Clinical and radiological hip parameters do not precede, but develop simultaneously with cam morphology: a 5-year follow-up study.

PURPOSE: The aim of this study was to (1) investigate whether radiographic and clinical parameters, which influence how stresses during sporting activities act on the proximal femur, are associated with cam morphology or (2) precede cam morphology development. METHODS: Young male football players participated at baseline (n = 89, 12-19 years of age), 2.5-year (n = 63) and 5-year follow-up (n = 49). Standardized anteroposterior pelvic and frog-leg lateral radiographs were obtained at each time-point. Cam morphology was quantified by an alpha angle ≥ 60°, and large cam morphology ≥ 78°. The neck-shaft angle (NSA), epiphyseal extension (EE), lateral center-edge angle (LCEA) and hip internal rotation (IR) were also measured. Cross-sectional associations between NSA, EE, LCEA and IR and (large) cam morphology were studied at all time-points. To study whether these variables preceded cam morphology development, hips without cam morphology at baseline were studied prospectively. RESULTS: A lower NSA, a higher EE and limited IR were consistently associated with cam morphology at all three time-points. These differences were more pronounced in hips with large cam morphology. No association between cam morphology and the LCEA was found. None of the parameters studied preceded cam morphology development. CONCLUSION: Cam morphology developed simultaneously with a varus orientation, growth plate extension towards the femoral neck and limited hip internal rotation. These parameters did not precede cam morphology development. The hip parameters studied cannot be used to identify individuals at risk of developing cam morphology. LEVEL OF EVIDENCE: Level II.

Pincer deformity does not lead to osteoarthritis of the hip whereas acetabular dysplasia does: acetabular coverage and development of osteoarthritis in a nationwide prospective cohort study (CHECK).

OBJECTIVE: Determining the relation between acetabular coverage, especially overcoverage which may lead to pincer impingement, and development of osteoarthritis (OA) of the hip. DESIGN: From a prospective cohort study of 1,002 individuals with symptoms of early OA (Cohort Hip and Cohort Knee, CHECK), 720 participants were included. Standardized anteroposterior pelvic radiographs and false profile lateral radiographs were obtained at baseline and 5 years follow-up. Acetabular undercoverage (mild dysplasia) and overcoverage (pincer deformity) were measured by a centre edge angle of <25° and >40° respectively in both radiographic views. The strength of association between those parameters at baseline and development of incident OA (Kellgren and Lawrence (K&L) grade >2 or total hip replacement), or joint space narrowing within 5 years was expressed in odds ratio (OR) adjusted for K&L grade, age, body mass index (BMI), and sex using generalized estimating equations. RESULTS: At baseline, 76% of the included hips had no signs of radiographic OA (K&L = 0) whereas 24% had doubtful OA (K&L = 1). Within 5 years, 7.0% developed incident OA. Acetabular dysplasia was significantly associated with development of incident OA with ORs between 2.62 (95% confidence interval (CI) 1.44-4.77) and 5.45 (95% CI 2.40-12.34), dependent on the radiographic view. A pincer deformity was not associated with any outcome measure, except for a significantly protective effect on incident OA when a pincer deformity was present in both radiographic views OR 0.34 (95% CI 0.13-0.87). CONCLUSION: Acetabular dysplasia was significantly associated with development of OA. However, a pincer deformity was not associated with OA, and might even have a protective effect on its development, which questions the supposed detrimental effect of pincer impingement.

Risk factors of recurrent hamstring injuries: a systematic review.

BACKGROUND: Although recurrent hamstring injury is a frequent problem with a significant impact on athletes, data on factors determining the risk for a recurrent hamstring injury are scarce. OBJECTIVE: To systematically review the literature and provide an overview of risk factors for re-injury of acute hamstring muscle injuries. STUDY DESIGN: Prospective studies on risk factors for re-injury following acute hamstring injuries were systematically reviewed. Medical databases and reference lists of the included articles were searched. Two reviewers independently selected potential studies and assessed methodological quality; one reviewer extracted the data. A best-evidence synthesis of all studied risk factors was performed. RESULTS: Of the 131 articles identified, five prospective follow-up studies fulfilled our inclusion criteria. These studies reported a recurrence incidence of 13.9-63.3% in the same playing season up to 2 years after initial injury. Limited evidence for three risk factors and one protective factor for recurrent hamstring injury was found; patients with a recurrent hamstring injury had an initial injury with a larger volume size as measured on MRI (47.03 vs 12.42 cm(3)), more often had a Grade 1 initial trauma (Grade 0: 0-30.4%; Grade 1: 60.9-100%; Grade 2: 8.7%) and more often had a previous ipsilateral anterior cruciate ligament (ACL) reconstruction (66.6% vs 17.1%) independent of graft selection. Athletes in a rehabilitation programme with agility/stabilisation exercises rather than strength/stretching exercises had a lower risk for re-injury (7.7% vs 70%). No significant relationship with re-injury was found for 11 related determinants. There was conflicting evidence that a larger cross-sectional area is a risk factor for recurrent hamstring injury. CONCLUSIONS: There is limited evidence that athletes with a larger volume size of initial trauma, a Grade 1 hamstring injury and a previous ipsilateral ACL reconstruction are at increased risk for recurrent hamstring injury. Athletes seem to be at lower risk for re-injury when following agility/stabilisation exercises.

Correlation between radiological assessment of acute ankle fractures and syndesmotic injury on MRI.

OBJECTIVE: Owing to the shortcomings of clinical examination and radiographs, injury to the syndesmotic ligaments is often misdiagnosed. When there is no indication requiring that the fractured ankle be operated on, the syndesmosis is not tested intra-operatively, and rupture of this ligamentous complex may be missed. Subsequently the patient is not treated properly leading to chronic complaints such as instability, pain, and swelling. We evaluated three fracture classification methods and radiographic measurements with respect to syndesmotic injury. MATERIALS AND METHODS: Prospectively the radiographs of 51 consecutive ankle fractures were classified according to Weber, AO-Müller, and Lauge-Hansen. Both the fracture type and additional measurements of the tibiofibular clear space (TFCS), tibiofibular overlap (TFO), medial clear space (MCS), and superior clear space (SCS) were used to assess syndesmotic injury. MRI, as standard of reference, was performed to evaluate the integrity of the distal tibiofibular syndesmosis. The sensitivity and specificity for detection of syndesmotic injury with radiography were compared to MRI. RESULTS: The Weber and AO-Müller fracture classification system, in combination with additional measurements, detected syndesmotic injury with a sensitivity of 47% and a specificity of 100%, and Lauge-Hansen with both a sensitivity and a specificity of 92%. TFCS and TFO did not correlate with syndesmotic injury, and a widened MCS did not correlate with deltoid ligament injury. CONCLUSION: Syndesmotic injury as predicted by the Lauge-Hansen fracture classification correlated well with MRI findings. With MRI the extent of syndesmotic injury and therefore fracture stage can be assessed more accurately compared to radiographs.

Ultrasonographic tissue characterisation of human Achilles tendons: quantification of tendon structure through a novel non-invasive approach.

OBJECTIVE: To assess whether three-dimensional imaging of the Achilles tendon by ultrasonographic tissue characterisation (UTC) can differentiate between symptomatic and asymptomatic tendons. DESIGN: Case-control study. SETTING: Sports Medical Department of the Hague Medical Centre. PATIENTS: Twenty-six tendons from patients with chronic midportion Achilles tendinopathy were included. The "matched" control group consisted of 26 asymptomatic tendons. INTERVENTIONS: Symptomatic and asymptomatic tendons were scanned using the UTC procedure. One researcher performed the ultrasonographic data collection. These blinded data were randomised, and outcome measures were determined by two independent observers. MAIN OUTCOME MEASUREMENTS: The raw ultrasonographic images were analysed with a custom-designed algorithm that quantifies the three-dimensional stability of echo patterns, qua intensity and distribution over contiguous transverse images. This three-dimensional stability was related to tendon structure in previous studies. UTC categorises four different echotypes that represent (I) highly stable; (II) medium stable; (III) highly variable and (IV) constantly low intensity and variable distribution. The percentages of echo-types were calculated, and the maximum tendon thickness was measured. Finally, the inter-observer reliability of UTC was determined. RESULTS: Symptomatic tendons showed less pixels in echo-types I and II than asymptomatic tendons (51.5% vs 76.6%, p<0.001), thus less three-dimensional stability of the echo pattern. The mean maximum tendon thickness was 9.2 mm in the symptomatic group and 6.8 mm in the asymptomatic group (p<0.001). The Intraclass Correlation Coefficient (ICC) for the interobserver reliability of determining the echo-types I+II was 0.95. The ICC for tendon thickness was 0.84. CONCLUSION: UTC can quantitatively evaluate tendon structure and thereby discriminate symptomatic and asymptomatic tendons. As such, UTC might be useful to monitor treatment protocols.

[Imaging techniques in sports medicine]. / Beeldvormende technieken in de sportgeneeskunde.

Sports radiology is a new radiological subspecialty. Traumatic sports-related injuries can be acute, but are more frequently caused by over-use. Close collaboration between the treating physician and radiologist optimizes the choice of the best imaging technique to confirm the tentative diagnosis and to determine the treatment plan. Conventional radiology is indicated when a bone injury is suspected. In the case of discrepancy between the x-ray findings (no abnormality) and the clinical findings (presence of symptoms) additional investigation is, however, indicated. Ultrasound is the indicated technique for lesions of superficial soft tissue, such as tendons and muscles. MRI is very valuable in both acute and over-use injuries involving bone and soft tissue.

Ten year follow-up study comparing conservative versus operative treatment of anterior cruciate ligament ruptures. A matched-pair analysis of high level athletes.

OBJECTIVE: To compare long term outcome of highly active patients with anterior cruciate ligament ruptures treated operatively versus non-operatively. DESIGN: We reviewed high level athletes with an anterior cruciate ligament rupture on either MRI or arthroscopic evaluation more than 10 years previously, who were treated conservatively. They were pair-matched with patients who had had an anterior cruciate ligament reconstruction with bone-patella-tendon-bone, with respect to age, gender and Tegner activity score before injury. PARTICIPANTS: In total 50 patients were pair-matched. RESULTS: We found no statistical difference between the patients treated conservatively or operatively with respect to osteoarthritis or meniscal lesions of the knee, as well as activity level, objective and subjective functional outcome. The patients who were treated operatively had a significantly better stability of the knee at examination. CONCLUSION: We conclude that the instability repair using a bone-patella-tendon-bone anterior cruciate ligament reconstruction is a good knee stabilising operation. Both treatment options however show similar patient outcome at 10 year follow up.

Successful endoscopic treatment of chronic groin pain in athletes.

BACKGROUND: Chronic groin pain, especially in professional sportsmen, is a difficult clinical problem. METHODS: From January 1999 to August 2005, 55 professional and semiprofessional sportsmen (53 males; mean age, 25 +/- 4.5 years; range, 17-36 years) with undiagnosed chronic groin pain were followed prospectively. All the patients underwent an endoscopic total extraperitoneal (TEP) mesh placement. RESULTS: Incipient hernia was diagnosed in the study athletes: 15 on the right side (27%), 12 on the left side (22%), and 9 bilaterally (16%). In 20 patients (36%), an inguinal hernia was found: 3 direct inguinal hernias (5%) and 17 indirect hernias (31%). All the athletes returned to their normal sports level within 3 months after the operation. CONCLUSIONS: A TEP repair must be proposed to patients with prolonged groin pain unresponsive to conservative treatment. If no clear pathology is identified, reinforcement of the wall using a mesh offers good clinical results for athletes with idiopathic groin pain.

Diagnostic value of blind synovial biopsy in clinical practice.

OBJECTIVE: To assess the diagnostic value of blindly performed synovial biopsies in carefully selected patients with unclassified arthritis. METHODS: Synovial tissue was obtained blindly under local anaesthesia. The Arthroforce III take-apart 3.5 mm needle and 1.5 mm grasping forceps were used for this purpose. RESULTS: Four patients with unclassified arthritis could be diagnosed properly based upon examination of synovial tissue of the knee obtained by an easy-to-perform blind biopsy. The arthritis of the four patients was diagnosed as being part of Erdheim-Chester disease, sarcoidosis, multicentric reticulohistiocytosis and arthritis caused by foreign-body material, respectively. CONCLUSIONS: Analysis of synovial tissue obtained during a blind biopsy procedure has diagnostic potential in carefully selected patients with unclassified arthritis. The common denominator in all the cases presented was a differential diagnosis consisting of a rheumatological disease with characteristic histological features.

[Development, physiology, and cell activity of bone]. / Ontwikkeling, fysiologie en celactiviteit van bot.

Bones are of crucial importance for the human body, providing skeletal support, serving as a home for the formation of haematopoietic cells, and reservoiring calcium and phosphate. Long bones develop by endochondral ossification. Flat bones develop by intramembranous ossification. Bone tissue contains hydroxyapatite and various extracellular proteins, producing bone matrix. Two biological mechanisms, determining the strength of bone, are modelling and remodelling. Modelling can change bone shape and size through bone formation by osteoblasts at some sites and through bone destruction by osteoclasts at other sites. Remodelling is bone turnover, also performed by osteoclasts and osteoblasts. The processes of modelling and remodelling are induced by mechanical loads, predominantly muscle loads. Osteoblasts develop from mesenchymal stem cells. Many stimulating factors are known to activate the differentiation. Mature osteoblasts synthesize bone matrix and may further differentiate into osteocytes. Osteocytes maintain structural bone integrity and allow bone to adapt to any mechanical and chemical stimulus. Osteoclasts derive from haematopoietic stem cells. A number of transcription and growth factors have been identified essential for osteoclast differentiation and function. Finally, there is a complex interaction between osteoblasts and osteoclasts. Bone destruction starts by attachment of osteoclasts to the bone surface. Following this, osteoclasts undergo specific morphological changes. The process of bone destruction starts by acid dissolution of hydroxyapatite. After that osteoclasts start to destruct the organic matrix.

[Health care in sports by a team physician, especially in soccer]. / Medische begeleiding in de sport, in het bijzonder in de voetbalsport.

The aim of health care in sports is to promote, to secure, and to recover general health of sportsmen, taking into consideration the sport's specific loads. In general, a (professional) sports club has a private (para)medical team consisting of a team physician, a physiotherapist, and an attendant or masseur. The team physician organizes the arrangements and the preventive, diagnostic, and curative tasks of the (para)medical team. In sports, sometimes medical emergencies occur, such as tongue bite, cardiac problems, hypoglycaemia in diabetes, anaphylactic shock, and hypo- as well hyperthermia. Sports injuries are caused by acute physical forces, chronic overload or repeated micro-traumas. High-incidence injuries in all sports are injuries of joints, bones, head, neck, back and abdomen. In case of medical emergencies, the team physician has to take action quickly and professionally. If sports injuries occur, the team physician has to provide first aid and to arrange a treatment and rehabilitation plan in consultation with the paramedical members of the team. During the treatment and rehabilitation, the team physician has to be of assistance to sportsmen. In arranging some of his tasks, a team physician can ask for assistance or help from a dentist or an oral and maxillofacial surgeon.

[Osteopetrosis. Classification, etiology, treatment options and implications for oral health]. / Osteopetrose. Classificatie, etiologie, behandelmogelijkheden en implicaties voor de mondgezondheid.

Bone is continuously remodelled to maintain its strength and structural integrity. Remodelling is the result of an equilibrium between bone formation performed by osteoblasts and bone resorption performed by osteoclasts. In osteopetrosis this equilibrium is disturbed by a defect in the osteoclastogenesis or by disfunction of osteoclasts. Osteopetrosis is divided into four types: malignant infantile osteopetrosis, intermediate osteopetrosis, and two types of autosomal osteopetrosis. Malignant infantile osteopetrosis is usually diagnosed within the first year of birth by bone sclerosis and bone marrow obliteration. This type is very severe and usually results in death within a few years. The intermediate type usually appears before the age of ten and leads to recurrent pathologic fractures and cranial nerve compression. Autosomal dominant osteopetrosis is usually mild and consists of two sybtypes. Type I involves marked thickening of the cranial vault. Type II patients have predominantly sclerosis of the pelvis, the vertebrae and the base of the skull. Type I and II patients may often be long-lasting asymptomatic, but will eventually present with pathologic fractures, bone pain, and the effects of cranial nerve compression. Oral problems of osteopetrosis are delayed tooth eruption, absence of some teeth, malformed teeth, enamel hypoplasia, disturbed dentinogenesis, hypomineralisation of enamel and dentin, propensity for tooth decay, defects of the periodontal membrane, thickened lamina dura, mandibular protrusion, and the presence of odontomas. Tooth removal should be limited as it may induce bone fractures and osteomyelitis.

Medial instability of the elbow: findings on valgus load radiography and MRI in 16 athletes.

Medial discomfort of the elbow in athletes can be due to valgus instability after acute ligament rupture or attenuation of the medial collateral ligament caused by repetitive microtrauma during overhead throwing. We studied 16 athletes with medial instability of the elbow due to insufficiency of the medial collateral ligament. 4 patients had sensory ulnar nerve symptoms, of whom 2 had abnormalities of the ulnar nerve on electromyography. 13 showed an increase in the ulno-humeral joint space on dynamic radiography under valgus load. MRI of 10 of these 13 elbows revealed rupture of the medial collateral ligament or avulsion of the medial collateral ligament. Dynamic radiography under valgus load seems to be of value for the diagnosis of chronic medial collateral ligament insufficiency.

[One hundred years of orthopedics in the Netherlands. X. Sports injuries]. / Honderd jaar orthopedie in Nederland. X. Sportletsel.

Sports injuries result from frequently repeated similar movements performed with submaximal force. In practice the term is also used, incorrectly, for many other injuries sustained during, or even outside, the practising of sports. Running may lead to injuries of muscles (rupture, chronic compartment syndrome), of tendons (peritendinitis, tendinosis, partial rupture, insertion tendinitis), of bone (stress fracture) and of cartilage (athrosis). Jumping mostly puts the ankle at risk, especially of development of an anterior or posterior impingement syndrome. Throwing puts much strain on the shoulder muscles; possible problems are microruptures in the rotator cuff, avulsion of the glenoid rim, chronic tendinitis of the biceps tendon and entrapment of the suprascapular nerve. The main element of the treatment is rest. If symptoms persist, surgery may be considered. Previous diagnostic imaging may then be of value.

Gastric diverticula.

The cases of three patients with a gastric diverticulum are described and the symptoms, diagnosis and treatment are reviewed.