Physician preferences in diagnostics and treatment of juvenile osteochondritis dissecans are diverse across the knee, ankle and elbow: an ESSKA survey.

PURPOSE: To investigate the current preferences regarding the work-up and treatment choices of juvenile osteochondritis dissecans (JOCD) of the knee, ankle and elbow among orthopaedic surgeons. METHODS: An international survey was set up for all European Society of Sports Traumatology, Knee Surgery and Arthroscopy (ESSKA) members, which assessed various questions on diagnosis and treatment of JOCD of different joints. Respondents answered questions for one or more joints, based on their expertise. Proportions of answers were calculated and compared between joints. Consensus was defined as more than 75% agreement on an item; disagreement was defined as less than 25% agreement. RESULTS: Fifty physicians responded to the survey, of whom forty-two filled out the questions on the knee, fourteen on the ankle and nine on the elbow. Plain radiography and MRI were the most used imaging modalities for the assessment and follow-up of JOCD in the knee and ankle, but not for the elbow. MRI was also the preferred method to assess the stability of a lesion in the knee and ankle. There was universal agreement on activity and/or sports restriction as the non-operative treatment of choice for JOCD. Size, stability and physeal closure were the most important prognostic factors in determining the operative technique for the elbow. For the knee, these factors were size and stability and for the ankle, these were size and location. CONCLUSION: Activity and/or sports restriction was the non-operative treatment of choice. Furthermore, plain radiography and MRI were the preferred imaging modalities for the knee and ankle, but not for the elbow. For determining the operative technique, physicians agreed that the size of the lesion is an important prognostic factor in all joints. These findings help us understand how juvenile osteochondritis dissecans is treated in current practice and may provide opportunities for improvement. LEVEL OF EVIDENCE: Level V.

Magnetic Resonance Imaging compatible Elastic Loading Mechanism (MELM): A minimal footprint device for MR imaging under load.

Quantitative Magnetic Resonance Imaging (MRI) can enable early diagnosis of knee cartilage damage if imaging is performed during the application of load. Mechanical loading via ropes, pulleys and suspended weights can be obstructive and require adaptations to the patient table. In this paper, a new lightweight MRI-compatible elastic loading mechanism is introduced. The new device showed sufficient linearity (|α/ß| = 0.42 ± 0.25), reproducibility (CoV = 5 ± 2%), and stability (CoV = 0.5 ± 0.1%). In vivo and ex vivo scans confirmed the ability of the device to exert sufficient force to study the knee cartilage under loading conditions, inducing up to a 29% decrease in $T_2^{\ast}$ of the central medial cartilage. With this device mechanical loading can become more accessible for researchers and clinicians, thus facilitating the translational use of MRI biomarkers for the detection of cartilage deterioration.

Normal values for hip muscle strength and range of motion in elite, sub-elite and amateur male field hockey players.

OBJECTIVES: To determine normal values for hip strength and range of motion (ROM) of elite, sub-elite and amateur male field hockey players and to examine the effect of age, leg dominance, playing position, playing level and non-time-loss groin pain on hip strength and ROM. DESIGN: Cross-sectional study. SETTING: Physical testing took place at field hockey clubs. PARTICIPANTS: Male field hockey players competing in the three highest Dutch field hockey leagues (n = 104). MAIN OUTCOME MEASURES: Eccentric adduction, eccentric abduction, adductor squeeze strength, adduction/abduction ratio, internal rotation, external rotation and bent knee fall out (BKFO). RESULTS: Strength and ROM values (mean ± standard deviation) were: adduction = 2.8 ± 0.4 Nm/kg, abduction = 2.6 ± 0.4 Nm/kg, adduction/abduction ratio = 1.1 ± 0.2, squeeze test = 4.5 ± 0.8 N/kg, internal rotation = 34° ± 11°, external rotation = 47° ± 9°, BKFO = 15 ± 4 cm. Age, leg dominance, playing position, playing level and non-time-loss groin pain had no effect on these profiles. CONCLUSIONS: Normal values were established for hip strength and ROM of male field hockey players and showed to be independent of age, leg dominance, playing position, playing level and non-time-loss groin pain.

Non-operative treatment of peroneal tendon dislocations: A systematic review.

PURPOSE: This study evaluated the clinical outcome of non-operative treatment of peroneal tendon dislocations. METHODS: A systematic review of literature was performed. RESULTS: Six studies were included. Redislocation rates differed between treatments: taping ≥ 3 weeks; 18/30 (60%) patients. Plaster cast ≥ 4 weeks; 5/13 (32%) plaster cast ≥ 6 weeks; 1/6 (17%). Strapping or taping treatment indicated a higher rate of pain and instability and a lower rate of ability to return to former activity. CONCLUSIONS: A non-weight bearing cast ≥ 6 weeks was successful in 5/6 patients. A non-weight bearing cast might be a good alternative for surgical intervention.Level of Clinical Evidence: Level IV, systematic review of level IV studies.

A novel test for assessment of anterolateral rotatory instability of the knee: the tibial internal rotation test (TIR test).

BACKGROUND: Rotational instability of the knee may persist after anterior cruciate ligament (ACL) reconstruction, which may be due to insufficiency of anterolateral stabilizing structures. However, no reliable diagnostic tool or physical examination test is available for identifying patients with anterolateral rotatory instability (ALRI). As shown in cadaveric studies, static internal rotation of the knee is increased in higher flexion angles of the knee after severing the anterolateral structures. This might also be the case in patients with an ACL-deficient knee and concomitant damage to the anterolateral structures. The objective of this study is to assess anterolateral rotatory instability of the knee during physical examination with a tibial internal rotation test. METHODS: ACL-injured knees of 52 patients were examined by two examiners and side-to-side differences were compared. Both lower legs were internally rotated by applying manual internal rotation torque to both feet in prone position with the knees in 30°, 60° and 90° of flexion. For quantification of the amount of rotation in degrees, a torque adapter on a booth was used. Intra-rater, inter-rater and rater-device agreement were determined by calculating kappa (κ) for the tibial internal rotation test. RESULTS: Tibial internal rotation is increased in 19.2% of the patients with ACL injury according to the tibial internal rotation test. Good intra-rater agreement was found for the tibial internal rotation test, κC = 0.63 (95%CI -0.02-1.28), p = 0.015. Fair inter-rater agreement was found, κF = 0.29 (95%CI 0.02-0.57), p = 0.038. Good rater-device agreement was found, κC = 0.62 (95%CI 0.15-1.10), p = 0.001. CONCLUSION: The tibial internal rotation test shows increased tibial internal rotation in a small amount of patients with ACL injury. Even though no gold standard for assessment of increased tibial internal rotation of the knee is available yet, the test can be of additional value. It can be used for assessment of internal rotatory laxity of the knee as part of ALRI in addition to the pivot shift test. No clinical implications should yet be based on this test alone.

Rater agreement reliability of the dial test in the ACL-deficient knee.

BACKGROUND: Posterolateral rotatory instability (PLRI) of the knee can easily be missed, because attention is paid to injury of the cruciate ligaments. If left untreated this clinical instability may persist after reconstruction of the cruciate ligaments and may put the graft at risk of failure. Even though the dial test is widely used to diagnose PLRI, no validity and reliability studies of the manual dial test are yet performed in patients. This study focuses on the reliability of the manual dial test by determining the rater agreement. METHODS: Two independent examiners performed the dial test in knees of 52 patients after knee distorsion with a suspicion on ACL rupture. The dial test was performed in prone position in 30°, 60° and 90° of flexion of the knees. ≥10° side-to-side difference was considered a positive dial test. For quantification of the amount of rotation in degrees, a measuring device was used with a standardized 6 Nm force, using a digital torque adapter on a booth. The intra-rater, inter-rater and rater-device agreement were determined by calculating kappa (κ) for the dial test. RESULTS: A positive dial test was found in 21.2% and 18.0% of the patients as assessed by a blinded examiner and orthopaedic surgeon respectively. Fair inter-rater agreement was found in 30° of flexion, κF = 0.29 (95% CI: 0.01 to 0.56), p = 0.044 and 90° of flexion, κF = 0.38 (95% CI: 0.10 to 0.66), p = 0.007. Almost perfect rater-device agreement was found in 30° of flexion, κC = 0.84 (95% CI: 0.52 to 1.15), p < 0.001. Moderate rater-device agreement was found in 30° and 90° combined, κC = 0.50 (95% CI: 0.13 to 0.86), p = 0.008. No significant intra-rater agreement was found. CONCLUSIONS: Rater agreement reliability of the manual dial test is questionable. It has a fair inter-rater agreement in 30° and 90° of flexion.

Quantifying osteoarthritic cartilage changes accurately using in vivo microCT arthrography in three etiologically distinct rat models.

In vivo microCT arthrography (µCTa) can be used to measure both quantity (volumetric) and quality (glycosaminoglycan content) of cartilage. This study investigated the accuracy of four segmentation techniques to isolate cartilage from µCTa datasets and then used the most accurate one to investigate if the µCTa method could show osteoarthritic changes in rat models during longitudinal follow-up. Volumetric measurements and glycosaminoglycan contents of patellar cartilage from in vivo µCTa-scans were compared with an ex vivo gold standard µCT-scan. Cartilage was segmented with three global thresholds and one local threshold algorithm. Comparisons were made for healthy and osteoarthritic cartilage. Next, three rat models were investigated for 24 weeks using µCTa. Osteoarthritis was induced by injection with a chemical (mono-iodoacetate), a surgical intervention (grooves applied in articular cartilage), and via exercise (strenuous running). After euthanasia, all knee joints were isolated for histology. Local thresholds accurately segmented cartilage from in vivo µCTa scans and best measured cartilage quantity and glycosaminoglycan content. Each of the three osteoarthritic rat models showed a specific pattern of osteoarthritis progression. All µCTa results were comparable to histology. In vivo µCTa is a sensitive technique for imaging cartilage degradation. Local thresholds enhanced the sensitivity of this method and will probably more accurately detect disease-modulating effects from interventional strategies. The data from rat models may serve as a reference for the time sequence of cartilage degeneration during in vivo testing of new strategies in osteoarthritis treatment.

Imaging of activated macrophages in experimental osteoarthritis using folate-targeted animal single-photon-emission computed tomography/computed tomography.

OBJECTIVE: Evaluation of macrophage activation may provide essential information about the etiology and progression rate of osteoarthritis (OA). Activated macrophages abundantly express folate receptor ß (FRß), which can be targeted using radioactive-labeled folic acid. This study was undertaken to investigate whether macrophage activation can be monitored in small animal models of OA using a folate radiotracer and to determine whether macrophage activation differs in different models of OA with different OA progression. METHODS: Two rat models of OA were used: the mono-iodoacetate (MIA) model, which is a fast-progressing biochemically induced model, and the anterior cruciate ligament transection (ACLT) model, which induces OA at a slower pace. Images were obtained using high-resolution small animal single-photon-emission computed tomography/computed tomography. The specificity of the technique was tested by eradicating macrophages using clodronate-laden liposomes and blockade of FRß by cold folic acid. RESULTS: The MIA model had high initial macrophage activation, with a peak after 2 weeks which disappeared after 8 weeks. The ACLT model showed less activation but was still active 12 weeks after induction. The technique allowed monitoring of the disease process over time, in which late stages of the disease showed less macrophage activation than early stages, especially in the fast-progressing MIA model of OA. CONCLUSION: Our findings indicate that macrophage activation in experimental OA can clearly be demonstrated and monitored by the folate radiotracer. The high resolution, high sensitivity, and high specificity of the technique allow clear localization of macrophage activity in a disease model that is not known for abundant macrophage involvement.

Unfocused extracorporeal shock wave therapy as potential treatment for osteoporosis.

Extracorporeal shock wave therapy (ESWT) influences the differentiation of bone marrow stroma cells towards osteoprogenitors and increases the expression of several growth factors. To assess whether unfocused ESWT might serve as a treatment for osteoporosis, we examined the bone architecture dynamics of ESWT-treated and untreated rat tibiae using in vivo micro-computed tomography (CT) scanning. In addition, the effects of ESWT on fracture healing, using a bilateral fibula osteotomy, were examined. Unilateral unfocused ESWT with 2,000 pulses and an energy flux density of 0.16 mJ/mm(2) was applied to the hind leg of ovariectomized and sham-ovariectomized rats. A single treatment with unfocused ESWT resulted in a higher trabecular bone volume fraction (BV/TV) in the proximal tibia of the sham-ovariectomized animals. Three weeks after ESWT, BV/TV was 110% of baseline BV/TV in treated legs versus 101% in untreated contralateral control legs (p = 0.001) and 105% of baseline BV/TV versus 95% at 7 weeks after ESWT (p = 0.0004). In ovariectomized rats, shock wave treatment resulted in a diminished bone loss. At 7 weeks, the BV/TV of the treated legs was 50% of baseline BV/TV, whereas in untreated control legs this was 35% (p = 0.0004). ESWT did not influence acute fracture healing. This study shows that bone microarchitecture can be affected by unfocused shock waves, and indicates that unfocused ESWT might be useful for the treatment of osteopenia and osteoporosis.