Postoperative laxity of the lateral soft tissue is largely negligible in total knee arthroplasty for varus osteoarthritis.

PURPOSE: To evaluate the integrity of lateral soft tissue in varus osteoarthritis knee by comparing the mechanical axis under varus stress during navigation-assisted total knee arthroplasty before and after compensating for a bone defect with the implant. METHODS: Sixty-six knees that underwent total knee arthroplasty were investigated. The mechanical axis of the operated knee was evaluated under manual varus stress immediately after knee exposure and after navigation-assisted implantation. The correlation between each value of the mechanical axis and degree of preoperative varus deformity was compared by regression analysis. RESULTS: The maximum mechanical axis under varus stress immediately after knee exposure increased in proportion to the degree of preoperative varus deformity. Moreover, the maximum mechanical axis under varus stress after implantation increased in proportion to the degree of preoperative varus deformity. Therefore, the severity of varus knee deformity leads to a progressive laxity of the lateral soft tissue. However, regression coefficients after implantation were much smaller than those measured immediately after knee exposure (0.99 vs 0.20). Based on the results of the regression formula, the postoperative laxity of the lateral soft tissue was negligible, provided that an appropriate thickness of the implant was compensated for the bone and cartilage defect in the medial compartment without changing the joint line. CONCLUSION: The severity of varus knee deformity leads to a progressive laxity of the lateral soft tissue. However, even if the degree of preoperative varus deformity is severe, most cases may not require additional procedures to address the residual lateral laxity.

Wrist deformity, bother and function following wrist fracture in the elderly.

OBJECTIVE: Wrist deformity in older people is common following treatment for a wrist fracture, particularly after non-surgical treatment. A cohort of older wrist fracture patients were surveyed by telephone regarding perceived deformity, bother with deformity and patient-reported wrist function. The objectives were to: (1) determine whether older patients with wrist fractures perceived a deformity of their wrist and if they were bothered by it; (2) test if there were associations between deformity and treatment-type and between deformity and function; (3) test for associations between bother and treatment-type and between bother and function; (4) measure the test-retest reliability of the 'bother' question. RESULTS: Of 98 eligible patients who were invited to participate, 41 responded. Out of 41, 14 (34%) believed they had a deformity and 4 (10%) reported that they were bothered by the appearance of their wrist. Deformity was associated with non-surgical treatment (RR = 3.85, p = 0.006) but was not significantly associated with functional outcomes (p = 0.15). All those who were bothered belonged to the non-surgical treatment group. Bother was significantly associated with poorer functional outcomes (p = 0.006) and this association was clinically significant (MD = 35 points). The deformity and bother questions were found to have excellent test-retest reliability; κ = 1.00 and κ = 0.92, respectively.

A New Classification for the Varus Knee.

BACKGROUND: A new classification for osteoarthritis of the knee associated with varus deformity is presented. This classification is derived from the combination of conventional radiographs, stress radiographs (when needed), and clinical examination. METHODS: This study included the analysis of coronal alignment on full-leg standing radiographs of 526 patients awaiting knee arthroplasty for varus deformity in a single institution. Various mechanical and anatomic angles were measured, and these findings were combined with a basic clinical examination of patients. The radiographs were measured on 2 separate occasions to determine the intraobserver reliability. Cross-sectional studies such as computed tomography or magnetic resonance imaging were used to further refine observations about different wear patterns. RESULTS: Varus deformity can either be intra-articular or extra-articular. Intra-articular deformities can be correctable or fixed. In fixed deformities, the status of the lateral ligament is taken into account. Extra-articular deformity can be metaphyseal or diaphyseal, and the possibility for intra-articular correction will depend on the degree of deformity and its distance from the joint. CONCLUSION: This new classification allows for better definition of varus deformity, which can help surgeons during preoperative planning, particularly with their choice of implant and potentially the degree of constraint. The classification can also be a tool for further prospective studies about varus deformity.

Failure to restore sagittal tibiotalar alignment in total ankle arthroplasty: Its relationship to the axis of the tibia and the positioning of the talar component.

The purpose of this study was to evaluate the change in sagittal tibiotalar alignment after total ankle arthroplasty (TAA) for osteoarthritis and to investigate factors affecting the restoration of alignment. This retrospective study included 119 patients (120 ankles) who underwent three component TAA using the Hintegra prosthesis. A total of 63 ankles had anterior displacement of the talus before surgery (group A), 49 had alignment in the normal range (group B), and eight had posterior displacement of the talus (group C). Ankles in group A were further sub-divided into those in whom normal alignment was restored following TAA (41 ankles) and those with persistent displacement (22 ankles). Radiographic and clinical results were assessed. Pre-operatively, the alignment in group A was significantly more varus than that in group B, and the posterior slope of the tibial plafond was greater (p < 0.01 in both cases). The posterior slope of the tibial component was strongly associated with restoration of alignment: ankles in which the alignment was restored had significantly less posterior slope (p < 0.001). An anteriorly translated talus was restored to a normal position after TAA in most patients. We suggest that surgeons performing TAA using the Hintegra prosthesis should aim to insert the tibial component at close to 90° relative to the axis of the tibia, hence reducing posterior soft-tissue tension and allowing restoration of normal tibiotalar alignment following surgery.

Posterior Humeral Avulsion of the Glenohumeral Ligament and Associated Injuries: Assessment Using Magnetic Resonance Imaging.

BACKGROUND: Lesions associated with posterior humeral avulsion of the glenohumeral ligament (HAGL) can lead to persistent symptoms related to posterior shoulder instability and can be commonly missed or delayed in diagnosis. PURPOSE: To identify and characterize the MRI findings in patients with a posterior HAGL lesion. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: This retrospective case series included 27 patients (28 shoulders) identified by search through the senior authors' databases, with cross-reference to their institutional radiologic communication system for MRI review. Baseline patient demographic data were collected, including age and sex. All posterior HAGL lesions were identified on MRI and characterized as partial, complete, or floating lesions. All acute glenohumeral pathologic changes concurrent with the posterior HAGL were documented. Chondrolabral retroversion of the injured shoulder was measured on axial MRI. RESULTS: The average age of the identified cohort was 33.6 years (range, 15-81 years), and 23 patients were male (86%). Posterior HAGL injuries were found to be complete tears (71%), partial tears (25%), and floating lesions (4%); concomitant bony HAGL avulsion was found in 7% of injuries. Additional traumatic glenohumeral disorders occurred in 93% of cases. The most common concurrent injuries were reverse Hill-Sachs lesions (36%), anterior Bankart lesions (29%), and posterosuperior rotator cuff tears (25%). Notably, concomitant anterior labral or capsular injury was found in 50% of patients, signifying bidirectional disruption of the capsule. In addition, increased chondrolabral version was found in this cohort (10.2° ± 3.7° retroversion). CONCLUSION: This study depicts the high association of combined injury with posterior HAGL lesions and increased chondrolabral retroversion. Findings on MRI related to a posterior HAGL injury could potentially be masked by additional injury and may occur with mechanisms that also lead to anterior glenohumeral disorders.

Two positive tuberculosis cases in the late Nigrovits family, 18th century, Vác, Hungary.

Two mummies of the Hungarian mummy collection from Vác were the subjects of anthropological, paleopathological, radiological, paleomicrobiological, paleohistological and paleoproteomic studies. Both individuals belonged to the same family. The father, József Nigrovits (No 29), died at the age of 55 on the 11th of November 1793; his son, Antal Nigrovits (No 54), died on the 16th of July 1803, at the age of 22. They lived in the 18th century in Vác, a small town in northern Hungary. The macroscopic examination of the son showed a severely deformed neck and back region; the father has no visible mark of any illnesses. As earlier researches showed that tuberculosis was widespread in the community, the etiology of these deformities was examined. The paleomicrobiological results found that both individuals were infected with tuberculosis. Although they suffered from TB, the CT scan data of the bodies and their 3D reconstructions showed no skeletal evidence of tuberculosis. The deformity of the son turned to be a developmental abnormality of unknown origin, but no Pott's gibbus was present.

[Lesions of the radio-carpal joint in patients with rheumatoid arthritis and its surgical treatment].

Affection of radio-carpal joint is most frequently revealed in patients, suffering rheumatoid arthritis. While the disease progressing in almost 75% of patients the inflammatory changes in radio-carpal joint occur. An acute and chronic synovitis, damage of a cartilage constitute a cause of a typical erosion of bones inside a joint, weakening of a tendo-ligamentous apparatus and its further deformity. Operative treatment was aimed for the inflammatory focus elimination, reduction of the pain syndrome severity, the function loss, and the joint deformity correction. The mostly used operative interventions are tenoectomy, synovectomy, arthrodesis, total endoprosthesis.

Common postburn deformities and their management.

This article describes a practical, clinically based approach to classification of postburn deformities. Burn scar contractures are of either the broad diffuse type or linear band-like type. The former generally respond well to release and insertion of a skin graft or substitute, whereas the latter are generally repaired using a simple or modified Z-plasty or a transpositional flap technique. The pulsed dye laser is a promising technique used to reduce scar thickness and redness. Postburn deformities of the face, upper and lower extremities, and trunk are discussed, in addition to novel techniques for vascularized composite allotransplantation of the face.

Clinical alignment variations in total knee arthroplasty with different navigation methods.

BACKGROUND: We compared the resulting alignment in 90° of flexion and in full extension after total knee arthroplasty (TKA) with two navigation systems using different techniques: a measured resection (MR) system and a gap - balancing (GB) system. METHODS: Varus and valgus alignment in extension and flexion was compared in 100 consecutive patients who had TKA with an MR distal-femoral-cut-first technique at one institution and 100 consecutive patients in whom a GB tibial-cut-first technique was used at another institution. Alignment deviation of three degrees or more from neutral was considered an outlier. RESULTS: No significant difference between the groups in coronal alignment in extension or flexion was found, but there were three times the number of outliers for clinical alignment in flexion for the MR group compared to the GB group. CONCLUSIONS: The use of the GB tibial-cut-first computer-assisted TKA navigation may provide a more consistent clinical alignment in flexion than systems using an MR technique. LEVEL OF EVIDENCE: Therapeutic study. Level 2.

Prevalence of HAGL lesions and associated abnormalities on shoulder MR examination.

OBJECTIVE: Humeral avulsion of the glenohumeral ligament (HAGL) is an uncommon shoulder injury. We report the prevalence of HAGL lesions and other associated shoulder injuries in a large series of shoulder MR examinations. All results were correlated with surgery. MATERIALS AND METHODS: MR reports of 1,000 consecutive conventional shoulder MR exams performed on patients with shoulder pain were reviewed in our information system for the word HAGL. A total of 743 patients went on to surgery. There were 23 HAGL lesions reported at surgery. Those 23 examinations were reviewed retrospectively in consensus by two musculoskeletal radiologists. Scans were assessed for HAGL lesions, full or partial thickness supraspinatus, infraspinatus or subscapularis tendon tears, superior labral anterior posterior (SLAP) tears, anterior or posterior labral tears, and Hill-Sachs lesions. RESULTS: All 23 patients had HAGL lesions at surgery. Sixteen HAGL lesions were seen on prospective MR reading and 17 HAGL lesions were seen on retrospective MR consensus reading. Six HAGL lesions were not seen on retrospective consensus reading. Sixteen patients had Hill-Sachs deformities, ten had subscapularis tendon tears, five had supraspinatus tendon tears, six had superior labral tearing, and six had anterior labral tears. The above findings were confirmed on arthroscopy. CONCLUSIONS: In this series, there was a 1.6 % prevalence on all MR examinations, and prevalence of 2.1 % seen on MR examination for those who went to surgery. Common injuries associated with HAGL lesions are Hill-Sachs deformities and subscapularis tendon tears. Anterior labral tears were seen in only six cases despite Hill-Sachs deformities in 16 patients. In patients with Hill-Sachs deformities without anterior labral tears, one must carefully assess for the presence of a HAGL lesion.

Forearm post-traumatic deformities: classification and treatment.

INTRODUCTION: There is no classification for acquired forearm deformities. A clinical-radiographic study was conducted to classify these deformities and evaluate the results. MATERIALS AND METHODS: Thirteen patients with forearm deformities following traumas or their treatment were included (11 men and two women, from 2000 to 2010). Mean age was 31 years (range 10-75 years). Initial treatment was conservative in five patients and surgical in eight patients. One segment was affected in seven patients (the radius in four patients, the ulna in three), and both segments were affected in six patients. Location assessment: 2 projections X-rays, including wrist and elbow. Deformity location: proximal, diaphisary, distal, defined with the abbreviation, in distal sense, R1, R2, R3 for the radius, and U1, U2, U3 for the ulna. Primary and secondary deformities were distinguished: secondary deformities occurred later in a different location than the primary one. Six patients were treated with plate and screws. An external fixator was used in six patients. One patient was treated with bone resection. Iliac crest bone graft was used in 10 patients, and vascularised fibula graft in one patient. RESULTS: The primary deformity affecting the radial diaphysis (R2) determined a secondary deformity in four patients: in the distal ulna (U3) with ulnocarpal dislocation in three patients and in the distal radius (R3) in one patient. Results of osteosynthesis treatment were excellent in one patient, satisfactory in four and unsatisfactory in one. External fixation was excellent in one patient and satisfactory in five. Bone resection was satisfactory in one patient. DISCUSSION: Surgical treatments with osteosynthesis are the major cause of acquired forearm deformities in adults. Location and aetiology of the deformities are essential for the surgical indication and the result. It is important to restore the length of the deformed segment, realigning the anatomical axis. X-rays enable clinicians to distinguish between primary and secondary forearm deformities. CONCLUSION: Characteristics and locations of post-traumatic deformities were identified. The major location is diaphisary and distal, the elbow is rarely affected. The functional consequence is a limitation in the range of motion of the hand. The best results are achieved with short-term treatment.

Arthritis mutilans: a report from the GRAPPA 2012 annual meeting.

Arthritis mutilans is often described as the most severe form of psoriatic arthritis. However, a widely agreed on definition of the disease has not been developed. At the 2012 annual meeting of the Group for Research and Assessment of Psoriasis and Psoriatic Arthritis (GRAPPA), members hoped to agree on a definition of arthritis mutilans and thus facilitate clinical and molecular epidemiological research into the disease. Members discussed the clinical features of arthritis mutilans and definitions used by researchers to date; reviewed data from the ClASsification for Psoriatic ARthritis study, the Nordic psoriatic arthritis mutilans study, and the results of a premeeting survey; and participated in breakout group discussions. Through this exercise, GRAPPA members developed a broad consensus on the features of arthritis mutilans, which will help us develop a GRAPPA-endorsed definition of arthritis mutilans.

Geometry of the proximal humeral articular surface in young children: a study to define normal and analyze the dysplasia due to brachial plexus birth palsy.

BACKGROUND: Little is known regarding the morphology of the proximal humerus in growing children. This study reports bilateral magnetic resonance imaging measurements in children with internal rotation contractures from birth palsy, hypothesizing that dysplasia alters normal humeral sphericity and symmetry. METHODS: We studied 25 children with unilateral internal rotation contractures (mean age, 3.7 years) for humeral shape by bilateral magnetic resonance imaging studies at the mid-glenoid level. Local radii of curvature were compared for symmetry and orientation. RESULTS: Neither side showed uniform radii (sphericity), but normal humeri showed symmetry lost in dysplasia. Internal rotation contractures were correlated with flattening of the anterior humeral head (P = .0002). All heads were flatter in the region of articular contact. The skew axis (the largest cross-sectional diameter of the proximal humerus) was collinear with the articular surface centerline in normal humeri, an alignment often lost with dysplasia, resulting in a skew axis angle. The severity of glenoid deformity correlated with progressive posterior displacement of the humeral head center (P < .0003). CONCLUSION: The normal humeral articular surface in the young child is not spherical and is flatter in the middle than at the periphery but is symmetric about its central axis. Internal rotation contractures result in loss of this symmetry with characteristic flattening of the anterior humeral head and development of a skew axis angle. CLINICAL RELEVANCE: Posterior displacement of the humeral head center of rotation beyond 50% of the calculated head radius warrants vigilance and possibly surgical intervention because there is a high likelihood for development of a pseudoglenoid.

Psoriatic arthritis mutilans (PAM) in the Nordic countries: demographics and disease status. The Nordic PAM study.

OBJECTIVE: To determine the prevalence and clinical characteristics of psoriatic arthritis mutilans (PAM) in the Nordic countries. METHOD: Patients with putative PAM aged ≥ 18 years were recruited. Fifty-nine patients were included after clinical examination. RESULTS: The prevalence of PAM in the adult Nordic population was estimated to be 3.69 per million inhabitants [95% confidence interval (CI) 2.75-4.63]. The female to male ratio was close to 1:1. The mean age of skin disease onset was 25 years and the mean age of onset of joint disease was 30 years. The onset of skin disease was 2 years earlier among female patients. At inclusion, the mean duration of arthritis was 27 ± 11 years for male patients and 33 ± 11 years for female patients. PAM was most frequently seen in the distal interphalangeal (DIP) joints of the toes, followed by the IP joint of the thumb and the DIP joint of the little finger on the left hand. Female and male patients had similar numbers of painful and swollen joints. Enthesitis was found in 19 patients (32%), while 38 patients (64%) had a history of dactylitis. Twenty-three of these 38 patients (61%) had a history of dactylitis in the same finger/toe as they had PAM. At the time of inclusion, 45% of the patients were found to have clear or almost clear skin. CONCLUSIONS: PAM in the Nordic countries has a low prevalence, with only three to five cases per million inhabitants. The majority of the patients present with mild skin disease.

MRI abnormalities of the acetabular labrum and articular cartilage are common in healed Legg-Calvé-Perthes disease with residual deformities of the hip.

BACKGROUND: Varying degrees of femoral deformity may result as Legg-Calvé-Perthes disease heals. Our aims were to investigate the prevalence of abnormalities of the acetabular labrum and cartilage, using noncontrast magnetic resonance imaging, and to correlate the findings with radiographic deformities that may exist after the healing of Legg-Calvé-Perthes disease. METHODS: In a sample of ninety-nine patients with healed Legg-Calvé-Perthes disease, anteroposterior and lateral radiographs were used to assess the Stulberg classification, femoral head size and sphericity, femoral neck morphology, and acetabular version. A subgroup of fifty-four patients (fifty-nine hips) underwent noncontrast magnetic resonance imaging of the hip an average of eight years after disease onset. The acetabular labrum was evaluated according to a modified classification system, and the acetabular cartilage was evaluated for the presence of delamination and defects. The association among abnormalities of the acetabular labrum, articular cartilage, and radiographic deformities was assessed. RESULTS: Abnormalities of the acetabular labrum and cartilage were found on magnetic resonance imaging scans in 75% and 47% of the hips, respectively. An alpha angle of ≥55° was the deformity most significantly associated with labral and cartilage abnormalities, followed by coxa brevis. Coxa magna and a higher greater trochanter showed a significant association with labral abnormalities only. Acetabular retroversion showed an increased risk for labral abnormalities when the alpha angle was normal. When deformities coexisted, the alpha angle showed the greatest relative risk for abnormality. CONCLUSIONS: On the basis of magnetic resonance imaging evaluation of the hip, labral and cartilage abnormalities were a common finding in patients with healed Legg-Calvé-Perthes disease. Our results suggest that hip deformities are significantly associated with labral and cartilage abnormalities on magnetic resonance imaging, and the main predisposing factor was the asphericity of the femoral head with a reduced femoral head-neck offset.

Pentosan polysulfate: a novel therapy for the mucopolysaccharidoses.

BACKGROUND: Pentosan polysulfate (PPS) is an FDA-approved, oral medication with anti-inflammatory and pro-chondrogenic properties. We have previously shown that animal models of the mucopolysaccharidoses (MPS) exhibit significant inflammatory disease, contributing to cartilage degeneration. Enzyme replacement therapy (ERT) only partly reduced inflammation, and anti-TNF-alpha antibody therapy significantly enhanced clinical and pathological outcomes. Here we describe the use of PPS for the treatment of MPS type VI rats. METHODOLOGY/PRINCIPAL FINDINGS: Treatment began during prenatal development and at 1 and 6 months of age. All animals were treated until they were 9 months old. Significant reductions in the serum and tissue levels of several inflammatory markers (e.g., TNF-alpha, MIP-1alpha and RANTES/CCL5) were observed, as was reduced expression of inflammatory markers in cultured articular chondrocytes. ADAMTS-5/aggrecanase-2 levels also were reduced in chondrocytes, consistent with an elevation of serum tissue inhibitor of metalloproteinase 1. Marked improvements in motility and grooming behavior occurred, along with a reduction in eye and nasal secretions and a lessening of the tracheal deformities. MicroCT and radiographic analyses further revealed that the treated MPS skulls were longer and thinner, and that the teeth malocclusions, misalignments and mineral densities were improved. MicroCT analysis of the femurs and vertebrae revealed improvements in trabecular bone mineral densities, number and spacing in a subset of treated MPS animals. Biomechanical assessments of PPS-treated spines showed partially restored torsional behaviors, suggesting increased spinal stability. No improvements were observed in cortical bone or femur length. The positive changes in the PPS-treated MPS VI rats occurred despite glycosaminoglycan accumulation in their tissues. CONCLUSIONS: Based on these findings we conclude that PPS could be a simple and effective therapy for MPS that might provide significant clinical benefits alone and in combination with other therapies.

A patient with multifocal tabetic arthropathy: a case report and review of literature.

A 55-year-old man presented with a painless destruction of multiple joints and neurologic deficits. He was admitted with a painless pyogenic arthritis of the right ankle. Four years earlier, he had experienced instability of the right knee after an inexplicable, progressive but painless destruction of the joint. Radiographs showed erosive changes at the smaller joints of both hands and the left foot, as well as deformation and destruction of the right foot. Results from both treponemal and nontreponemal serologic test were positive in blood. The Treponema pallidum particle agglutination index was positive in the cerebrospinal fluid. Tabetic arthropathy was diagnosed.Tabetic arthropathy is a manifestation of neurosyphilis. Because syphilis is known as "the great imitator" and tertiary syphilis is rare, recognizing the disease is the biggest challenge for health care providers. Symptoms may mimic any other disease, and many different medical specialists may be faced with these patients, or as Sir William Osler put it: "He who knows syphilis, knows medicine." Initial diagnosis is usually made on serum and cerebrospinal fluid examination. Penicillin is an effective treatment for neurosyphilis to stop progression of neurologic damage, but it does not cure the previously developed tabetic arthropathy. This case is reported to raise awareness of this uncommon but important manifestation of tertiary syphilis. Unfamiliarity with the clinical presentation of tabetic arthropathy may lead to considerable delay in diagnosis.