. In this review, we identify the key components, design preferences, and criteria that are required for the development of an ideal bioreactor for engineering tendons and ligaments. PMID:23072472

Role of collateral paths in long-range diffusion in lungs

PubMed Central

Bartel, Seth-Emil T.; Haywood, Susan E.; Woods, Jason C.; Chang, Yulin V.; Menard, Christopher; Yablonskiy, Dmitriy A.; Gierada, David S.; Conradi, Mark S.

2010-01-01

The long-range apparent diffusion coefficient (LRADC) of 3He gas in lungs, measured over times of several seconds and distances of 1–3 cm, probes the connections between the airways. Previous work has shown the LRADC to be small in health and substantially elevated in emphysema, reflecting tissue destruction, which is known to create collateral pathways. To better understand what controls LRADC, we report computer simulations and measurements of 3He gas diffusion in healthy lungs. The lung is generated with a random algorithm using well-defined rules, yielding a three-dimensional set of nodes or junctions, each connected by airways to one parent node and two daughters; airway dimensions are taken from published values. Spin magnetization in the simulated lung is modulated sinusoidally, and the diffusion equation is solved to 1,000 s. The modulated magnetization decays with a time constant corresponding to an LRADC of ~0.001 cm2/s, which is smaller by a factor of ~20 than the values in healthy lungs measured here and previously in vivo and in explanted lungs. It appears that collateral gas pathways, not present in the simulations, are functional in healthy lungs; they provide additional and more direct routes for long-range motion than the canonical airway tree. This is surprising, inasmuch as collateral ventilation is believed to be physiologically insignificant in healthy lungs. We discuss the effect on LRADC of small collateral connections through airway walls and rule out other possible mechanisms. The role of collateral paths is supported by measurements of smaller LRADC in pigs, where collateral ventilation is known to be smaller. PMID:18292298

Morphology of the dorsal and lateral calcaneocuboid ligaments.

PubMed

Dorn-Lange, Nadja V; Nauck, Tanja; Lohrer, Heinz; Arentz, Sabine; Konerding, Moritz A

2008-09-01

The dorsolateral calcaneocuboid ligaments have different configurations. In the literature they are only described as either the dorsal or lateral calcaneocuboid ligament. However, recent reconstructive surgical techniques may benefit from a better understanding of the anatomy. The aims of this study were to classify the morphology and attachments of the dorso-lateral calcaneocuboid ligaments and to determine their dimensions. The dorso-lateral aspects of the calcaneocuboid joint of 30 cadaver feet were dissected to expose the associated ligaments. Further, we evaluated possible bony landmarks of the calcaneus that could imply which shape or course the ligament would have in a specific individual. Our findings showed a wide variety of configurations in shape, number, and attachment sites. A constant dorsal ligament and an additional narrower lateral ligament was detectable in half of the cases. The majority of the dorso-lateral calcaneocuboid ligament-complex had an upward course and fanning out from proximal to distal. No bony predictor for the ligaments' shape or course was found. The dorso-lateral ligament-complex of the calcaneocuboid joint revealed a wide variety of configurations. Better understanding of the anatomy of these ligaments may aid in the anatomic reconstruction of these ligaments.

Isolated Major Aortopulmonary Collateral as the Sole Pulmonary Blood Supply to an Entire Lung Segment.

PubMed

Kim, Hannah S; Grady, R Mark; Shahanavaz, Shabana

2017-01-01

Congenital systemic-to-pulmonary collateral arteries or major aortopulmonary collaterals are associated with cyanotic congenital heart disease with decreased pulmonary blood flow. Though it is usually associated with congenital heart diseases, there is an increased incidence of isolated acquired aortopulmonary collaterals in premature infants with chronic lung disease. Interestingly, isolated congenital aortopulmonary collaterals can occur without any lung disease, which may cause congestive heart failure and require closure. We present a neonate with an echocardiogram that showed only left-sided heart dilation. Further workup with a CT angiogram demonstrated an anomalous systemic artery from the descending thoracic aorta supplying the left lower lobe. He eventually developed heart failure symptoms and was taken to the catheterization laboratory for closure of the collateral. However, with the collateral being the only source of blood flow to the entire left lower lobe, he required surgical unifocalization. Isolated aortopulmonary collaterals without any other congenital heart disease or lung disease are rare. Our patient is the first reported case to have an isolated aortopulmonary collateral being the sole pulmonary blood supply to an entire lung segment. Due to its rarity, there is still much to learn about the origin and development of these collaterals that possibly developed prenatally.

Biomechanical implications of lumbar spinal ligament transection.

PubMed

Von Forell, Gregory A; Bowden, Anton E

2014-11-01

Many lumbar spine surgeries either intentionally or inadvertently damage or transect spinal ligaments. The purpose of this work was to quantify the previously unknown biomechanical consequences of isolated spinal ligament transection on the remaining spinal ligaments (stress transfer), vertebrae (bone remodelling stimulus) and intervertebral discs (disc pressure) of the lumbar spine. A finite element model of the full lumbar spine was developed and validated against experimental data and tested in the primary modes of spinal motion in the intact condition. Once a ligament was removed, stress increased in the remaining spinal ligaments and changes occurred in vertebral strain energy, but disc pressure remained similar. All major biomechanical changes occurred at the same spinal level as the transected ligament, with minor changes at adjacent levels. This work demonstrates that iatrogenic damage to spinal ligaments disturbs the load sharing within the spinal ligament network and may induce significant clinically relevant changes in the spinal motion segment.

70° frontal visualization of lateral compartment of the elbow allows extensor carpi radialis brevis tendon release with preservation of the radial lateral collateral ligament.

PubMed

Arrigoni, Paolo; Fossati, Chiara; Zottarelli, Leonardo; Brady, Paul C; Cabitza, Paolo; Randelli, Pietro

2014-01-01

To determine whether the radial component of the lateral collateral ligament (R-LCL) and extensor carpi radialis brevis (ECRB) are consistently visible, using a 70° arthroscope, as parallel structures in the extra-articular space of the elbow, and to evaluate the clinical outcomes of these techniques in a series of patients. An arthroscopic ECRB tendon release was performed between 2008 and 2010. Eighteen patients were retrospectively evaluated at a minimum of 24 months' follow-up. The surgeon performed the ECRB release while protecting the R-LCL and viewing the structures extra-articularly with a 70° arthroscope through the anteromedial portal. Patients underwent surgery if they presented with localized tenderness and pain not responding to conservative treatment for 12 months and had magnetic resonance imaging scans indicating tendinopathy or degeneration. Arthritis, posterolateral rotatory instability, trauma, and previous surgeries were exclusion criteria. Intraoperative videos were reviewed and a clinical examination was performed by an independent reviewer at 24 months postoperatively. Patients were also evaluated with the Mayo Elbow Performance Score; Andrews-Carson score; and shortened Disabilities of the Arm, Shoulder and Hand questionnaire. Direct varus stress was applied in extension and flexion (40°), and the posterolateral pivot-shift and chair tests were performed. Visualization with the 70° arthroscope through the anteromedial portal was successful in all of the cases (100%). Visualization of the residual ECRB tendon stump, as well as the posterior common extensor tendon, was also achieved 94% of the time. The final mean Mayo Elbow Performance Score and Andrews-Carson score were 82.5 (range, 60 to 100) and 185.3 (range, 125 to 200), respectively. The mean postoperative score on the shortened Disabilities of the Arm, Shoulder and Hand questionnaire was 20.14 (range, 5 to 57.5). Clinical tests showed stability in all the cases. The 70° arthroscope

[Prioritisation of topics for systematic reviews in hand surgery. Results of an expert survey].

PubMed

Schädel-Höpfner, M; Diener, M K; Eisenschenk, A; Lögters, T; Windolf, J

2011-02-01

Systematic reviews are fundamental decision-making tools for the assessment of the effectiveness of healthcare interventions and for determining future research fields. In the field of hand surgery, so far, there exists only a limited number of systematic reviews. According to the diversity and multitude of hand surgical topics, relevant fields for systematic reviews were identified by means of an expert ranking. A catalogue of 24 topics was extracted from publications of representative hand surgical journals. These topics were categorized and integrated into a questionnaire which was presented to 30 experts in the field of hand surgery. Every single topic had to be rated by marks from 1 (very relevant) to 5 (not relevant). Further topics could have been indicated. Averaging of the marks allowed to define a ranking and a prioritisation of the topics. 29 of 30 questionnaires were returned. The ranking showed scapholunate ligament injury, Kienboeck's disease and scaphoid nonunion to have the highest relevance, followed by 5 other topics dealing with wrist problems. The lowest relevance was attributed to neck fractures of the fifth metacarpal, ulnar collateral ligament injury of the thumb metacarpophalangeal joint and postoperative management following replantation. The results of the presented survey allow for a prioritisation of topics for systematic reviews in hand surgery. The ranking of the topics emphasises the particular relevance of injuries and diseases of the wrist. © Georg Thieme Verlag KG Stuttgart · New York.

Value of Quantitative Collateral Scoring on CT Angiography in Patients with Acute Ischemic Stroke.

PubMed

Boers, A M M; Sales Barros, R; Jansen, I G H; Berkhemer, O A; Beenen, L F M; Menon, B K; Dippel, D W J; van der Lugt, A; van Zwam, W H; Roos, Y B W E M; van Oostenbrugge, R J; Slump, C H; Majoie, C B L M; Marquering, H A

2018-06-01

Many studies have emphasized the relevance of collateral flow in patients presenting with acute ischemic stroke. Our aim was to evaluate the relationship of the quantitative collateral score on baseline CTA with the outcome of patients with acute ischemic stroke and test whether the timing of the CTA acquisition influences this relationship. From the Multicenter Randomized Clinical Trial of Endovascular Treatment of Acute Ischemic Stroke in the Netherlands (MR CLEAN) data base, all baseline thin-slice CTA images of patients with acute ischemic stroke with intracranial large-vessel occlusion were retrospectively collected. The quantitative collateral score was calculated as the ratio of the vascular appearance of both hemispheres and was compared with the visual collateral score. Primary outcomes were 90-day mRS score and follow-up infarct volume. The relation with outcome and the association with treatment effect were estimated. The influence of the CTA acquisition phase on the relation of collateral scores with outcome was determined. A total of 442 patients were included. The quantitative collateral score strongly correlated with the visual collateral score (ρ = 0.75) and was an independent predictor of mRS (adjusted odds ratio = 0.81; 95% CI, .77-.86) and follow-up infarct volume (exponent β = 0.88; P < .001) per 10% increase. The quantitative collateral score showed areas under the curve of 0.71 and 0.69 for predicting functional independence (mRS 0-2) and follow-up infarct volume of >90 mL, respectively. We found significant interaction of the quantitative collateral score with the endovascular therapy effect in unadjusted analysis on the full ordinal mRS scale ( P = .048) and on functional independence ( P = .049). Modification of the quantitative collateral score by acquisition phase on outcome was significant (mRS: P = .004; follow-up infarct volume: P < .001) in adjusted analysis. Automated quantitative collateral scoring in patients with acute ischemic

13 CFR 123.513 - Does SBA require collateral on its Military Reservist EIDL?

Code of Federal Regulations, 2010 CFR

2010-01-01

..., or both. SBA will not decline a loan if you do not have a particular amount of collateral so long as SBA is reasonably sure that you can repay the loan. If you refuse to pledge the available collateral... 13 Business Credit and Assistance 1 2010-01-01 2010-01-01 false Does SBA require collateral on its...

Knee injuries in women collegiate rugby players.

PubMed

Levy, A S; Wetzler, M J; Lewars, M; Laughlin, W

1997-01-01

We evaluated the prevalence and patterns of knee injuries in 810 women collegiate rugby players. Injuries that resulted in players missing at least one game were recorded and a questionnaire was used to delineate players' rugby and knee injury history. There were 76 total knee injuries in 58,296 exposures. This resulted in a 1.3 knee injury rate per 1000 exposures. Twenty-one anterior cruciate ligament tears were reported for a 0.36 incidence per 1000 exposures. Other injuries included meniscal tears (25), medical collateral ligament sprains (23), patellar dislocations (5), and posterior cruciate ligament tears (2). Sixty-one percent of the medial collateral ligament sprains occurred in rugby forwards and 67% of anterior cruciate ligament tears occurred in rugby backs. All other injuries occurred with equal frequency in backs and forwards. This study demonstrates that knee injury rates in women's collegiate rugby are similar to those reported for other women's collegiate sports. The overall rate of anterior cruciate ligament injury in women's rugby, however, is slightly higher than that reported for women soccer and basketball players.

Spray-painted human fibronectin coating as an effective strategy to enhance graft ligamentization of a polyethylene terephthalate artificial ligament.

PubMed

Li, Hong; Chen, Chen; Ge, Yunsheng; Chen, Shiyi

2014-05-01

To enhance graft ligamentization after anterior cruciate ligament (ACL) reconstruction, human fibronectin (FN) was coated on polyethylene terephthalate (PET) ligaments by spray painting. The FN-coated PET ligaments were investigated in vitro using rat mesenchymal stromal cells (MSCs). MSCs cultured on FN-coated grafts resulted in similar cell densities and amounts of proliferating cells with control grafts without coating. The FN-coated group not only gave rise to MSC-derived collagen-like tissues but also enhanced the expression of collagen-I gene. Furthermore, rat ACL reconstruction models were used to evaluate the effect of the FN coating in vivo. The FN coating significantly promoted new ligament tissue regeneration into the graft fibers. In conclusion, sprayed FN coating had a positive effect to enhance graft ligamentization of PET artificial ligament.

Histological analysis of the structural composition of ankle ligaments.

PubMed

Rein, Susanne; Hagert, Elisabet; Schneiders, Wolfgang; Fieguth, Armin; Zwipp, Hans

2015-02-01

Various ankle ligaments have different structural composition. The aim of this study was to analyze the morphological structure of ankle ligaments to further understand their function in ankle stability. One hundred forty ligaments from 10 fresh-frozen cadaver ankle joints were dissected: the calcaneofibular, anterior, and posterior talofibular ligaments; the inferior extensor retinaculum, the talocalcaneal oblique ligament, the canalis tarsi ligament; the deltoid ligament; and the anterior tibiofibular ligament. Hematoxylin-eosin and Elastica van Gieson stains were used for determination of tissue morphology. Three different morphological compositions were identified: dense, mixed, and interlaced compositions. Densely packed ligaments, characterized by parallel bundles of collagen, were primarily seen in the lateral region, the canalis tarsi, and the anterior tibiofibular ligaments. Ligaments with mixed tight and loose parallel bundles of collagenous connective tissue were mainly found in the inferior extensor retinaculum and talocalcaneal oblique ligament. Densely packed and fiber-rich interlacing collagen was primarily seen in the areas of ligament insertion into bone of the deltoid ligament. Ligaments of the lateral region, the canalis tarsi, and the anterior tibiofibular ligaments have tightly packed, parallel collagen bundles and thus can resist high tensile forces. The mixed tight and loose, parallel oriented collagenous connective tissue of the inferior extensor retinaculum and the talocalcaneal oblique ligament support the dynamic positioning of the foot on the ground. The interlacing collagen bundles seen at the insertion of the deltoid ligament suggest that these insertion areas are susceptible to tension in a multitude of directions. The morphology and mechanical properties of ankle ligaments may provide an understanding of their response to the loads to which they are subjected. © The Author(s) 2015.

3-Tesla MRI-assisted detection of compression points in ulnar neuropathy at the elbow in correlation with intraoperative findings.

PubMed

Hold, Alina; Mayr-Riedler, Michael S; Rath, Thomas; Pona, Igor; Nierlich, Patrick; Breitenseher, Julia; Kasprian, Gregor

2018-03-06

Releasing the ulnar nerve from all entrapments is the primary objective of every surgical method in ulnar neuropathy at the elbow (UNE). The aim of this retrospective diagnostic study was to validate preoperative 3-Tesla MRI results by comparing the MRI findings with the intraoperative aspects during endoscopic-assisted or open surgery. Preoperative MRI studies were assessed by a radiologist not informed about intraoperative findings in request for the exact site of nerve compression. The localizations of compression were then correlated with the intraoperative findings obtained from the operative records. Percent agreement and Cohen's kappa (κ) values were calculated. From a total of 41 elbows, there was a complete agreement in 27 (65.8%) cases and a partial agreement in another 12 (29.3%) cases. Cohen's kappa showed fair-to-moderate agreement. High-resolution MRI cannot replace thorough intraoperative visualization of the ulnar nerve and its surrounding structures but may provide valuable information in ambiguous cases or relapses. Copyright © 2018 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.

CUDA-based acceleration of collateral filtering in brain MR images

NASA Astrophysics Data System (ADS)

Li, Cheng-Yuan; Chang, Herng-Hua

2017-02-01

Image denoising is one of the fundamental and essential tasks within image processing. In medical imaging, finding an effective algorithm that can remove random noise in MR images is important. This paper proposes an effective noise reduction method for brain magnetic resonance (MR) images. Our approach is based on the collateral filter which is a more powerful method than the bilateral filter in many cases. However, the computation of the collateral filter algorithm is quite time-consuming. To solve this problem, we improved the collateral filter algorithm with parallel computing using GPU. We adopted CUDA, an application programming interface for GPU by NVIDIA, to accelerate the computation. Our experimental evaluation on an Intel Xeon CPU E5-2620 v3 2.40GHz with a NVIDIA Tesla K40c GPU indicated that the proposed implementation runs dramatically faster than the traditional collateral filter. We believe that the proposed framework has established a general blueprint for achieving fast and robust filtering in a wide variety of medical image denoising applications.

Low-Magnitude, High-Frequency Vibration Fails to Accelerate Ligament Healing but Stimulates Collagen Synthesis in the Achilles Tendon.

PubMed

Thompson, William R; Keller, Benjamin V; Davis, Matthew L; Dahners, Laurence E; Weinhold, Paul S

2015-05-01

Low-magnitude, high-frequency vibration accelerates fracture and wound healing and prevents disuse atrophy in musculoskeletal tissues. To investigate the role of low-magnitude, high-frequency vibration as a treatment to accelerate healing of an acute ligament injury and to examine gene expression in the intact Achilles tendon of the injured limb after low-magnitude, high-frequency vibration. Controlled laboratory study. Complete surgical transection of the medial collateral ligament (MCL) was performed in 32 Sprague-Dawley rats, divided into control and low-magnitude, high-frequency vibration groups. Low-magnitude, high-frequency vibration started on postoperative day 2, and rats received vibration for 30 minutes a day for 12 days. All rats were sacrificed 2 weeks after the operation, and their intact and injured MCLs were biomechanically tested or used for histological analysis. Intact Achilles tendons from the injured limb were evaluated for differences in gene expression. Mechanical testing revealed no differences in the ultimate tensile load or the structural stiffness between the control and vibration groups for either the injured or intact MCL. Vibration exposure increased gene expression of collagen 1 alpha (3-fold), interleukin 6 (7-fold), cyclooxygenase 2 (5-fold), and bone morphogenetic protein 12 (4-fold) in the intact Achilles tendon when compared with control tendons ( P < .05). While no differences were observed in the mechanical or histological properties of the fully transected MCL after low-magnitude, high-frequency vibration treatment, significant enhancements in gene expression were observed in the intact Achilles tendon. These included collagen, several inflammatory cytokines, and growth factors critical for tendons. As low-magnitude, high-frequency vibration had no negative effects on ligament healing, vibration therapy may be a useful tool to accelerate healing of other tissues (bone) in multitrauma injuries without inhibiting ligament healing

[Tenotomy of carpal and digital flexor tendons for correction of congenital neuromyodysplasia in a calf].

PubMed

Sohrt, J T; Heppelmann, M; Rehage, J; Staszyk, C

2013-01-01

In a 7-day-old heifer calf, a bilateral flexural deformity of the forelimbs involving the digital flexor tendons, the suspensory ligament and the ulnar and radial carpal flexor tendons was diagnosed. After 2 weeks of conservative treatment consisting of manual stretching of the legs and the application of splints and wooden blocks, which were glued to the soles and extended beyond the tip of the claws, the right forelimb could be extended sufficiently to allow weight bearing, whereas the left forelimb could be passively extended to only approximately 120°. Therefore, tenotomy of the ulnar carpal flexor tendon, the digital flexor tendons and the suspensory ligament was carried out in the left leg. A support bandage was then applied to the leg for 8 weeks, after which the carpus and fetlock could be completely extended passively. Flexural deformity of the carpus caused by contracture of the carpal flexor tendons was treated by means of a tenotomy of the ulnar carpal flexor tendon proximal to the accessory carpal bone, which allowed preservation of the carpal tunnel and avoided the risk of iatrogenic damage to nerves and the carpal joint capsule.

7 CFR 1980.331 - Collateral.

Code of Federal Regulations, 2010 CFR

2010-01-01

... 7 Agriculture 14 2010-01-01 2009-01-01 true Collateral. 1980.331 Section 1980.331 Agriculture Regulations of the Department of Agriculture (Continued) RURAL HOUSING SERVICE, RURAL BUSINESS-COOPERATIVE... security interest is obtained, maintained in existence, and of record to protect the interests of the...

Preoperative Evaluation of Collateral Venous Anastomoses in Meningioma Involving Cerebral Venous Sinus by Susceptibility Weighted Imaging

PubMed Central

Wang, Qing; He, Jingzhen; Ma, Xiangxing

2014-01-01

Abstract Precise preoperative identification of the collateral venous anastomoses is critical for proper surgical management of patients with meningioma involving sinus. This study was to assess the feasibility of susceptibility weighted imaging (SWI) to delineate the collateral venous anastomoses before surgery. Twenty-five patients with meningiomas that were involved in sinuses underwent surgery and the collateral anastomoses were evaluated with SWI and phase-contrast magnetic resonance venography (MRV) before surgery. The results obtained with SWI were compared with those obtained with MRV. Intraoperative findings were used as the gold standard. By surgery, a total of 98 collateral anastomotic veins were identified in the 25 patients. SWI depicted 85 collateral anastomotic veins close to the meningioma with a sensitivity of 87%, whereas MRV showed 57 collateral anastomotic veins with a sensitivity of 58%. The detectability of collateral anastomotic veins in SWI images was superior to MRV. The results suggest that SWI is superior to MRV and could provide more reliable information on the collateral venous anastomoses in patients with meningioma. PMID:25501068

Neck ligament strength is decreased following whiplash trauma

PubMed Central

Tominaga, Yasuhiro; Ndu, Anthony B; Coe, Marcus P; Valenson, Arnold J; Ivancic, Paul C; Ito, Shigeki; Rubin, Wolfgang; Panjabi, Manohar M

2006-01-01

Background Previous clinical studies have documented successful neck pain relief in whiplash patients using nerve block and radiofrequency ablation of facet joint afferents, including capsular ligament nerves. No previous study has documented injuries to the neck ligaments as determined by altered dynamic mechanical properties due to whiplash. The goal of the present study was to determine the dynamic mechanical properties of whiplash-exposed human cervical spine ligaments. Additionally, the present data were compared to previously reported control data. The ligaments included the anterior and posterior longitudinal, capsular, and interspinous and supraspinous ligaments, middle-third disc, and ligamentum flavum. Methods A total of 98 bone-ligament-bone specimens (C2–C3 to C7-T1) were prepared from six cervical spines following 3.5, 5, 6.5, and 8 g rear impacts and pre- and post-impact flexibility testing. The specimens were elongated to failure at a peak rate of 725 (SD 95) mm/s. Failure force, elongation, and energy absorbed, as well as stiffness were determined. The mechanical properties were statistically compared among ligaments, and to the control data (significance level: P < 0.05; trend: P < 0.1). The average physiological ligament elongation was determined using a mathematical model. Results For all whiplash-exposed ligaments, the average failure elongation exceeded the average physiological elongation. The highest average failure force of 204.6 N was observed in the ligamentum flavum, significantly greater than in middle-third disc and interspinous and supraspinous ligaments. The highest average failure elongation of 4.9 mm was observed in the interspinous and supraspinous ligaments, significantly greater than in the anterior longitudinal ligament, middle-third disc, and ligamentum flavum. The average energy absorbed ranged from 0.04 J by the middle-third disc to 0.44 J by the capsular ligament. The ligamentum flavum was the stiffest ligament, while the

13 CFR 120.934 - Collateral.

Code of Federal Regulations, 2010 CFR

2010-01-01

... 13 Business Credit and Assistance 1 2010-01-01 2010-01-01 false Collateral. 120.934 Section 120.934 Business Credit and Assistance SMALL BUSINESS ADMINISTRATION BUSINESS LOANS Development Company... must be insured against such hazards and risks as SBA may require, with provisions for notice to SBA...

12 CFR 221.7 - Supplement: Maximum loan value of margin stock and other collateral.

Code of Federal Regulations, 2010 CFR

2010-01-01

... value of margin stock and other collateral. (a) Maximum loan value of margin stock. The maximum loan... nonmargin stock and all other collateral. The maximum loan value of nonmargin stock and all other collateral... 12 Banks and Banking 3 2010-01-01 2010-01-01 false Supplement: Maximum loan value of margin stock...

Medial Collateral Ligament (MCL) Injuries

MedlinePlus

... torn MCL tend to play contact sports, like football and soccer. More severe injuries happen when the ... the things you love — like running or playing football, field hockey, or softball — can be frustrating. If ...

Collateral ligament (CL) injury - aftercare

MedlinePlus

... Disorders, Pain, and Rehabilitation . 3rd ed. Philadelphia, PA: Elsevier Saunders; 2015:chap 66. Miller RH, Azar FM. ... eds. Campbell's Operative Orthopaedics . 13th ed. Philadelphia, PA: Elsevier; 2017:chap 45. Niska JA, Petrigliano FA, McAllister ...

Anatomy of the ankle ligaments: a pictorial essay.

PubMed

Golanó, Pau; Vega, Jordi; de Leeuw, Peter A J; Malagelada, Francesc; Manzanares, M Cristina; Götzens, Víctor; van Dijk, C Niek

2016-04-01

Understanding the anatomy of the ankle ligaments is important for correct diagnosis and treatment. Ankle ligament injury is the most frequent cause of acute ankle pain. Chronic ankle pain often finds its cause in laxity of one of the ankle ligaments. In this pictorial essay, the ligaments around the ankle are grouped, depending on their anatomic orientation, and each of the ankle ligaments is discussed in detail.

Mechanical tensile properties of the anterolateral ligament.

PubMed

Zens, Martin; Feucht, Matthias J; Ruhhammer, Johannes; Bernstein, Anke; Mayr, Hermann O; Südkamp, Norbert P; Woias, Peter; Niemeyer, Philipp

2015-12-01

In a noticeable percentage of patients anterolateral rotational instabilities (ALRI) remain after an isolated ACL reconstruction. Those instabilities may occur due to an insufficiently directed damage of anterolateral structures that is often associated with ACL ruptures. Recent publications describe an anatomical structure, termed the anterolateral ligament (ALL), and suggest that this ligament plays a significant role in the pathogenesis of ALRI of the knee joint. However, only limited knowledge about the biomechanical characteristics and tensile properties of the anterolateral ligament exists. The anterolateral ligament was dissected in four fresh-frozen human cadaveric specimens and all surrounding tissue removed. The initial length of the anterolateral ligament was measured using a digital caliper. Tensile tests with load to failure were performed using a materials testing machine. The explanted anterolateral ligaments were histologically examined to measure the cross-sectional area. The mean ultimate load to failure of the anterolateral ligament was 49.90 N (± 14.62 N) and the mean ultimate strain was 35.96% (± 4.47%). The mean length of the ligament was 33.08 mm (± 2.24) and the mean cross-sectional area was 1.54 m m (2) (± 0.48 m m (2)). Including the areal measurements the maximum tension was calculated to be 32.78 [Formula: see text] (± 4.04 [Formula: see text]). The anterolateral ligament is an anatomical structure with tensile properties that are considerably weaker compared to other peripheral structures of the knee. Knowledge of the anterolateral ligament's tensile strengths may help to better understand its function and with graft choices for reconstruction procedures.

Vasoresponsiveness of collateral vessels in the rat hindlimb: influence of training.

PubMed

Colleran, Patrick N; Li, Zeyi; Yang, Hsiao T; Laughlin, M Harold; Terjung, Ronald L

2010-04-15

Exercise training is known to be an effective means of improving functional capacity and quality of life in patients with peripheral arterial insufficiency (PAI). However, the specific training-induced physiological adaptations occurring within collateral vessels remain to be clearly defined. The purpose of this study was to determine the effect of exercise training on vasomotor properties of isolated peripheral collateral arteries. We hypothesized that daily treadmill exercise would improve the poor vasodilatory capacity of collateral arteries isolated from rats exposed to surgical occlusion of the femoral artery. Following femoral artery ligation, animals were either kept sedentary or exercise trained daily for a period of 3 weeks. Hindlimb collateral arteries were then isolated, cannulated and pressurized via hydrostatic reservoirs to an intravascular pressure of either 45 or 120 cmH(2)O. Non-occluded contralateral vessels of the sedentary animals served as normal Control. Vasodilatory responses to acetylcholine (ACh; 1 x 10(9)-1 x 10(5)m) and sodium nitroprusside (SNP; 1 x 10(9)-1 x 10(4)m), constrictor responses to phenylephrine (PE; 1 x 10(9)-1 x 10(4)m), and flow-induced vasodilatation were determined. Endothelium-mediated vasodilatation responses were significantly greater to either ACh (P < 0.02) or intravascular flow (P < 0.001) in collateral arteries of trained rats. Neither blockade of cyclooxygenase with indomethacin (Indo; 5 microm) nor blockade of endothelial nitric oxide synthase with N(G)-nitro-L-arginine methyl ester (L-NAME; 300 microm) eliminated this ACh- or flow-induced vasodilatation. The depressed vasodilatory response to SNP caused by vascular occlusion was reversed with training. These data indicate that exercise training improves endothelium-mediated vasodilatory capacity of hindlimb collateral arteries, apparently by enhanced production of the putative endothelium-derived hyperpolarizing factor(s). If these findings were applicable to

Independent predictors of retrograde failure in CTO-PCI after successful collateral channel crossing.

PubMed

Suzuki, Yoriyasu; Muto, Makoto; Yamane, Masahisa; Muramatsu, Toshiya; Okamura, Atsunori; Igarashi, Yasumi; Fujita, Tsutomu; Nakamura, Shigeru; Oida, Akitsugu; Tsuchikane, Etsuo

2017-07-01

To evaluate factors for predicting retrograde CTO-PCI failure after successful collateral channel crossing. Successful guidewire/catheter collateral channel crossing is important for the retrograde approach in percutaneous coronary intervention (PCI) for chronic total occlusion (CTO). A total of 5984 CTO-PCI procedures performed in 45 centers in Japan from 2009 to 2012 were studied. The retrograde approach was used in 1656 CTO-PCIs (27.7%). We investigated these retrograde procedures to evaluate factors for predicting retrograde CTO-PCI failure even after successful collateral channel crossing. Successful guidewire/catheter collateral crossing was achieved in 77.1% (n = 1,276) of 1656 retrograde CTO-PCI procedures. Retrograde procedural success after successful collateral crossing was achieved in 89.4% (n = 1,141). Univariate analysis showed that the predictors for retrograde CTO-PCI failure were in-stent occlusion (OR = 1.9829, 95%CI = 1.1783 - 3.3370 P = 0.0088), calcified lesions (OR = 1.9233, 95%CI = 1.2463 - 2.9679, P = 0.0027), and lesion tortuosity (OR = 1.5244, 95%CI = 1.0618 - 2.1883, P = 0.0216). On multivariate analysis, lesion calcification was an independent predictor of retrograde CTO-PCI failure after successful collateral channel crossing (OR = 1.3472, 95%CI = 1.0614 - 1.7169, P = 0.0141). The success rate of retrograde CTO-PCI following successful guidewire/catheter collateral channel crossing was high in this registry. Lesion calcification was an independent predictor of retrograde CTO-PCI failure after successful collateral channel crossing. Devices and techniques to overcome complex CTO lesion morphology, such as lesion calcification, are required to further improve the retrograde CTO-PCI success rate. © 2016 Wiley Periodicals, Inc. © 2016 Wiley Periodicals, Inc.

10 CFR 609.16 - Perfection of liens and preservation of collateral.

Code of Federal Regulations, 2011 CFR

2011-01-01

... 10 Energy 4 2011-01-01 2011-01-01 false Perfection of liens and preservation of collateral. 609.16 Section 609.16 Energy DEPARTMENT OF ENERGY (CONTINUED) ASSISTANCE REGULATIONS LOAN GUARANTEES FOR PROJECTS THAT EMPLOY INNOVATIVE TECHNOLOGIES § 609.16 Perfection of liens and preservation of collateral. (a...

Anatomy of the ankle ligaments: a pictorial essay

PubMed Central

Vega, Jordi; de Leeuw, Peter A. J.; Malagelada, Francesc; Manzanares, M. Cristina; Götzens, Víctor; van Dijk, C. Niek

2010-01-01

Understanding the anatomy of the ankle ligaments is important for correct diagnosis and treatment. Ankle ligament injury is the most frequent cause of acute ankle pain. Chronic ankle pain often finds its cause in laxity of one of the ankle ligaments. In this pictorial essay, the ligaments around the ankle are grouped, depending on their anatomic orientation, and each of the ankle ligaments is discussed in detail. PMID:20309522

Thoracolumbar spinal ligaments exhibit negative and transverse pre-strain.

PubMed

Robertson, Daniel J; Von Forell, Gregory A; Alsup, Jeremy; Bowden, Anton E

2013-07-01

The present work represents the first reported bi-axial spinal ligament pre-strain data for the thoracic and lumbar spine. Ligament pre-strain (in-situ strain) is known to significantly alter joint biomechanics. However, there is currently a lack of comprehensive data with regards to spinal ligament pre-strain. The current work determined the pre-strain of 71 spinal ligaments (30 anterior longitudinal ligaments, 27 supraspinous ligaments and 14 interspinous ligaments). The interspinous ligament and the anterior longitudinal ligament exhibited bi-axial pre-strain distributions, demonstrating they are not uniaxial structures. The supraspinous ligament frequently exhibited large amounts of negative pre-strain or laxity suggesting it makes no mechanical contribution to spinal stability near the neutral posture. Upon implementing multi-axial pre-strain results into a finite element model of the lumbar spine, large differences in spinal biomechanics were observed. These results demonstrate the necessity of accounting for ligament pre-strain in biomechanical models. In addition, the authors present a unique experimental method for obtaining ligament pre-strain that presents a number of advantages when compared to standard techniques. Copyright © 2013 Elsevier Ltd. All rights reserved.

Computed tomographic characteristics of collateral venous pathways in dogs with caudal vena cava obstruction.

PubMed

Specchi, Swan; d'Anjou, Marc-André; Carmel, Eric Norman; Bertolini, Giovanna

2014-01-01

Collateral venous pathways develop in dogs with obstruction or increased blood flow resistance at any level of the caudal vena cava in order to maintain venous drainage to the right atrium. The purpose of this retrospective study was to describe the sites, causes of obstruction, and configurations of venous collateral pathways for a group of dogs with caudal vena cava obstruction. Computed tomography databases from two veterinary hospitals were searched for dogs with a diagnosis of caudal vena cava obstruction and multidetector row computed tomographic angiographic (CTA) scans that included the entire caudal vena cava. Images for each included dog were retrieved and collateral venous pathways were characterized using image postprocessing and a classification system previously reported for humans. A total of nine dogs met inclusion criteria and four major collateral venous pathways were identified: deep (n = 2), portal (n = 2), intermediate (n = 7), and superficial (n = 5). More than one collateral venous pathway was present in 5 dogs. An alternative pathway consisting of renal subcapsular collateral veins, arising mainly from the caudal pole of both kidneys, was found in three dogs. In conclusion, findings indicated that collateral venous pathway patterns similar to those described in humans are also present in dogs with caudal vena cava obstruction. These collateral pathways need to be distinguished from other vascular anomalies in dogs. Postprocessing of multidetector-row CTA images allowed delineation of the course of these complicated venous pathways and may be a helpful adjunct for treatment planning in future cases. © 2014 American College of Veterinary Radiology.

7 CFR 1434.16 - Release of the honey pledged as collateral for a loan.

Code of Federal Regulations, 2010 CFR

2010-01-01

... 7 Agriculture 10 2010-01-01 2010-01-01 false Release of the honey pledged as collateral for a loan... MARKETING ASSISTANCE LOAN AND LDP REGULATIONS FOR HONEY § 1434.16 Release of the honey pledged as collateral for a loan. (a)(1) A producer shall not move or dispose of any honey pledged as collateral for a loan...

7 CFR 1434.16 - Release of the honey pledged as collateral for a loan.

Code of Federal Regulations, 2011 CFR

2011-01-01

... 7 Agriculture 10 2011-01-01 2011-01-01 false Release of the honey pledged as collateral for a loan... MARKETING ASSISTANCE LOAN AND LDP REGULATIONS FOR HONEY § 1434.16 Release of the honey pledged as collateral for a loan. (a)(1) A producer shall not move or dispose of any honey pledged as collateral for a loan...

Differential impact of diabetes mellitus type II and arterial hypertension on collateral artery growth and concomitant macrophage accumulation.

PubMed

Ito, Wulf D; Lund, Natalie; Sager, Hendrik; Becker, Wiebke; Wenzel, Ulrich

2015-01-01

Diabetes mellitus type II and arterial hypertension are major risk factors for peripheral arterial disease and have been considered to reduce collateral growth (arteriogenesis). Collateral growth proceeds through different stages. Vascular proliferation and macrophage accumulation are hallmarks of early collateral growth. We here compare the impact of arterial hypertension and diabetes mellitus type II on collateral proliferation (Brdu incorporation) and macrophage accumulation (ED 2 staining) as well as collateral vessel function (collateral conductance) in a rat model of peripheral vascular disease (femoral artery occlusion), diabetes mellitus type II (Zucker fatty diabetic rats and Zucker lean rat controls) and arterial hypertension (induced via clip placement around the right renal arteriy). We furthermore tested the impact of monocyte chemoattractant protein-1 (MCP‑1) on collateral proliferation and macrophage accumulation in these models Diabetic animals showed reduced vascular proliferation and macrophage accumulation, which however did not translate into a change of collateral conductance. Hypertensive animals on the contrary had reduced collateral conductances without altered macrophage accumulation and only a marginal reduction in collateral proliferation. Infusion of MCP‑1 only enhanced vascular proliferation in diabetic animals. These findings illustrate that impaired monocyte/macrophage recruitment is responsible for reduced collateral growth under diabetic conditions but not in arterial hypertension suggesting that diabetes mellitus in particular affects early stages of collateral growth whereas hypertension has its impact on later remodeling stages. Successful pro-arteriogenic treatment strategies in a patient population that presents with diabetes mellitus and arterial hypertension need to address different stages of collateral growth and thus different molecular and cellular targets simultaneously.

12 CFR 7.1009 - National bank holding collateral stock as nominee.

Code of Federal Regulations, 2010 CFR

2010-01-01

... 12 Banks and Banking 1 2010-01-01 2010-01-01 false National bank holding collateral stock as nominee. 7.1009 Section 7.1009 Banks and Banking COMPTROLLER OF THE CURRENCY, DEPARTMENT OF THE TREASURY BANK ACTIVITIES AND OPERATIONS Bank Powers § 7.1009 National bank holding collateral stock as nominee...

12 CFR 7.1009 - National bank holding collateral stock as nominee.

Code of Federal Regulations, 2011 CFR

2011-01-01

... 12 Banks and Banking 1 2011-01-01 2011-01-01 false National bank holding collateral stock as nominee. 7.1009 Section 7.1009 Banks and Banking COMPTROLLER OF THE CURRENCY, DEPARTMENT OF THE TREASURY BANK ACTIVITIES AND OPERATIONS Bank Powers § 7.1009 National bank holding collateral stock as nominee...

12 CFR 950.7 - Collateral.

Code of Federal Regulations, 2010 CFR

2010-01-01

... board of directors of the Bank has specifically approved such acceptance by formal resolution, and the... 12 Banks and Banking 7 2010-01-01 2010-01-01 false Collateral. 950.7 Section 950.7 Banks and Banking FEDERAL HOUSING FINANCE BOARD FEDERAL HOME LOAN BANK ASSETS AND OFF-BALANCE SHEET ITEMS ADVANCES...

13 CFR 120.349 - Collateral.