Osteochondral lesions of the talus: are there any differences between osteochondral and chondral types?

BACKGROUND: Among the types of osteochondral lesions of the talus (OLTs), the osteochondral and chondral types make up the majority of OLTs. There is a possibility that between these two types of lesions, the clinical outcomes and characteristics may differ. PURPOSE: This study was designed to compare the clinical outcomes, demographics, and characteristics of osteochondral- and chondral-type lesions of OLTs. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: The authors retrospectively analyzed 298 ankles that underwent arthroscopic marrow-stimulating procedures for OLTs between 2001 and 2009 that had been arthroscopically determined as either chondral type (210 ankles) or osteochondral type (88 ankles). Clinical outcomes, demographics, and characteristics of the lesions were compared. RESULTS: The age distribution showed that the chondral type reached its peak in patients in their 50s, whereas the osteochondral type had a peak distribution for those in their 20s. The average duration of symptoms was greater in the chondral type (28.3 months; range, 7-240 months) than in the osteochondral type (14.4 months; range, 8-120 months) (P < .001). With regard to the characteristics of the lesions, differences only existed in the combined intra-articular lesions between the two types. Subchondral cysts (odds ratio [OR], 3.71; 95% CI, 1.61-8.55; P = .001) and soft tissue impingement (OR, 1.82; 95% CI, 1.10-3.03; P = .021) were more frequently present in the chondral type. The American Orthopaedic Foot and Ankle Society (AOFAS) and visual analog scale (VAS) for pain showed significant improvement from preoperative to postoperative scores in both groups. However, the preoperative and postoperative VAS and AOFAS scores did not differ significantly between the groups. CONCLUSION: Differences were found with age distribution, duration of symptoms, and combined intra-articular lesions between the osteochondral- and chondral-type lesions of OLTs. We achieved similar successful clinical outcomes in both types of lesions using arthroscopic marrow stimulating procedures, such as microfracture or abrasion arthroplasty.

Posterior malleolar fracture is often associated with spiral tibial diaphyseal fracture: a retrospective study.

BACKGROUND: It is known that posterior malleolar fracture is often associated with tibial diaphyseal fractures. However, in literature there are very few studies on tibial shaft fractures with respect to posterior malleolus fragment. We hypothesized that the incidence of posterior malleolar fracture is higher than in previous studies. METHODS: A total of 74 closed tibial shaft fractures were treated with intramedullary nailing in Turku University Central Hospital between January 1994 and December 1998. There were 55 men and 19 women, with a mean age of 39 years (range, 16 to 58 years). Two cases were excluded and 72 tibial shaft fractures were analyzed retrospectively. RESULTS: Posterior malleolar fracture was observed in 18 cases (25.0%). Only 10 were observed preoperatively in plain films, seven were detected postoperatively and one was not detected at all during the treatment. Retrospectively, all 18 posterior malleolar fractures were detectable in preoperative plain films. CONCLUSION: A fracture of the posterior malleolus was involved in every fourth tibial diaphyseal fracture. The fractures of the posterior malleolus were always detected in preoperative plain films and should be suspected, especially in cases of low-energy spiral distal tibial diaphyseal fractures. We recommend additional plain films to be taken at the ankle region to better visualize these fractures.

Synovial joints: evaluation of intraarticular bodies with US.

PURPOSE: To determine the efficacy of ultrasonography (US) for the detection of intraarticular bodies. MATERIALS AND METHODS: US was performed in 280 patients with symptoms in various appendicular joints by using 5.0-, 7.5-, or 10.0-MHz transducers. Three patients also underwent US with intraarticular saline infusion. US findings were confirmed at surgery in 61 patients. RESULTS: In the 61 patients with surgical correlation, sonograms were positive in 39 and did not show intraarticular bodies in 22. Surgical results confirmed 37 of the positive and all of the negative sonograms. Sensitivity and specificity of US were 100% and 95%, respectively. CONCLUSION: US is an accurate method for identification of intraarticular bodies.

The fate of intra-articular debris following arthroscopic anterior cruciate ligament reconstruction.

The debris generated during arthroscopic anterior cruciate ligament (ACL) reconstruction may be seen on postoperative radiographs. The purpose of this study was to evaluate the incidence, effects, and natural history of intra-articular debris following ACL reconstruction. This retrospective review included 99 ACL reconstructed knees in 96 patients. Radiographically visible debris was present in 63% of knees (bone in 59% and metal in 4%), and 37% of knees had no visible debris. Bone was most commonly seen in the posterior compartment (95%), and metal within the intercondylar notch. There were no differences in the incidence of debris between reaming techniques, single and dual incision techniques, or between graft types. Metal debris was always associated with retrograde reaming. Complete disappearance of bone debris was noted in 71% (3 to 6 months). Of the 25% of knees that showed persistent bone debris, in 79% it had decreased in size. There was no change in the appearance of metal debris (4%). No patient experienced mechanical symptoms directly related to debris. No secondary surgeries for debridement of debris or loose body removal were required. Bone debris produced during arthroscopic ACL reconstruction appears clinically benign, and is likely to disappear by 6 months. Long-term effects are unknown. Metal debris is persistent, but not problematic over the short-term.

MR imaging of acetabular fractures: value in detecting femoral head injury, intraarticular fragments, and sciatic nerve injury.

OBJECTIVE: The purpose of this prospective study was to compare the value of MR imaging in the detection of injuries associated with acute acetabular fractures (femoral head fracture, free fragments within the hip joint, and injury to the sciatic nerve) with the value of preoperative CT examinations, intraoperative inspection, intraoperative somatosensory evoked potentials (SEP), and clinical neurologic examinations. SUBJECTS AND METHODS: Coronal fat suppressed long TR/TE and unenhanced and contrast-enhanced T1-weighted MR images were obtained preoperatively in 37 patients with acetabular fractures. The sciatic nerve was assessed for injury and the femoral head was assessed for fracture, dislocation, and contusion. MR results were compared with CT findings for acetabular fractures and fractures of the femoral head. The appearance of the sciatic nerve on MR images was correlated with intraoperative changes in SEP and results of the clinical neurologic examination. RESULTS: Although MR images showed acetabular fractures, intraarticular fragments were often obscured. Fragments were readily apparent on CT scans. MR images showed fracture of the femoral head in 10 (27%) of 37 cases. Nine of these fractures also were seen on CT scans. MR images showed subchondral contusion of the femoral head in 24 (65%) of 37 cases. The same areas appeared normal on CT scans. MR images of the sciatic nerve obtained after injection of contrast material showed intraneural or perineural enhancement in all patients with either changes in baseline SEP (n = 19) or preoperative neurologic deficit (n = 10). Although baseline changes in SEP were more common with intraneural enhancement, the difference in the prevalence of neurologic deficits was not significant. The preoperative enhancement pattern alone could not be used to predict a neurologic deficit. CONCLUSIONS: MR imaging of acetabular fractures can be used to detect subclinical injury of the sciatic nerve and occult injuries of the femoral head not readily apparent on CT scans. However, intraarticular fragments may be obscured.

Generalized synovial chondromatosis of the knee: a comparison of removal of the loose bodies alone with arthroscopic synovectomy.

Thirteen patients with generalized synovial chondromatosis of the knee were treated by either removal of the loose bodies alone (n = 5) or arthroscopic synovectomy (n = 8). The average follow-up was 38 months (range 23-61). There were three recurrences in the loose body removal group, which were subsequently treated by arthroscopic synovectomy. Statistical analysis of the results shows a significant improvement in pain, synovitis and effusion, range of movement, and function after either treatment. The group treated by arthroscopic synovectomy had significantly lower recurrence rates (p = 0.02). We recommend arthroscopic synovectomy for patients with generalized synovial chondromatosis. However, if loose bodies alone are removed, a recurrence can be successfully treated by an arthroscopic synovectomy.

Acute haemarthrosis of the knee in athletes. A prospective study of 106 cases.

We made a prospective arthroscopic study of 106 skeletally mature male sportsmen with an average age of 28.35 years (16.8 to 44) who presented with an acute haemarthrosis of the knee due to sporting activities. We excluded those with patellar dislocations, radiographic bone injuries, extra-articular ligamentous lesions or a previous injury to the same joint. The anterior cruciate ligament (ACL) was intact in 35 patients, partially disrupted in 28 and completely ruptured in 43. In the patients with an ACL lesion, associated injuries included meniscal tears (17 patients), cartilaginous loose bodies (6), and minimal osteochondral fractures of the patella (2), the tibial plateau (3) or the femoral condyle (9). We found no age-related trend in the pattern of ACL injuries. Isolated injuries included one small osteochondral fracture of the patella, and one partial and one total disruption of the posterior cruciate ligament. Three patients had cartilaginous loose bodies, and no injury was detected in five. Acute traumatic haemarthrosis indicates a serious ligament injury until proved otherwise, and arthroscopy is needed to complement careful history and clinical examination. All cases with a tense effusion developing within 12 hours of injury should have an aspiration. If haemarthrosis is confirmed, urgent admission and arthroscopy are indicated.

The morbidity associated with lost or irretrievable resected meniscal fragments.

Between January 1984 and April 1989 pieces of already-separated meniscus were lost in the knees of 23 patients as a complication of knee arthroscopy. These patients were asked to complete a questionnaire with regard to their postoperative problems. Despite the fact that some of these pieces were up to 4 cm in length, only 3 patients were dissatisfied with the results and had to undergo arthroscopy once again. When compared with the total number of arthroscopies (2,927) performed in the same period, we found no significant differences in patient ages, accompanying injury patterns, nor the time they were unable to work. These surprisingly excellent results demonstrate that a lost piece of meniscus in the knee space does not always indicate immediate repeat arthroscopy. In most cases, this loose piece probably will adhere to a place inside the knee where it will no longer be a mechanical hindrance.