Thomas Neri

The anterolateral ligament: Anatomic implications for its reconstruction

BACKGROUND The purpose of this study was to define the best anatomic parameters with which to perform an accurate anterolateral ligament (ALL) reconstruction. These parameters were anatomical insertions, allowing favorable isometry, length variation during flexion, and anthropometric predictors of ALL lengths. METHODS A total of 84 fresh-frozen cadaver knees were dissected to analyze the ALL, focusing on its femoral insertion. The ALL length was measured in different degrees of flexion (extension, 30°, 60°, and 90° of flexion) and rotation (neutral, internal or external rotation). The ALL width and thickness were measured. A correlation between ALL length, the general knee size and individual characteristics was investigated. RESULTS The ALL was present in 80 specimens (95%). The femoral footprint was always posterior (5.52±0.93 mm, range 3.83-6.94) and slightly proximal (1.51±0.75mm, range 0.63-2.37) to the lateral femoral epicondyle. The mean ALL length increased with internal rotation and decreased with external rotation (P<0.05). The maximum ALL length was found at 30° of flexion, and the minimum at 90°. There was a significant correlation between the ALL length and height, sex, and proximal femur dimensions. CONCLUSION In order to get an anatomical reconstruction with favorable isometry, it is recommended that the ALL femoral graft is implanted posterior and slightly proximal to the epicondyle. It is also suggested that the tension be adjusted by fixing the graft between 0 and 30° of flexion, being tighter near extension. This will allow good rotational stability without implying any stiffness.

Radiologic analysis of hindfoot alignment: Comparison of Méary, long axial, and hindfoot alignment views

BACKGROUND Among radiographic views available for assessing hindfoot alignment, the antero-posterior weight-bearing view with metal cerclage of the hindfoot (Méary view) is the most widely used in France. Internationally, the long axial view (LAV) and hindfoot alignment view (HAV) are used also. The objective of this study was to compare the reliability of these three views. HYPOTHESIS The Méary view with cerclage of the hindfoot is as reliable as the LAV and HAV for assessing hindfoot alignment. MATERIAL AND METHODS All three views were obtained in each of 22 prospectively included patients. Intra-observer and inter-observer reliabilities were assessed by having two observers collect the radiographic measurements then computing the intra-class correlation coefficients (ICCs). RESULTS The intra-observer and inter-observer ICCs were 0.956 and 0.988 with the Méary view, 0.990 and 0.765 with the HAV, and 0.997 and 0.991 with the LAV, respectively. Correlations were far stronger between the LAV and HAV than between each of these and the Méary view. Compared to the LAV and HAV, the Méary view indicated a greater degree of hindfoot valgus. DISCUSSION Intra-observer reliability was excellent with both the LAV and HAV, whereas inter-observer reliability was better with the LAV. Excellent reliability was also obtained with the Méary view. Combining the Méary view to obtain a radiographic image of the clinical deformity with the LAV to measure the angular deviation of the hindfoot axis may be useful when assessing hindfoot malalignment. A comparison of the three views in a larger population is needed before clinical recommendations can be made. LEVEL OF EVIDENCE II, prospective study.

The anterolateral ligament is a distinct ligamentous structure: A histological explanation

BACKGROUND The aim was to determine whether the anterolateral ligament (ALL) had a histological structure that defined it as a real ligament. METHODS Histological examination of 30 ALL samples taken from fresh-frozen knees were performed. The ALL femoral insertion and its relationship with the lateral collateral ligament (LCL) were studied and the tibial insertion and its relationship with articular cartilage of the tibial joint surface were analyzed. For the ligamentous part, its histological structure and its differences with the articular capsule were studied. RESULTS This connective tissue is composed of a dense fibrous core constituted by a network of oriented collagenous fibers. The periphery of this dense connective center is made up of loose fibrocollagenous tissue with vascular structures and focal deposits of adipose tissue. This part was in contact but different to the joint capsule. With a perpendicular orientation of the collagen fibers relative to the bone, a fibrocartilaginous zone with an unmineralized hyalinized aspect, a mineralization front, its bone insertions presented a typical ligamentous insertion. With a cleavage plane between ALL and LCL femoral insertion, the ALL appeared to have a femoral insertion distinct from the LCL. ALL tibial insertion was less characteristic with less organized connective tissue and was at a distance from the articular cartilage. CONCLUSION From its bony insertion to its tissue composition and organization, the ALL has all the histological characteristics of a ligamentous structure. Our study confirms that ALL can be considered a real and distinct ligament.

Non-operative treatment options for knee osteoarthritis: current concepts

Knee osteoarthritis in younger patients can be a challenging condition to manage. The patient and clinician have a range of non-operative management options available, although the guidance to effectively apply these options is lacking. The following review summarises a range of non-operative treatment options as an accessible reference for primary care providers to establish a coordinated care plan in consultation with the patient as part of a shared decision making process. Options are summarised in non-pharmacological and pharmacological treatments. These options are based on the latest guidelines based on authoritative recommendations, as well as recent articles with a good level of evidence that have not yet been incorporated into these official contents. The coordination of treatment using a range of modalities remains poorly explained in the literature and the current review proposes a conceptual model for coordinated care to be provided. In this model, the patient is central to the interaction between the coordinator and specialist providers, and the treatment plan is tailored to provide the optimal pain relief and functional benefit specific to the patient.

Correction to: Intraprosthetic dislocation of dual mobility total hip arthroplasty: still occurring?

The published online version contains mistake in the author list for the author name “Di Iorio Alexandre” was incorrectly presented.

Clinical And Radiological Predictors Of Medial Patellofemoral Ligament Reconstruction

Introduction: Among the numerous techniques available, medial patellofemoral ligament (MPFL) reconstruction is increasingly used for the surgical treatment of objective patellar instability. Although the value of this technique has been demonstrated, few studies have assessed predictors of good clinical results. The main objective of this study was to isolate, through a clinical series of 107 patients, the clinical and radiological predictors that can significantly influence the clinical results of the MPFL ligament. Methods: One hundred and seven patients (110 ligament reconstructions) presenting an objective patellar instability, were evaluated with a mean follow-up of 55 months (24 to 91). The standardized procedure comprised MPFL reconstruction using the gracilis tendon. Complementary distal bone graft was associated if a preoperative tibial tubercle-trochlear groove (TT-TG) distance exceeded 20 mm or a patella alta. Functional IKDC and Kujala scores were preoperatively assessed and at end of follow-up. Plain X-ray with radiological assessment of patellar height and tilt (Laurin angle, Merchant angle, Maldague classification) and a CT scan measurement of the patellar tilt (quadriceps contracted and relaxed) and TT-GT distance were performed preoperatively and at 6 months. Femoral tunnel position was assessed following the criteria formulated by Schöttle. The amount of femoral tunnel widening was measured by means of the 3D CT scan image at 6 months. Predictors were determined from univariate and multivariate analyzes integrating clinical and radiological criteria pre and postoperative. The variables of interest were defined as the difference in functional scores between pre and postoperative. Results: Clinical factors, such as age, Body Mass Index, number of dislocation, time between the first dislocation and surgery, did not influence functional scores (all p> 0.05). For technical factors: association with a bone graft or incorrect positioning of the femoral tunnel, also had no effect on clinical outcome (p> 0.05). It was the same for preoperative radiological factors: radiological and CT scan tilt, TT-TG distance, patellar height (all p> 0.05). For postoperative radiological factors, patellar height and tilt were not predictors. However, the correction of patellar tilt with quadriceps contracted (p = 0.013) and relaxed (p = 0.003) and the TT-GT distance correction (p = 0.023) were predictors of good clinical results. Discussion and Conclusion: For the MPFL ligament reconstruction, predictors of clinical improvement of the patient were patellar tilt and TT-GT distance correction at CT scan.