Morphological features of the deep component of the posterior inferior tibiofibular ligament.

PURPOSE: The deep component of the posterior inferior tibiofibular ligament (PITFL) was classified by type in this large-scale cadaveric study to provide basic information that will help elucidate the mechanisms underlying ankle joint posterior impingement syndrome. METHODS: This investigation examined 100 legs from 49 Japanese cadavers (mean age at death, 79 ± 11 years; 58 sides from men, 42 from women). In classification, absence of an independent fiber of the deep component of the PITFL were classified as Type I, an independent fiber of the deep component of the PITFL was classified as Type II-a, an independent fiber of the deep component of the PITFL with bundles of fibers connected to the posterior intermalleolar ligament (PIML) was classified as Type II-b, and an independent fiber of the deep component of PITFL with a band shape connected to the PIML was classified as Type III. RESULTS: A deep component of the PITFL was present in all specimens. An independent fiber of the deep component of the PITFL was present in 37 legs (37%), connecting to the deep component of the PITFL and PIML in 26 (70.3%). Several types of deep component of the PITFL were identified: Type I in 63 legs (63%); Type II-a in 11 (11%); Type IIb in 12 (12%); and Type III in 14 (14%). No significant differences were seen between the right and left legs. Type I male were significantly more than Type I female (p < 0.05). Type III female were significantly more than Type III male (p < 0.05). CONCLUSIONS: Strong relationships exist between the PITFL and PIML.

Isolated meniscus extrusion associated with meniscotibial ligament abnormality.

PURPOSE: The purpose of this study was to describe meniscus extrusion, present imaging characteristics, and provide clinical correlations for patients with isolated meniscus extrusion. METHODS: Of the 3244 MRI reports identified as having meniscus extrusion, 20 patients were identified to have isolated meniscus extrusion (0.62%). Patients with moderate to severe chondromalacia, meniscus tears, intra-articular fractures, tumours, and ligament tears were excluded. Radiographs were reviewed and graded using Kellgren-Lawrence (K-L) scores. MRI's were reviewed for the extent of extrusion and whether or not the meniscotibial ligament was intact. Clinical presentation and management were recorded. RESULTS: The study population consisted of 12 females and 8 males with a mean age of 40.5, diagnosed with meniscus extrusion and minimal concomitant knee pathology. 68% of patients were considered symptomatic as their knee pain correlated with the side of their meniscus extrusion and no other reason for pain was identified. The mean amount of meniscus extrusion was 2.5 mm (SD ± 1.1 mm) with 45% (9 of 20) having 3 + mm of extrusion. Meniscotibial ligament abnormality was identified in 65% of cases (13 of 20). Patients with 3 + mm of meniscus extrusion were much more likely to have associated meniscotibial ligament abnormality (100%, 9 of 9) compared to those with < 3 mm of extrusion (36%, 4 of 11) (RR 2.75, p = 0.048). The mean K-L grade obtained at the initial visit was 0.9 (95% CI 0.7-1.4) and the mean K-L grade obtained on final follow-up was 1.3 (95% CI 0.8-2.8) (n.s.) at a mean of 44.7 months. No correlation was found between K-L grade, gender, age, acute injury, and BMI in relation to meniscotibial ligament abnormality or amount of meniscal extrusion. CONCLUSIONS: Meniscus extrusion often occurs in the presence of significant knee pathology, predominantly with meniscus tears or osteoarthritis. Isolated meniscus extrusion is a rare occurrence that may present clinically with knee pain, commonly to the side in which the extrusion occurs. In patients with three or more millimetres of meniscus extrusion, an intact meniscus and minimal knee pathology, meniscotibial ligament abnormality is likely. This may provide an opportunity to treat the meniscotibial ligament abnormality with meniscus centralisation technique and decrease the amount of meniscus extrusion.

MRI appearance of the anomalous volar radiotriquetral ligament in true Madelung deformity.

OBJECTIVE: To characterize the MRI appearance of the anomalous volar radiotriquetral ligament in cases of classic Madelung deformity. MATERIALS AND METHODS: With institutional review board approval, a search of the radiology information system was performed to identify cases of potential Madelung deformity using variations of the criteria "Madelung deformity." Cases of classic Madelung deformity were included based on the following criteria: dorsal subluxation of the ulnar head, volar tilt of the distal radius, increased radial inclination of greater than 25°, triangulation of the carpus, and presence of Vickers ligament defined as an anomalous volar radiolunate ligament. Patients with a history of wrist trauma or severe degenerative change distorting anatomy were excluded. The resulting cases were reviewed to characterize the anomalous radiotriquetral ligament. RESULTS: Eight cases of classic Madelung deformity in 6 patients were identified. All 8 cases were characterized by the presence of an anomalous radiotriquetral ligament, which was more conspicuous than Vickers ligament. None of the excluded pseudo-Madelung deformity cases displayed a Vickers ligament or radiotriquetral ligament. CONCLUSION: The radiotriquetral ligament is an anomalous ligament that is a constant and distinguishing finding in classic Madelung deformity in this study. Awareness of the radiotriquetral ligament and distinguishing it from Vickers ligament on imaging studies and at surgery may have clinical implications that need to be further investigated.

Medial-sided Ankle Pain: Deltoid Ligament and Beyond.

Abnormalities of the medial ligaments and posterior tibial tendon can occur because of acute injury or chronic instability or malalignment. Medial ankle injuries may occur because of pronation or supination-external rotation injuries. Deltoid ligament injuries have a significant impact on lateral ankle instability but can be overlooked in patients with lateral ligament injuries. Posterior tibial tendon dysfunction is usually associated with spring ligament or flexor retinaculum injury. Tarsal tunnel syndrome, accessory flexor muscles, and subtalar coalition should be considered as well as ligament and tendon tears in differential diagnosis of chronic medial ankle pain.

MRI of the annular ligament of the elbow: review of anatomic considerations and pathologic findings in patients with posterolateral elbow instability.

OBJECTIVE: The annular ligament is one of the major stabilizers of the proximal radioulnar joint. However, it is one of the least studied structures in the lateral elbow because of imaging challenges and low pathologic incidence. This article will examine the anatomy of the annular ligament, its biomechanics, and its functional importance. Eight surgically proven cases of annular ligament abnormality in patients with posterolateral and nursemaid elbow, along with the associated findings, are presented. CONCLUSION: Adequate understanding of the anatomy and familiarity with the associated injuries that can be seen in annular ligament displacement or rupture will improve detection of annular ligament abnormality.

Pitfalls in shoulder MRI: part 1--normal anatomy and anatomic variants.

OBJECTIVE: The purpose of this article is to review frequently encountered pitfalls as they pertain to normal and variant anatomy of the shoulder, including the rotator cuff and rotator cable, blood vessels, glenoid labrum, and the glenohumeral ligaments. CONCLUSION: MRI is the preferred method for evaluating internal derangement of the shoulder. Radiologists interpreting MR images should have a detailed understanding of pertinent anatomy and knowledge of common and uncommon pitfalls to avoid during image interpretation.

Is the iliolumbar ligament a reliable identifier of the L5 vertebra in lumbosacral transitional anomalies?

OBJECTIVE: Sufficiently sized studies to determine the value of the iliolumbar ligament (ILL) as an identifier of the L5 vertebra in cases of a lumbosacral transitional vertebra (LSTV) are lacking. METHODS: Seventy-one of 770 patients with LSTV (case group) and 62 of 611 subjects without LSTV with confirmed L5 level were included. Two independent radiologists using coronal MR images documented the level(s) of origin of the ILL. The interobserver agreement was analysed using weighted kappa/kappa (wκ/κ) and a Fischer's exact test to assess the value of the ILL as an identifier of the L5 vertebra. RESULTS: The ILL identified the L5 vertebra by originating solely from L5 in 95 % of the controls; additional origins were observed in 5 %. In the case group, the ILL was able to identify the L5 vertebra by originating solely from L5 in 25-38 %. Partial origin from L5, including origins from other vertebra was observed in 39-59 % and no origin from L5 at all in 15-23 % (wκ = 0.69). Both readers agreed that an ILL was always present and its origin always involved the last lumbar vertebra. CONCLUSION: The level of the origin of the ILL is unreliable for identification of the L5 vertebra in the setting of an LSTV or segmentation anomalies. KEY POINTS: • The origin of the ILL is evaluated in subjects with an LSTV. • The origin of the ILL is anatomically highly variable in LSTV. • The ILL is not a reliable landmark of the L5 vertebra in LSTV.

High prevalence of anterolateral ligament abnormalities in magnetic resonance images of anterior cruciate ligament-injured knees.

The purpose of this study was to identify the newly described anterolateral ligament of the human knee on magnetic resonance imaging and to describe its eventual radiological abnormalities in anterior cruciate ligament-injured subjects. A retrospective cohort study on a series of consecutive subjects undergoing anterior cruciate ligament reconstructive surgery was performed. The MR images of 206 included knees were studied and the status of the anterolateral ligament status was judged to be either "non-visualized", "normal" or "abnormal". Of all the visualized anterolateral ligaments, 44 (21.3%) were considered uninjured, while 162 (78.8%) knees demonstrated radiological ALL abnormalities. The majority of ALL abnormalities were situated in the distal part of the ligament (77.8%). In conclusion, the anterolateral ligament can be identified on classic knee magnetic resonance images. Although anterior cruciate ligament injured subjects often demonstrated associated anterolateral ligament lesions, further research is needed in order to establish the clinical relevance of these highly frequent radiological abnormalities.

[A 15-year-old adolescent presenting both Madelung deformity with Vickers' ligament and additional palmaris profundus muscle]. / 15-jährige Heranwachsende mit symptomatischer Madelung-Deformität, Vickers-Band und M. palmaris profundus.

The palmaris profundus muscle is a rare entity which has been mentioned in association with nerve compressions. Madelung deformity is based both on an osteochondral lesion of the distal radial physis and often on the Vickers' ligament which originates around the lunate and inserts proximally in the radial physis. A 15-year-old right-handed female adolescent suffered from symptomatic left-sided Madelung deformity with Vickers' ligament and additional palmaris profundus muscle.

[Spontaneous fixation of MP-joint of the index finger in flexion]. / Spontane fixierte Blockade des Zeigefingergrundgelenks in Beugestellung.

Spontaneous fixations of MP-joints of fingers and thumbs are rare and are often a challenging task for hand surgeons. We present a 25-year-old female office employee with a fixed painless MP-joint of the left index finger in 90° flexion with normal PIP- und DIP-joint range of motion. Using the palmar approach to the MP-joint the entrapped accessory collateral ligament which was constrained by a prominent radial condylus could be identified. Operative removal of the prominence has released the joint. An uncomplicated wound healing has followed with completely unrestricted range of motion. If a closed reduction should be considered, it ought to be done cautiously without anaesthetics. A failed -reduction entails an operative revision using the palmar approach.

Prevalence of abnormalities in knees detected by MRI in adults without knee osteoarthritis: population based observational study (Framingham Osteoarthritis Study).

OBJECTIVE: To examine use of magnetic resonance imaging (MRI) of knees with no radiographic evidence of osteoarthritis to determine the prevalence of structural lesions associated with osteoarthritis and their relation to age, sex, and obesity. DESIGN: Population based observational study. SETTING: Community cohort in Framingham, MA, United States (Framingham osteoarthritis study). PARTICIPANTS: 710 people aged >50 who had no radiographic evidence of knee osteoarthritis (Kellgren-Lawrence grade 0) and who underwent MRI of the knee. MAIN OUTCOME MEASURES: Prevalence of MRI findings that are suggestive of knee osteoarthritis (osteophytes, cartilage damage, bone marrow lesions, subchondral cysts, meniscal lesions, synovitis, attrition, and ligamentous lesions) in all participants and after stratification by age, sex, body mass index (BMI), and the presence or absence of knee pain. Pain was assessed by three different questions and also by WOMAC questionnaire. RESULTS: Of the 710 participants, 393 (55%) were women, 660 (93%) were white, and 206 (29%) had knee pain in the past month. The mean age was 62.3 years and mean BMI was 27.9. Prevalence of "any abnormality" was 89% (631/710) overall. Osteophytes were the most common abnormality among all participants (74%, 524/710), followed by cartilage damage (69%, 492/710) and bone marrow lesions (52%, 371/710). The higher the age, the higher the prevalence of all types of abnormalities detectable by MRI. There were no significant differences in the prevalence of any of the features between BMI groups. The prevalence of at least one type of pathology ("any abnormality") was high in both painful (90-97%, depending on pain definition) and painless (86-88%) knees. CONCLUSIONS: MRI shows lesions in the tibiofemoral joint in most middle aged and elderly people in whom knee radiographs do not show any features of osteoarthritis, regardless of pain.

Variations in bifid superior transverse scapular ligament as a possible factor of suprascapular entrapment: an anatomical study.

PURPOSE: The suprascapular region is the most common place for suprascapular nerve entrapment. The purpose of this research was to investigate the influence of the superior transverse scapular ligament (STSL) on the reduced space for suprascapular nerve passage at the suprascapular notch. Additionally, we precisely described other structures that seem important during arthroscopic and open procedures in this region. METHODS: The study was carried out on 96 formalin-fixed cadaveric shoulders. After dissection of the suprascapular region the superior transverse scapular ligament was visualised. Measurements of the ligaments and area of the opening for the passage of the suprascapular nerve were taken using two independent methods: MultiScanBase v.14.02 software and electronic digimatic caliper. RESULTS: In three of 96 dissected shoulders (3.1 %), a bifid superior transverse scapular ligament was discovered. Morphologically, two subtypes of bifid STSL were distinguished. The first has medially separate superior and inferior bands and a common lateral attachment. In the second subtype, independent anterior and posterior parts are fixed to the lateral border of the suprascapular notch with a common medial attachment. Singular STSL in 93 of 96 shoulders was found. The mean area of the suprascapular opening in the specimens with singular STSL was larger than in the first subtype of bifid STSL and in the second subtype of bifid STSL with anterior coracoscapular ligament. CONCLUSION: Knowledge of the variations of the superior transverse scapular ligament is important for better understanding of the possible anatomical conditions that can promote suprascapular nerve entrapment. Its morphology should also be taken into particular consideration during surgical and arthroscopic procedures.

Undeveloped semiconic posterosuperior ligament and susceptibility to avulsion of the C-7 spinal nerve in Erb palsy.

OBJECT: In Erb palsy, the C-7 spinal nerve has been found to be more subject to avulsion than the C-5 and C-6 spinal nerves. This study investigated the morphological and biomechanical characteristics of the semiconic posterosuperior ligaments (SPLs) at the C-5, C-6, and C-7 spinal nerves in neonates. METHODS: Twenty-four brachial plexuses from 12 fresh neonate cadavers were used in this study. In 12 brachial plexuses from 6 cadavers, the following studies were performed with respect to the SPLs at the C-5, C-6, and C-7 spinal nerves: gross observation of morphological and histological characteristics; measurement of length, thickness, and width; and a semiquantitative analysis of collagen. In the other 6 cadavers, biomechanical tension testing was performed bilaterally on the C5-7 SPLs to assess the tensile strength of the ligaments. RESULTS: The C5-7 spinal nerves are fixed to the transverse process through the SPL, a structure not observed at the C-8 and T-1 spinal nerves. Except for the width of the SPL insertion on the spinal nerve, which was found to increase gradually from C-5 to C-7, there was no statistically significant difference in the dimensions of the C-5, C-6, and C-7 SPLs. The sectional area percentage of collagen was 51% ± 10% in SPLs for C-5, 51% ± 11% for C-6, and 41% ± 10% for C-7; and this percentage was significantly lower in SPLs for C-7 than for C-5 or C-6 (1-way ANOVA, F = 4.3, p = 0.02; Tukey honestly significant difference test, p = 0.04 and 0.04, respectively). Sharpey fibers were observed at the transverse process origin of the SPL at C-5 and C-6 but not at C-7. Biomechanical tension testing showed that the mean failure load was 6.6 ± 0.9 N for the C-5 SPL, 6.4 ± 1.0 N for the C-6 SPL, and 5.4 ± 0.9 N for the C-7 SPL, and the failure load was significantly lower in SPLs at C-7 than in those at C-5 or C-6 (1-way ANOVA, F = 5.1, p = 0.01; Tukey honestly significant difference, p = 0.01 and 0.048, respectively). Nine of 12 C-7 SPLs failed at their origin from the transverse process, while only 4 of 12 C-5 SPLs and 3 of 12 C-6 SPLs failed at the origin site. CONCLUSIONS: These findings suggest that the lower density of collagen and absence of Sharpey fibers decrease the biomechanical properties of the C-7 SPL, and this may account for the higher frequency of avulsion of the C-7 spinal nerve (in comparison with the C-5 or C-6 nerve) in Erb palsy.

Retrospective study of outcome following desmotomy of the accessory ligament of the deep digital flexor tendon for type 1 flexural deformity in Thoroughbreds.

OBJECTIVE: Determine the long-term outcome for Thoroughbreds undergoing desmotomy of the accessory ligament of the deep digital flexor tendon (DAL-DDFT) for type 1 flexural deformity of the distal interphalangeal joint (DIPJ). DESIGN: Retrospective matched cohort study PROCEDURE: Medical records were retrieved over a 17-year period for Thoroughbreds that underwent DAL-DDFT for type 1 flexural deformity. Long-term outcome was determined by analysis of race records and comparison with maternal siblings. Comparisons between cases and controls included 2-year-old, 3-year-old and total career performance data. RESULTS: There were 46 cases of DAL-DDFT. The mean age at surgery was 151 days (median 118, range 2-562); 48% of case horses and 77% of 90 controls started in a race. For case horses that did race, the time to first race, total number of starts and prize money per race were not significantly different to maternal siblings. Age at the time of surgery did not alter the likelihood of starting a race. CONCLUSION: Thoroughbreds undergoing DAL-DDFT for type 1 flexural deformity of the DIPJ are less likely to race when compared with their maternal siblings. For those that do race, the time to first race, total races and earnings per race are not different from controls. There is no evidence to suggest that age at the time of surgery influences the likelihood of racing.

Repair of SLAP lesions associated with a Buford complex: a novel surgical technique.

PURPOSE: The purpose of this study was to analyze outcomes of a novel arthroscopic repair technique for type II SLAP lesions associated with a Buford complex. METHODS: Patients selected for study enrollment had a symptomatic, isolated type II SLAP lesion and the Buford complex anatomic variant. Excluded were patients undergoing any concomitant shoulder procedure (e.g., subacromial decompression) or with any history of shoulder surgery. In addition to standard type II SLAP repair using suture anchors, the described technique also transects the cordlike middle glenohumeral ligament (MGHL) at the equator of the glenoid. This decreases postoperative stress on the repair and allows incorporation of the proximal MGHL segment for repair augmentation. The stout proximal MGHL segment is fixed to the anterosuperior glenoid rim, which is devoid of labral tissue, to enhance fixation of the SLAP repair anterior to the biceps anchor. The distal MGHL segment is left free so as to not impair external rotation. A single surgeon performed all procedures using the same surgical technique. Outcomes were assessed by University of California, Los Angeles (UCLA) and Constant shoulder scoring indexes. RESULTS: Twenty-one patients were evaluated. Both UCLA and Constant shoulder scores showed a statistically significant improvement after surgery. The mean UCLA score increased from 14.3 preoperatively to 32.1 postoperatively (P < .0001). The mean Constant score improved from 39.7 to 85.0 (P < .0001). Follow-up examination was performed at a mean of 44 months after surgery (range, 23 to 75 months). No patients had evidence of postoperative instability. CONCLUSIONS: For patients with a symptomatic type II SLAP tear and an associated Buford complex, using the proximal Buford MGHL to enhance repair and releasing the distal Buford MGHL segment resulted in significant improvement in outcomes at intermediate follow-up. LEVEL OF EVIDENCE: Level IV, therapeutic case series.

Is the location of the Wrisberg ligament related to frequent complete discoid lateral meniscus tear?

BACKGROUND: a discoid lateral meniscus is a relatively common anatomic variant in Korean and Japanese subjects that presents with snapping knee syndrome. PURPOSE: to evaluate the relationship between the location of the Wrisberg ligament and the frequency of lateral meniscus tear in patients with complete discoid lateral meniscus. MATERIAL AND METHODS: a total of 109 consecutive patients with arthroscopically proven complete discoid lateral menisci and another 100 patients with non-discoid lateral menisci were evaluated retrospectively. We reviewed the MR images to determine the attachment level of the Wrisberg ligament on the medial femoral condyle, the thickness of the Wrisberg ligament, and the presence and type of lateral meniscus tear. The relationship between the frequency of lateral meniscus tear according to the attachment level on the medial femoral condyle and the thickness of the Wrisberg ligament on both groups was analyzed. RESULTS: among them, 153 patients had Wrisberg ligament, 76 patients had complete lateral discoid menisci, and 77 patients had non-discoid lateral menisci. Lateral meniscus tears were found in 115 patients; 83 tears were in the Wrisberg ligament group (n=153) and 32 tears were in the non-Wrisberg ligament group (n =56). The presence of Wrisberg ligament alone was not significantly related to lateral meniscus tear (P=0.755). Among 83 lateral meniscus tears in the Wrisberg ligament group, 58 were identified in complete discoid lateral meniscus with high-riding Wrisberg ligament. The frequency of a lateral meniscus tear was lower in patients with low-riding Wrisberg ligament on complete discoid lateral meniscus (P = 0.020). CONCLUSION: in patients with complete discoid lateral meniscus, lateral meniscus tear is seen less often with low- than high-riding Wrisberg ligament.