Functional Anatomy of the Rear Attachment of the Deep Deltoid (RAD) Ligament of the Ankle.

The deltoid ligament plays a key role in ankle stability. Ankle fractures involving the medial ligamentous complex are evaluated on the basis of medial-sided tenderness and the Ottawa ankle rules. Evolution in our understanding of this ligament over the last three decades has shown that, within this medial ligamentous complex, it is the deep deltoid ligament that confers mechanical stability. The latest evolution in this understanding, and the learning point of this report, is that only a distinct component of the deep deltoid ligament - specifically the discreet posterior third - the rear attachment of the deep deltoid ligament (RAD) - confers mechanical value. The RAD is responsible for providing the medial ligamentous component of ankle stability - specifically talar shift, tilt, and importantly rotational stability. This knowledge is of key importance in the assessment and management of ankle fractures with associated deltoid ligament injuries. In this technical report, we highlight the biomechanical contribution of the RAD, which will help surgeons and physiotherapists to accurately manage ankle injuries.

Surgical Outcomes of Synthetic Cartilage Implant Hemiarthroplasty for Metatarsophalangeal Arthropathy.

Introduction Metatarsophalangeal joint (MTPJ) arthropathy in the great toe causes considerable pain and debilitation, severely impacting quality of life. Traditional management options included conservative measures, steroid injections, and arthrodesis. New options include Cartiva, a synthetic cartilage hemiarthroplasty for the MTPJ. This prosthesis has evidence of improved pain and function without the sacrifice of joint movement seen with arthrodesis. However, the implant itself has mixed reviews. This study aims to identify the pre-, peri, and short-term post-surgical outcomes of Cartiva surgery and review the literature for existing reported outcomes. Methods We retrospectively reviewed a cohort of 22 consecutive Cartiva procedures between 2016 and 2022 in a single UK institution. Hospital records were analyzed for peri-operative complications, implant survival, additional operative interventions, patient-reported outcomes, and functional improvement. Results Twenty-one patients underwent Cartiva for the first MTPJ pathology and one for the third MTPJ pathology. Prior to surgery, 40.9% of patients had undergone alternative therapies, including MTPJ steroid injections (seven patients), cheilectomy (four patients), and bunionectomy (one patient). Total complication rates, inclusive of medical, surgical, and implant complications were 45.5% (10/22). Total reoperation rates were 18.2% (4/22) including two revisions to arthrodesis and two manipulations under anesthesia (MUA) with local anesthetic injection. At the final follow-up, 55% were still experiencing pain, 15% neurovascular symptoms, 10% swelling, and 50% stiffness or reduced range of movement. However, 85% of patients returned to usual activities of daily living within two years. Conclusion Cartiva surgery for metatarsophalangeal arthropathy has demonstrated outcomes of persistent pain, limited range of movement, and restricted function at short-term follow-up. Rates of reoperation and revision to arthrodesis were comparable with similar studies.

Accuracy of Total Hip Arthroplasty Templating Using Set Calibration Magnifications.

Background Templating for total hip arthroplasty has been adopted over recent decades as a reliable and accurate method for pre-operative planning. The use of calibration markers for this process provides a recognised benefit at the expense of cost, availability and error. Many surgeons use a set magnification of 118% to account for calibration errors when templating total hip arthroplasty. This study aims to assess the accuracy of templating with standardised magnifications and assess the effect of BMI on templating accuracy. Materials and methods A retrospective analysis was performed using a single-surgeon series of 119 consecutive total hip arthroplasties. Anteroposterior radiographs were taken pre- or post-operatively without calibration hardware. Pre-operatively, the total hip arthroplasty was templated on TraumaCad (BrainLab Inc, Westchester, IL) using either 118% or 119% calibration magnification. Post-operative magnification was calibrated using the known femoral head diameter. Templated and implanted prostheses were compared for size. Results At 118%, 61.1% of cups matched those templated with 96.3% of cups within two sizes. At 119%, 52.5% of cups used matched their templates with 100% within two sizes. There was no significant difference between 118% and 119% cup size prediction (p=0.49). A trend was noticed in increasing magnification error with increasing BMI. However, BMI had no significant effect on the accuracy of templating cup size within two cup sizes (p=0.58). Conclusion. Templating acetabular cups using a set magnification of 118% or 119% yields accurate results and provides a reliable method to template without calibration equipment. Whilst BMI can affect magnification error, this has no significant effect on the accuracy of implanted cups and stems within two sizes.

A Rare Hoffa Fracture with Sagittal Split and Intra-articular Comminution: A Case Report and Literature Review.

Introduction: A Hoffa fracture is a rare coronal plane, intra-articular fracture of the femoral condyle involving the weight-bearing portion of the posterior distal femur. The anatomy of this fracture lends it to be an inherently unstable injury, requiring surgical fixation to achieve stability. To date, research describing Hoffa fractures is limited to small case series and case reports. This article aims to describe the first case discussion of a unique type of Hoffa fracture with a sagittal split within the fragment and intra-articular comminution. We review the etiology, management, and follow-up of this case with respect to the existing literature. Case Presentation: A 40-year-old man involved in a high-speed motorcycle collision presented with a displaced coronal plane, intra-articular fracture of the lateral femoral condyle (Hoffa fracture). Cross-sectional imaging with MRI identified a sagittal split in the Hoffa fragment and partial anterior cruciate ligament rupture. This was managed with open reduction and internal fixation (ORIF) through a lateral parapatellar approach with cannulated compression screws and a distal radius plate used in buttress mode. Postoperatively, the patient was rehabilitated with graduated increase in range of knee movement range of motion (ROM) and weight-bearing. Five months after surgery, he had regained independent motion of the knee but suffered residual stiffness, which required arthroscopic adhesiolysis. At 6-month follow-up, the patient was pain free and had resumed normal activities with knee ROM 5-90°. Conclusion: This article highlights a unique and rare subtype of Hoffa fracture not illustrated in current classifications. Management is notoriously challenging with little consensus as to the optimal approach, implants, and post-operative rehabilitation. ORIF provides the best choice for maximal post-operative knee function. In our case, a buttress plate was utilized to stabilize the sagittal fracture component. Post-operative rehabilitation may be complicated by soft-tissue and/or ligamentous injury. Choice of approach, technique, implant, and rehabilitation are dependent on fracture morphology. Close follow-up is required with strict physiotherapy to ensure sufficient long-term range of movement, patient satisfaction, and return to activity.