Detection of cartilage damage in femoroacetabular impingement with standardized dGEMRIC at 3 T.

OBJECTIVE: This study aimed at identifying the optimal threshold value to detect cartilage lesions with Standardized delayed Gadolinium-Enhanced MRI of Cartilage (dGEMRIC) at 3 T and evaluate intra- and inter-observer repeatability. DESIGN: We retrospectively reviewed 20 hips in 20 patients. dGEMRIC maps were acquired at 3 T along radial imaging planes of the hip and standardized to remove the effects of patient's age, sex and diffusion of gadolinium contrast. Two observers separately evaluated 84 Standardized dGEMRIC maps, both by visual inspection and using an average index for a region of interest (ROI) in the acetabular cartilage. A radiologist evaluated the acetabular cartilage on morphologic MR images at exactly the same locations. Using intra-operative findings as reference, the optimal threshold to detect cartilage lesions with Standardized dGEMRIC was assessed and results were compared with the diagnostic performance of morphologic magnetic resonance imaging (MRI). RESULTS: Using z < -2 as threshold and visual inspection of the color-adjusted maps, sensitivity, specificity and accuracy for Observer 1 and Observer 2, were 83%, 60% and 75%, and 69%, 70% and 69%, respectively. Overall performance was 52%, 67% and 58%, when using an average z for the acetabular cartilage, compared to 37%, 90% and 56% for morphologic assessment. The kappa coefficient was 0.76 and 0.68 for intra- and inter-observer repeatability, respectively, indicating substantial agreement. CONCLUSIONS: Standardized dGEMRIC at 3 T is accurate in detecting cartilage damage and could improve preoperative assessment in femoroacetabular impingement (FAI). As cartilage lesions in FAI are localized, visual inspection of the Standardized dGEMRIC maps is more accurate than an average z for the acetabular cartilage.

Managing collateral ligament tears of the knee.

Medial collateral ligament and lateral collateral ligament (LCL) tears are common sequelae of varus or valgus knee injuries. Assessment, focusing on the physical exam, requires a high degree of suspicion for associated cruciate ligament, meniscus, and posterolateral or posteromedial corner injuries. Nonoperative treatment consisting of RICE, pain modalities, activity modification, and protection with a hinged brace is standard for most injuries. Grade 3 LCL tears usually require surgery. Functional rehabilitation begins immediately. Return to play is generally allowed when the player has regained 90% of usual strength.

The acromion-splitting approach for large and massive rotator cuff tears.

A retrospective review of 42 patients in whom a rotator cuff injury was diagnosed and who subsequently underwent surgery with the superior acromion-spitting approach technique was conducted. The average size of the tear was 4.2 cm with an average tear retraction of 4.1 cm. Thirty-seven (38 shoulders) of the 42 patients underwent a physical examination, interview, and radiographs at an average followup of 33.4 months (range, 15 to 66). Using the University of California, Los Angeles Shoulder Rating Scale, 27 shoulders were graded as excellent or good, and 11 shoulders were graded as fair or poor. Radiographic examination demonstrated bony union in 29 shoulders. The remaining 9 shoulders had evidence of fibrous union that could be characterized as clinically asymptomatic. Twenty patients had computed tomography scans that demonstrated decompression where the bony or fibrous union had occurred. In addition, some increased decompression in several patients with fibrous union indicated that the anterior acromion sought its appropriate level. Based on the results of this study, the acromion-splitting approach, used as an extension of the miniapproach for rotator cuff tears, can be successfully used when a large or massive rotator cuff tear is identified.

Arthroscopic treatment of synovial impingement of the ankle.

Twenty-nine cases of operative arthroscopy of the ankle were done between 1985 and 1989 for synovial impingement of the ankle. The average age of the patients was 37 years. All patients (17 men, 12 women) reported an earlier history of injury, with 24 of the patients (83%) noting chronic ankle pain after an inversion injury and 5 of the patients (17%) reporting a previous ankle fracture. Physical examination elicited anterolateral tenderness at the ankle in all cases with associated anteromedial pain in 4 patients. A demonstrable "click" was evident in 6 of the patients (21%) on forced dorsiflexion of the ankle. All patients failed conservative treatment including physical therapy and nonsteroidal antiinflammatory drugs. Surgery was performed at an average of 36 months postinjury. Ankle arthroscopy revealed extensive hypertrophic synovial thickening and scar tissue anterolaterally, indicating synovial impingement in all patients. Associated chondromalacia of the distal tibia was seen in 21% of the patients. Operative arthroscopy included partial synovectomy and debridement of the hypertrophic tissue and partial shaving chondroplasty of the tibia when indicated. Postoperatively, patients were weightbearing as tolerated. Results were assessed subjectively and objectively. At 25-month followup 26 patients had excellent or good results and 3 had fair results; there were no poor results. There were no major complications, including infection or neurovascular compromise. The 3 patients with associated ankle instability comprised the "fair" result group and eventually required lateral ankle reconstruction. Thus, chronic ankle pain due to synovial impingement can be safely, predictably, and effectively treated by operative ankle arthroscopy.

Intramedullary nailing of subtrochanteric fractures: a critical review of device failure and case analysis.

Although device failure in intramedullary (IM) nailing of subtrochanteric fractures is uncommon, breakage of the nail can occur. Following a review of the literature on this subject, a case is reported that illustrates the surgical and biomechanical factors that can lead to nail failure.

Type III acromioclavicular joint separation associated with late brachial-plexus neurapraxia.

We report the case of a 28-year-old woman who developed signs and symptoms of brachial-plexus neurapraxia eight years after a type III acromioclavicular (AC) joint separation. Stabilization of the AC joint resulted in resolution of the symptoms.

Closed treatment of canine nonunions by controlled compression and distraction using an Ilizarov fixator: a preliminary study.

The Ilizarov fixator was used for closed treatment of canine nonunions by controlled compression and distraction. The fibrous matrix and cartilage formed within the nonunion site transformed to osteoid and bone with increased vascularity. Healing was demonstrated by substantial bone bridging the nonunion at 6 weeks. The Ilizarov method appears to be a viable treatment for nonunions.

Injections for joint and soft tissue disorders: when and how to use them.

Joint and soft tissue injections may be the only way to differentiate various arthritic disorders, accurately identify a septic joint, and apply focused treatment. Certain considerations can make these injections safer and more effective. This article reviews the principles of diagnostic and therapeutic use of joint and soft tissue injections and makes specific recommendations for common injection sites. Also described are appropriate aseptic techniques for aspirating and injecting joints, bursae, and soft tissue, as well as the judicious use of corticosteroid injections in this age group.

Gas gangrene. A review.

Gas gangrene continues to cause significant morbidity and mortality. This monograph reviews the entire spectrum of clostridial infection, including its etiology, pathophysiology, diagnosis, current recommended treatment, and prophylaxis. The early diagnosis of gas gangrene is paramount, as delay in aggressive combined treatment may result in death.

A biomechanical study of tendon adhesion reduction using a biodegradable barrier in a rabbit model.

Adhesion formation associated with tendon surgery is a widespread problem in which a healing tendon becomes adherent via scar tissue to surrounding structures such as bone, muscle, skin, tendon sheath, or other tendons. A model is described in which adhesions were generated reproducibly between the plantaris and Achilles tendons of the rabbit using a partial tenotomy, a Bunnel suture, and immobilization. Using this model, the effect of an absorbable barrier, INTERCEED (TC7), on adhesion formation was investigated. This material, which is a fabric comprised of oxidized regenerated cellulose, was found to diminish significantly the extent and severity of intertendinous adhesions, assessed both mechanically and histologically. No evidence of a foreign body reaction was observed.

A biomechanical analysis of the sliding hip screw: the question of plate angle.

There is general agreement that the implant of choice for intertrochanteric fractures is the sliding hip screw (SHS). However, considerable differences of opinion exist as to which plate angle--varying from 130 to 150 degrees--is preferred. Thus far there has been no cadaver-based biomechanical analysis of this problem. To examine these questions, we determined the effect of plate angle on plate strain and proximal medial femoral strain distribution in cadaver femurs fixed with 130, 135, 140, 145, and 150 degrees SHS after experimentally produced stable and unstable intertrochanteric fractures. Twenty-four fresh adult cadaver femurs were assigned randomly to either the 130, 135, 140, 145, or 150 degrees SHS group. Each femur was radiographed and bone mineral density was determined by dual-photon absorptiometry. Multiple-strain gauges were affixed to the femur, with specific focus on the proximal femur and plate. Femurs were loaded at 25 degrees adduction in increments of 70 N from 0 to 1,800 N in a servohydraulic testing machine. Femurs were tested in a progressive manner: (a) intact femur; (b) intact femur with SHS inserted; (c) a stable two-part intertrochanteric fracture reduced with SHS; (d) a four-part fracture with the posteromedial fragment (PMF) reduced anatomically by a lag screw; (e) the same fracture with the PMF rotated 180 degrees and held in place by a lag screw to approximate a "near-anatomic" reduction; and (f) the same fracture with the PMF discarded. Screw sliding measurements were determined at regular intervals throughout each test.(ABSTRACT TRUNCATED AT 250 WORDS)

Arthroscopic excision of synovial hemangioma of the knee.

A synovial hemangioma in the knee joint of a 33-year old woman was diagnosed and removed arthroscopically. Preoperatively, this rare benign soft tissue lesion had caused recurrent swelling of the knee along with persistent pain and occasional buckling. Two years after surgery, the patient has a painless range of motion with no evidence of recurrence.

Bilateral posterior hip dislocations with femoral head fractures.

An unusual case of bilateral posterior fracture-dislocation of the hip (Pipkin Type IV) occurred in a 63-year-old man with Paget's disease of the pelvis. Other injuries included a displaced humeral shaft fracture and patellar ligament disruption. Bilateral cemented total hip arthroplasty was performed to avoid the need for prolonged immobilization. Postoperative low-dose irradiation was used because of the risk of heterotopic ossification.

Management of an infected total knee arthroplasty.

Infection following total knee arthroplasty can be one of the most challenging problems in orthopaedic surgery. This article discusses the pertinent clinical factors to be considered and the treatment options in the management of patients with infection following total knee replacement.