Reliability of new radiographic measurement techniques for elbow bony impingement.

BACKGROUND: Identifying the location and scale of radiographic changes in elbow bony impingement (EBI) is critical in formulating an appropriate diagnosis and treatment plan for such patients. The purpose of present study was to evaluate the intra-rater and inter-rater reliability of the new radiographic parameters, Anterior Impingement angle (AIa) and Posterior Impingement angle (PIa), for EBI. In addition, to determine if there was a relationship between radiographic parameters and clinical evaluation. PATIENTS AND METHODS: Three raters of different levels of training evaluated the radiographs of 60 patients (30 in EBI group and 30 in normal group) twice, at least 2 weeks apart. Intra-rater and inter-rater reliabilities were calculated by Intraclass Correlation Coefficients (ICC) with 95% confidence intervals. Correlation between radiographic parameters and clinical evaluation was calculated by Pearson correlation coefficient. RESULTS: In both groups, intra-rater and inter-rater reliabilities were substantial. There were no significant differences in reliability between upper-hand expert surgeons and resident for either measurement. Good correlation was observed between impingement arcs and range of motion values. CONCLUSIONS: Both AIa and PIa measurements demonstrated substantial intra-rater and inter-rater reliability for normal radiographs and in EBI patients. Good reliability, for either expert surgeons or residents in training, and good correlation between radiographic measurements and manual testing, appoints this method may be easily and reliably used in every day practice.

MRI Findings of Early Osteoarthritis in Patients Who Sustained Septic Arthritis of the Knee After ACL Reconstruction.

BACKGROUND: Although a rare complication, septic arthritis (SA) after anterior cruciate ligament (ACL) reconstruction has potentially devastating consequences for the knee joint. PURPOSE: To prospectively analyze, at a mean 4-year follow-up, subjective, clinical, radiographic, and magnetic resonance imaging (MRI) findings between patients with SA and those with no septic complication after ACL reconstruction. STUDY DESIGN: Cohort study; Level of evidence, 2. METHODS: Of 2006 ACL reconstructions performed between 2004 and 2014, a total of 20 patients experienced SA. All patients were treated with arthroscopic irrigation and graft-retaining debridement immediately after diagnosis and at least 6 weeks of antibiotic treatment. After the exclusion process, 18 patients were included in the SA group and 20 in the control group. At final follow-up at a mean 48 months, a physical examination, KT-1000 arthrometer laxity test, Lysholm knee score, Tegner activity score, and International Knee Documentation Committee radiographic score were completed and then compared with preoperative data. The Boston-Leeds Osteoarthritis Knee Score was used for MRI evaluation at final follow-up to note chondral changes. RESULTS: No significant differences between the SA and control groups were observed in pre- and perioperative variables that could indicate a higher incidence of early osteoarthritis (OA). Although range of motion and knee stability were not significantly different between the groups at final follow-up, the Lysholm score (mean ± SD, 79.8 ± 13.1 vs 90.9 ± 8.6; P < .01) and Tegner score (6.0 ± 1.1 vs 7.0 ± 1.4; P = .03) were significantly lower in the SA group as compared with the control group. MRI evaluation at final follow-up demonstrated a significantly higher degree of early knee OA in the SA group versus the control group. However, no differences in the degree of OA were seen on plain radiographs at final follow-up between the groups. CONCLUSION: MRI evaluation provided signs of worsened chondral state in the SA group, which could be associated with reduced functional outcome and return to sports. In contrast to radiograph analyses, MRI was excellent at distinguishing damage to the cartilage and can be useful in early follow-up evaluation of patients with SA after ACL reconstruction.

Assessment of coxarthritis risk with dimensionless biomechanical parameters.

PURPOSE: Unfavourable distribution of contact stress over the load bearing area is considered a risk factor for early coxarthritis and it is of interest to outline respective biomechanical parameters for its prediction. The purpose of the work was to develop a transparent mathematical model which can be used to assess contact stress in the hip from imaged structures of pelvis and proximal femora, in large population studies and in clinical practice. METHODS: We upgraded a previously validated three-dimensional mathematical model of the human hip in the one-legged stance HIPSTRESS by introducing parameters independent from the size of the structures in the images. We validated a new parameter - dimensionless peak stress normalized by the body weight and by the radius of the femoral head (pmaxr²/WB) on the population of 172 hips that were in the childhood subjected to the Perthes disease and exhibited increased proportion of dysplastic hips. RESULTS: The dimensionless parameter pmaxr²/WB exhibited smaller number of indecisive cases of hip dysplasia predicted by the model than the previously used parameter pmax/WB (6% vs. 81%, respectively). A threshold for an increased risk of early coxarthritis development by the HIPSTRESS parameter H = pmaxr²/WB was found to be 2. CONCLUSIONS: We proposed a dimensionless peak stress on the load bearing area with the border value of 2 as a decisive parameter over which hips are at risk for early development of degenerative processes and presented a method for determination of biomechanical parameters with the use of nomogram.

Polyetheretherketone (PEEK) cages for anterior column reconstruction in pyogenic vertebral osteomyelitis.

The objective of study was to evaluate a case series of patients in whom polyetheretherketone (PEEK) cages were used for anterior column reconstruction in vertebral osteomyelitis. Fifteen patients underwent clinical and radiological evaluation with average follow-up of 26 months. Parameters assessed were time of surgery, blood loss, segmental kyphosis or lordosis angle, time to solid bony fusion, ambulatory status, and functional outcome. Mean time of surgery was 150 min with mean blood loss of 530 ml. One patient died in early postoperative period. All patients without preoperative neurologic deficit were walking unaided first day postoperatively. Solid bony fusion was demonstrated in 14 patients, on average 7.1 months postoperatively. Functional outcome at the latest follow-up was excellent, good, or fair in 86%. Two failures with recurrent infection were treated with PEEK cage removal and reinstrumentation. High success rate could be expected when PEEK cages are used for anterior column support in pyogenic vertebral osteomyelitis.

Arthroscopic removal of osteoid osteoma with gamma probe assistance in the hip joint.

AIM: The aim was to present the surgical technique and clinical outcome in a series of patients treated with gamma-probe-assisted arthroscopic removal of osteoid osteoma in the hip joint. METHODS: The case series consisted of 10 patients diagnosed with osteoid osteoma of the hip, who were treated by arthroscopic nidus removal. An endoscopic gamma probe was used intraoperatively to locate the nidus and to control the extent of its removal. Residual osteoma cavities were additionally treated with an arthroscopic radiofrequency ablator. Microfracturing was performed when the osteochondral defect was in the weight-bearing area and osteochondroplasty was done in cases of concomitant cam deformity. Nonarthritic Hip Score (NAHS), Tegner activity score, quality of life questionnaire (EQ-5D) and postoperative magnetic resonance imaging (MRI) were used for evaluation before and post-surgery, with a minimum follow-up of 2 years. RESULTS: The relative reduction of the gamma irradiation count immediately after removal of the nidus was 44.9% (range 33.3-54.5%). Postoperatively, all patients experienced prompt pain relief and a significant improvement according to all patient reported outcomes. Control MRI revealed fibro-cartilaginous tissue repair of post-osteoma osteochondral defects in the weight-bearing area; 1 patient showed signs of early degeneration. CONCLUSIONS: The results of this case series demonstrated the safety and high efficacy of gamma-probe-assisted arthroscopic removal of the osteoid osteoma from the hip joint. Endoscopic gamma probe was recognised as a very useful device for locating the nidus of the osteoid osteoma exactly and preventing incomplete or excessive removal of the bone.

A descriptive study of potential effect of anterior tibial translation, femoral tunnel and anterior cruciate ligament graft inclination on clinical outcome and degenerative changes.

INTRODUCTION: There is no evidence that anatomically correct anterior cruciate ligament reconstruction (ACLR) offers lower rate of degenerative changes development or that it would lead to a better outcome. The significance and understanding of the abnormal anterior tibial translation (ATT) in ACLR patients is yet to be established. METHODS: Sixty subjects (40 patients at 5.9 years after ACLR, 20 healthy controls) underwent 3 T MRI. Quantitative cartilage T2 mapping and morphological whole organ magnetic resonance imaging score (WORMS) evaluation was performed. Self-reported questionnaires were used for subjective clinical evaluation. Correlations were calculated with the following MRI measurements; femoral tunnel inclination, ACL graft inclination, lateral and medial compartment ATT. RESULTS: In the ACLR group positive correlation was found between the patellar cartilage T2 values and sagittal ACL graft inclination. In the ACLR group lateral compartment ATT showed negative correlation with ACL graft inclination and subjective clinical evaluation, and positive correlation with morphological degenerative changes. Femoral tunnel showed positive correlation with ACL graft inclination in the same plane. CONCLUSIONS: Increased ATT offers worse clinical outcome and increased rate of degenerative changes. Furthermore, ATT is affected by the ACL inclination. Inclination of the drilling tunnel affects ACL graft inclination; thereby independent drilling techniques provide superior results of anatomical ACL graft positioning.

Retrospective quantitative cartilage and semi-quantitative morphological evaluation at 6 years after ACL reconstruction.

UNLABELLED: Purpose We analyzed anterior cruciate ligament reconstruction (ACLR) patients in order to evaluate degenerative changes and the effect of meniscal insufficiency at mid-term follow-up. METHODS: Sixty subjects (40 patients at 5.9 years after ACLR, 20 healthy controls) underwent 3T MRI. Quantitative cartilage T2 mapping and morphological Whole Organ Magnetic Resonance Imaging Score (WORMS) evaluation were performed. Self-reported questionnaires were used for subjective clinical evaluation. Based on the meniscal status at ACLR, further subdivision within each compartment (lateral and medial) was made: menisci intact and menisci insufficient. RESULTS: The ACLR subjects showed significantly elevated T2 values and higher WORMS scores compared to the control group. T2 values of the anterior lateral femoral subcompartment were significantly higher in menisci insufficient group compared to the control group. In both compartments significantly higher WORMS scores were observed in the menisci insufficient group compared to the menisci intact group. CONCLUSIONS: ACLR knees exhibit cartilage matrix and morphological degeneration at mid-term follow-up. Lateral meniscal insufficiency noted at ACLR presents a higher risk of developing degenerative changes than does the medial meniscus insufficiency; however, this difference may not be detected clinically.

Intraarticular nodular fasciitis of the hip.

Intraarticular nodular fasciitis is a rare lesion that has only recently been recognised. We present a case of intraarticular nodular fasciitis of the hip joint in a 25-year-old woman, who presented with a 9-month-history of right groin pain and a decreased range of right hip motion. A polypoid mass, composed of five nodules attached to the synovial membrane of the distal peripheral compartment of the hip was removed arthroscopically, together with two detached nodules. Histopathological examination revealed a myofibroblastic proliferation typical of nodular fasciitis. Complete resolution of symptoms and restoration of function was achieved, without recurrence 2 years after removal of the lesion. To the best of our knowledge, this is the first case of intraarticular nodular fasciitis of the hip, presenting a new indication for arthroscopic treatment.

Shear stress in epiphyseal growth plate is a risk factor for slipped capital femoral epiphysis.

BACKGROUND: Slipping of the capital femoral epiphysis is an important orthopaedic problem of early adolescence. Many hypotheses about its etiology have been examined, yet the underlying mechanisms have not yet been fully elucidated. We examined elevated shear stress in the epiphyseal growth plate and elevated contact hip stress exerted on the femoral head as risk factors for slipping of the capital femoral epiphysis. METHODS: Two groups of hips were compared: a group of 100 hips contralateral to the slipped ones and a group of 70 age- and gender-matched healthy hips. The characteristics of individual hips were incorporated by means of geometrical parameters determined from standard anteroposterior radiographs. Shear stress was calculated by using a mathematical model where the femoral neck was considered to function as an elastic rod. Contact hip stress was calculated by the HIPSTRESS method. RESULTS: Hips contralateral to the slipped ones had higher average shear stress (0.81 vs 0.51 MPa; P < 0.001) and more vertically inclined physeal angle (55.4 vs 63.2 degrees.; P < 0.001) in comparison to healthy hips. Shear stress in the contralateral hips to the slipped ones remained significantly higher even when normalized to the body weight (1400 vs 1060 Pa/N; P < 0.001). There was no significant difference in the average contact hip stress (1.86 vs 1.74 MPa; P = 0.145). CONCLUSIONS: Elevated shear stress, but not elevated contact stress, is a risk factor for slipping of the capital femoral epiphysis. LEVEL OF EVIDENCE: III (prognostic study, case-control study).

Arthroscopic treatment of knee joint injury for intraarticular mercury from a broken thermometer.

INTRODUCTION: Intraarticular injection of metallic mercury (Hg) such as those found in thermometers is very rare. According to available data in literature, an arthroscopic presentation and treatment of knee injury that had intraarticular elementary mercury seems not to have been published yet. MATERIAL AND METHODS: We report a first case of arthroscopically treated chronic right knee synovitis after accidental intraarticular mercury infusion by a broken thermometer in an 11-year-old boy. RESULT: Mercury levels in blood and urine were slightly increased, but no systemic mercury intoxication developed. Inflamed synovia as well as synovia with incorporated metal particles was excised. A histological analysis of macroscopically inflamed synovia revealed an unspecific inflammation reaction. The symptoms gradually subsided and the knee regained full function. However, all the metal particles were not successfully removed from the injured knee; therefore a careful follow-up of the patient was provided. CONCLUSION: It seems that arthroscopic excision and lavage could be suitable treatments for knee injury, infused with elementary mercury, and toxic knee synovitis.

Arthroscopic removal of juxtaarticular osteoid osteoma of the elbow.

A case of a 42-year-old male patient with symptomatic juxtaarticular osteoid osteoma of the capitulum humeri is presented. After the clinical diagnosis was confirmed with plain radiographs, bone scan, computer tomography and magnetic resonance imaging, the patient underwent arthroscopic removal of the lesion. A partial synoviectomy was performed first and then the center of the lesion was marked with Kirschner wire using the X-ray monitoring. The marked lesion was transarticularly removed with a motorized shaver device. Post-operatively, the patient reported prompt relief of pain that had not reoccurred during 1 year of follow up. To the authors' knowledge, this is the first report of the arthroscopic removal of juxtaarticular osteoid osteoma of the humeral capitulum which promises to be an effective and less invasive alternative to the existing treatment options.

The effect of proprioceptive training in patients with recurrent dislocation of the patella.

Eleven patients with recurrent dislocation of the patella were subjected to knee proprioceptive training. Patients exhibited a gain in their Lysholm and Activity scores (p 0.03 and 0.009). No patient needed operative procedure.

Biochemical aspects of Salter's osteotomy for treatment of acetabular dysplasia.

The center-edge (CE) angle was measured on serial antero-posterior radiographs of 44 hips treated by Salter's innominate osteotomy for developmental dysplasia of the hip. Radiographic examination according to Severin was performed and the peak hip joint pressure was calculated using geometrical parameters determined from radiographs at the most recent follow-up examination, 7 to 13 years postoperatively.At the latest follow-up assessment, there was a positive correlation between the postoperative CE angle and radiographic results. Negative correlation was found between the postoperative CE angle and peak hip joint pressure at the latest follow up.In conclusion, Salter's osteotomy performed to treat developmental dysplasia of the hip should involve radical acetabular correction resulting in maximum increase of the CE angle.

Different operative treatment of slipped capital femoral epiphysis: A comparative study of biomechanical status of the hip.

The biomechanical status of the hips subject to two different operative treatments was studied. The biomechanical status was determined by the peak stress on the weight bearing area using the 3-d mathematical model. It was found that the procedure according to Imhäuser yields considerably and statistically significantly higher peak stress than the procedure according to Dunn-Fish.