Diagnosis of glenoid labral tears using 3-tesla MRI vs. 3-tesla MRA: a systematic review and meta-analysis.

BACKGROUND: Various protocols exist for magnetic resonance arthrogram (MRA) of the shoulder, including 3D isotropic scanning and positioning in neutral (2D neutral MRA), or abduction-external-rotation (ABER). HYPOTHESIS: MRA does not improve diagnostic accuracy for labral tears when compared to magnetic resonance imaging (MRI) performed using 3-Tesla (3T) magnets. METHOD: Systematic review of the Cochrane, MEDLINE, and PubMed databases according to PRISMA guidelines. Included studies compared 3T MRI or 3T MRA (index tests) to arthroscopic findings (reference test). Methodological appraisal performed using QUADAS-2. Pooled sensitivity and specificity were calculated. RESULTS: Ten studies including 929 patients were included. Index test bias and applicability were a concern in the majority of studies. The use of arthroscopy as the reference test raised concern of verification bias in all studies. For anterior labral lesions, 3T MRI was less sensitive (0.83 vs. 0.87 p = 0.083) than 3T 2D neutral MRA. Compared to 3T 2D neutral MRA, both 3T 3D Isotropic MRA and 3T ABER MRA significantly improved sensitivity (0.87 vs. 0.95 vs. 0.94). For SLAP lesions, 3T 2D neutral MRA was of similar sensitivity to 3T MRI (0.84 vs. 0.83, p = 0.575), but less specific (0.99 vs. 0.92 p < 0.0001). For posterior labral lesions, 3T 2D neutral MRA had greater sensitivity than 3T 3D Isotropic MRA and 3T MRI (0.90 vs. 0.83 vs. 0.83). CONCLUSIONS: At 3-T, MRA improved sensitivity for diagnosis of anterior and posterior labral lesions, but reduced specificity in diagnosis of SLAP tears. 3T MRA with ABER positioning further improved sensitivity in diagnosis of anterior labral tears. LEVEL OF EVIDENCE: IV.

Biomechanical properties of bovine tendon xenografts treated with a modern processing method.

Xenograft tendons have been used in few human studies, with variable results. With the advent of novel tissue processing techniques, which may mitigate against an immune-mediated rejection response without adversely affecting mechanical properties, there may now be a clinical role for xenograft tendons, particularly in knee ligament reconstruction. We hypothesize that 'BioCleanse®' processed bovine extensor digitorum medialis (EDM) tendons exhibit favorable time-zero pre-implantation biomechanical characteristics when compared to both unprocessed bovine EDM tendons and BioCleanse® processed human cadaveric allograft tibialis anterior tendons. In this in vitro case controlled laboratory study, three groups of tendons underwent a 5-stage static loading test protocol: 15 BioCleanse® bovine (BCB), 15 fresh frozen unprocessed bovine (FFB), and 12 BioCleanse® human allograft (BCA) tendons. Cross-sectional area of the grafts was measured using an alginate molding technique, and tendons were mounted within an Instron® 5565 Materials Testing System using cryogenic clamps. BCB tendons displayed a higher ultimate tensile stress (p<0.05), with equivalent ultimate failure load, creep, and modulus of elasticity when compared to the FFB tendons (p>0.05). BCB tendons had an equivalent cross-sectional area to the BCA tendons (p>0.05) whilst exhibiting a greater failure load, ultimate tensile stress, less creep and a higher modulus of elasticity (p<0.05). The BioCleanse® process did not adversely affect the time-zero biomechanical properties of bovine xenograft EDM tendons. BioCleanse® processed bovine xenograft EDM tendons exhibited superior biomechanical characteristics when compared with BioCleanse® processed allograft tibialis anterior tendons. These findings support further investigation of xenograft tendons in orthopedic soft tissue reconstructive surgery.

Diagnostic Efficacy of 3-T MRI for Knee Injuries Using Arthroscopy as a Reference Standard: A Meta-Analysis.

OBJECTIVE: The objectives of our study were to assess the evidence for the diagnostic efficacy of 3-T MRI for meniscal and anterior cruciate ligament (ACL) injuries in the knee using arthroscopy as the reference standard and to compare these results with the results of a previous meta-analysis assessing 1.5-T MRI. MATERIALS AND METHODS: The online Cochrane Library, MEDLINE, and PubMed databases were searched using the following terms: MRI AND ((3 OR three) AND (Tesla OR T)) AND knee AND arthroscopy AND (menisc* OR ligament). Patient demographics, patient characteristics, MRI scanning details, and diagnostic results were investigated. The methodologic quality of the included studies was assessed using the revised Quality Assessment of Diagnostic Accuracy Studies (QUADAS-2) tool. A meta-analysis of studies using 3-T MRI was performed, and the results were compared with a previous meta-analysis of studies using 1.5-T MRI. RESULTS: One hundred one studies were identified by the search strategy, and 13 studies were included in our review. Twelve studies were considered to have level 1b evidence, and one study was considered to have level 2b evidence. All 13 studies had high methodologic integrity and low risk of bias using the QUADAS-2 tool. The studies included 1197 patients with a mean age of 41.9 years. Ten of the 13 studies were eligible for meta-analysis. The mean sensitivity and mean specificity of 3-T MRI for knee injuries by location were as follows: medial meniscus, 0.94 (95% CI, 0.91-0.96) and 0.79 (95% CI, 0.75-0.83), respectively; lateral meniscus, 0.81 (95% CI, 0.75-0.85) and 0.87 (95% CI, 0.84-0.89); and ACL, 0.92 (95% CI, 0.83-0.96) and 0.99 (95% CI, 0.96-1.00). The specificity of 3-T MRI for injuries of the lateral meniscus was significantly lower than that of 1.5-T MRI (p = 0.0013). CONCLUSION: This study does not provide evidence that 3-T scanners have superior diagnostic efficacy for meniscal damage and ACL integrity when compared with previous studies of 1.5-T machines.

Functional outcomes of total hip arthroplasty in patients aged 30 years or less: a systematic review and meta-analysis.

INTRODUCTION: Young adult hip surgery is a growing subspecialty. Increasingly total hip arthroplasty (THA) is offered to patients aged 30 or less suffering from end-stage hip arthropathy from a variety of congenital, developmental and acquired conditions. There is a paucity of evidence to advise such patients and surgeons alike on the functional outcomes of THA in this age group, as individual studies tend to include small cohorts. METHODS: A systematic review and meta-analysis was performed to assess whether THA in patients aged 30 years or less provides significant functional improvement. The primary outcome measure was change in Harris Hip Score. Secondary outcome measures were implant survivorship and the effect of fixation type and bearing surface. RESULTS: The results of 743 primary THA procedures were included. Weighted mean patient age was 22.7 years. Harris Hip Score improved by a weighted mean difference of 42.17 points out of 100 (95% confidence interval, 36.48-47.86 points, p<0.001) after THA at a weighted mean follow-up of 8.4 years. Pooled revision rate was 5.0% for the same time period. CONCLUSIONS: This is the largest review to date of THA in patients aged 30 or less. The results show significant functional improvement measured by Harris Hip Score. The revision rate of 5% at 8.4 years is comparable to the general THA population. This contrasts high revision rates reported in older reviews of the literature, suggesting adoption of improved techniques and implants in the more recent literature.

Diagnosis of rotator cuff tears using 3-Tesla MRI versus 3-Tesla MRA: a systematic review and meta-analysis.

OBJECTIVE: To compare the diagnostic accuracy of magnetic resonance imaging (MRI), 2-dimensional magnetic resonance arthrogram (MRA) and 3-dimensional isotropic MRA in the diagnosis of rotator cuff tears when performed exclusively at 3-T. MATERIALS AND METHODS: A systematic review was undertaken of the Cochrane, MEDLINE and PubMed databases in accordance with the PRISMA guidelines. Studies comparing 3-T MRI or 3-T MRA (index tests) to arthroscopic surgical findings (reference test) were included. Methodological appraisal was performed using QUADAS 2. Pooled sensitivity and specificity were calculated and summary receiver-operating curves generated. Kappa coefficients quantified inter-observer reliability. RESULTS: Fourteen studies comprising 1332 patients were identified for inclusion. Twelve studies were retrospective and there were concerns regarding index test bias and applicability in nine and six studies respectively. Reference test bias was a concern in all studies. Both 3-T MRI and 3-T MRA showed similar excellent diagnostic accuracy for full-thickness supraspinatus tears. Concerning partial-thickness supraspinatus tears, 3-T 2D MRA was significantly more sensitive (86.6 vs. 80.5 %, p = 0.014) but significantly less specific (95.2 vs. 100 %, p < 0.001). There was a trend towards greater accuracy in the diagnosis of subscapularis tears with 3-T MRA. Three-Tesla 3D isotropic MRA showed similar accuracy to 3-T conventional 2D MRA. CONCLUSION: Three-Tesla MRI appeared equivalent to 3-T MRA in the diagnosis of full- and partial-thickness tears, although there was a trend towards greater accuracy in the diagnosis of subscapularis tears with 3-T MRA. Three-Tesla 3D isotropic MRA appears equivalent to 3-T 2D MRA for all types of tears.

The use of the ligament augmentation and reconstruction system (LARS) for posterior cruciate reconstruction.

PURPOSE: To systematically review and assess the use of the Ligament Advanced Reinforcement System (LARS; Surgical Implants and Devices, Arc-sur-Tille, France) for posterior cruciate ligament (PCL) reconstruction. METHODS: A search of multiple databases was conducted using the following terms: (LARS[All Fields] AND posterior[All Fields]) OR (LARS[All Fields] AND PCL[All Fields]). The methodologic quality of each article was assessed by use of abridged Downs and Black criteria. RESULTS: Fifty-four studies were found from the database search, of which 5 were included in the final review (4 case series and 1 case-control study). One hundred twenty-nine PCL reconstructions with LARS were performed. The mean patient age was 32.2 years, with 89 male and 40 female patients included. The mean follow-up time ranged from 10.5 to 44 months. Lysholm scores improved from a mean of 64.8 preoperatively to 89.8 postoperatively. No patients had International Knee Documentation Committee grade 1 or 2 preoperatively, with 93.0% achieving this postoperatively. Only 1 case of synovitis and 1 case of graft rupture were reported. CONCLUSIONS: There is little evidence on the effectiveness of PCL reconstructions using LARS ligaments. What data there are show great promise, with short- and medium-term outcome data appearing favorable to autograft reconstruction. Complication rates are encouragingly low. CLINICAL RELEVANCE: LARS has great potential for PCL reconstruction. Further studies are needed regarding the use of LARS ligaments during PCL reconstruction, including longer follow-up periods and investigation into the optimal timing for reconstruction. This may be best achieved by way of a multicenter study.

Anterior cruciate ligament injury and radiologic progression of knee osteoarthritis: a systematic review and meta-analysis.

BACKGROUND: Knee osteoarthritis after anterior cruciate ligament (ACL) injury has previously been reported. However, there has been no meta-analysis reporting the development and progression of osteoarthritis. PURPOSE: We present the first meta-analysis reporting on the development and progression of osteoarthritis after ACL injury at a minimum mean follow-up of 10 years, using a single and widely accepted radiologic classification, the Kellgren & Lawrence classification. STUDY DESIGN: Meta-analysis. METHOD: Articles were included for systematic review if they reported radiologic findings of ACL-injured knees and controls using the Kellgren & Lawrence classification at a minimum mean follow-up period of 10 years. Appropriate studies were then included for meta-analysis. RESULTS: Nine studies were included for systematic review, of which 6 studies were further included for meta-analysis. One hundred twenty-one of 596 (20.3%) ACL-injured knees had moderate or severe radiologic changes (Kellgren & Lawrence grade III or IV) compared with 23 of 465 (4.9%) uninjured ACL-intact contralateral knees. After ACL injury, irrespective of whether the patients were treated operatively or nonoperatively, the relative risk (RR) of developing even minimal osteoarthritis was 3.89 (P < .00001), while the RR of developing moderate to severe osteoarthritis (grade III and IV) was 3.84 (P < .0004). Nonoperatively treated ACL-injured knees had significantly higher RR (RR, 4.98; P < .00001) of developing any grade of osteoarthritis compared with those treated with reconstructive surgery (RR, 3.62; P < .00001). Investigation of progression to moderate or severe osteoarthritis (grade III or IV only) after 10 years showed that ACL-reconstructed knees had a significantly higher RR (RR, 4.71; P < .00001) compared with nonoperative management (RR, 2.41; P = .54). It was not possible to stratify for return to sports among the patients undergoing ACL reconstruction. CONCLUSION: Results support the proposition that ACL injury predisposes knees to osteoarthritis, while ACL reconstruction surgery has a role in reducing the risk of developing degenerative changes at 10 years. However, returning to sports activities after ligament reconstruction may exacerbate the development of arthritis.

Systematic review of total hip arthroplasty in patients under 30 years old.

We performed a systematic review to assess whether joint replacement in this very young patient group provides significant functional improvement and whether these procedures are associated with good implant survivorship. The studies included presented the results of 450 THA procedures. All patients showed an improvement in functional score and symptom relief. Uncemented stems showed good integration with no signs of loosening. Cemented implants showed high rates of loosening. This study shows that THA in the very young patient can provide good functional improvement and relief of symptoms and that the more modern uncemented implant designs used with hard-on-hard bearings can be associated with improved implant survival. Long-term studies are necessary to confirm the superiority and improved survivorship of these newer implants.

Publication trends in knee surgery: a review of the last 16 years.

The trends in the publication of articles regarding knee arthroplasty and soft tissue surgery were analysed with regard to geographical authorship, institutional funding and number of authors. Over 7500 articles from relevant journals with the highest impact factors according to the Thomson Reuters Journal Citation Report (2010) were evaluated from 1995 to 2010. The rate of publication increased by 16.9 per year for arthroplasty articles and by 13.9 per year for soft tissue surgery articles. The relative supremacy of the USA has declined over the 16 years, its share dropping from 72.2% to 39.2% for arthroplasty articles and from 61.7% to 36.6% for soft tissue surgery articles. The UK, Japan, South Korea and smaller countries in Asia and South America have become increasingly prolific.