Non-operative treatment for partial ruptures of the fibular collateral ligament occurring in combination with complete ruptures of the anterolateral ligament: a common injury pattern in Brazilian Jiu-jitsu athletes presenting with acute knee injury

Background: Combined partial lateral collateral and complete anterolateral ligament (PLCCALL) injuries are a specific injury pattern seen in Brazilian Jiu-jitsu due to the knee varus/flexion mechanism that frequently occurs during grappling. Purpose: The aim of this article was to evaluate the incidence of this injury pattern in a series of Brazilian Jiu-jitsu athletes with an acute knee injury, and also to evaluate clinical and functional outcomes after non-operative management, at a minimum follow up of one year. Hypothesis: Our hypotheses were that partial lateral collateral and complete anterolateral ligament (PLCCALL) injuries are common in BJJ and that non-operative treatment is associated with excellent clinical outcomes and return to the pre-injury level of sport Study Design: Case series – cohort Methods: All Brazilian Jiu-jitsu athletes presenting with an acute knee injury between July 2013 and June 2017 who underwent MRI of the knee were included. A specific emphasis was placed on identifying those whose imaging demonstrated PLCCALL injury. Clinical evaluation included physical examination, Lysholm and International Knee Documentation Committee (IKDC) score. Results: Of the 27 patients analyzed, seven (25.9%) were identified to have MRI proven PLCCALL injuries. The mean follow-up was 41.3 months. The mean IKDC/Lysholm score pre-injury was 94.3/92, at initial assessment after injury was 26/35.6 and this improved to 82.8/78.2 at 12 months post-injury (p<0.00001). All seven patients returned to the pre-injury level of sports after one year of follow-up. The mean time between injury and return to competition level was 4.7 months (range 4-6). Conclusion: Combined partial LCL rupture and complete rupture of the ALL is a specific but infrequent injury pattern in BJJ. The prognosis of this injury following non-operative treatment appears to be excellent. Improved functional scores (IKDC and Lysholm) and MRI demonstrate that the ALL has intrinsic healing potential because the images show complete healing of the previously documented rupture of the anterolateral ligament from its proximal attachment. Clinical Relevance: The present article primarily evaluates the incidence of a specific injury pattern in a large series of Brazilian Jiu-Jitsu athletes with an acute knee injury, and also evaluates clinical and functional outcomes of these patients. The second major finding of this study is that these injuries can heal as proven by improved functional scores (IKDC e Lysholm) and subsequent MRI, how has been debate in the recent literature

Detection of maturity and ligament injury using magic angle directional imaging

Purpose: To investigate whether magnetic field–related anisotropies of collagen may be correlated with postmortem findings in animal models. Methods: Optimized scan planning and new MRI data‐processing methods were proposed and analyzed using Monte Carlo simulations. Six caprine and 10 canine knees were scanned at various orientations to the main magnetic field. Image intensities in segmented voxels were used to compute the orientation vectors of the collagen fibers. Vector field and tractography plots were computed. The Alignment Index was defined as a measure of orientation distribution. The knees were subsequently assessed by a specialist orthopedic veterinarian, who gave a pathological diagnosis after having dissected and photographed the joints. Results: Using 50% less scans than reported previously can lead to robust calculation of fiber orientations in the presence of noise, with much higher accuracy. The 6 caprine knees were found to range from very immature ( 3 years). Mature specimens exhibited significantly more aligned collagen fibers in their patella tendons compared with the immature ones. In 2 of the 10 canine knees scanned, partial cranial caudal ligament tears were identified from MRI and subsequently confirmed with encouragingly high consistency of tractography, Alignment Index, and dissection results. Conclusion: This method can be used to detect injury such as partial ligament tears, and to visualize maturity‐related changes in the collagen structure of tendons. It can provide the basis for new, noninvasive diagnostic tools in combination with new scanner configurations that allow less‐restricted field orientations

Atypical femoral fractures related to bisphosphonate treatment

Aims: Treatment guidelines for atypical femoral fractures associated with bisphosphonates have not been established. We conducted a systematic review of the treatment of atypical femoral fractures first, to evaluate the outcomes of surgical fixation of complete atypical fractures and secondly, to assess whether prophylactic surgery is necessary for incomplete atypical fractures. Materials and Methods: Case reports and series were identified from the PubMed database and were included if they described the treatment of atypical femoral fractures. In total, 77 publications met our inclusion criteria and 733 patients with 834 atypical complete or incomplete femoral fractures were identified. Results: For complete fractures, internal fixation was predominantly achieved by intramedullary nailing. The mean time to healing post-operatively was 7.3 months (2 to 31). Revision surgery for nonunion or implant failure was needed in 77 fractures (12.6%). A greater percentage of fractures treated with plate fixation (31.3%) required revision surgery than those treated with intramedullary nailing (12.9%) (p < 0.01). Non-operative treatment of incomplete fractures failed and surgery was eventually needed in nearly half of the patients (47%), whereas prophylactic surgery was successful and achieved a 97% rate of healing. Conclusion: Intramedullary nailing is the first-line treatment for a complete fracture, although the risk of delayed healing and revision surgery seems to be higher than with a typical femoral fracture. Non-operative treatment does not appear to be a reliable way of treating an incomplete fracture: prophylactic intramedullary nailing should be considered if the patient is in intractable pain. Radiographs of the opposite side should be obtained routinely looking for an asymptomatic fracture. Bisphosphonates must be discontinued but ongoing metabolic management in the form of calcium and/or vitamin D supplements is advisable. Teriparatide therapy can be considered as an alternative treatment. Cite this article: Bone Joint J 2017;99-B:295–302