Do pre-operative radiologic assessment predict postoperative outcomes in patients with insertional Achilles tendinopathy?: a retrospective database study.

INTRODUCTION: Diagnosis and treatment of insertional tendinopathy of the Achilles tendon (IAT) remains a challenge. The aim of this study was to assess the influence of pre-operative radiological pathologies on the patient-reported outcomes following open debridement of all pathologies for IAT. MATERIALS AND METHODS: In this IRB-approved retrospective correlation and comparative study, patients with pre-operative imaging were identified from the authors' retrospective IAT database comprising of 118 patients. All were treated by a standardized surgical treatment strategy utilizing a midline, transachillary approach and debridement of all pathologies. A total of fifteen radiologic parameters were measured on radiographs (RX) and MRI. The patient-reported outcomes were assessed using the Victorian Institute of Sport Assessment-Achilles questionnaire (VISA-A-G) and the general health questionnaire SF-12 at a minimum follow-up of 12 months. The data are presented as mean ± SD (95% CI). RESULTS: 88 patients (74.6%) with an average age of 50 ± 12 (47-52) years were included. Radiographs were available in 68 patients and MRI in 53. The mean follow-up was 3.8 ± 1.9 (3.4-4.3) years. The overall VISA-A-G was 81 ± 22 (77-86), the SF-12 PCS 54 ± 7 (52-55), and the SF-12 MCS 52 ± 9 (50-54) points. None of the assessed radiological parameters had a significant influence on the patient-reported outcome following surgical treatment for IAT. CONCLUSION: In this retrospective correlation study, no significant association was found between preoperative radiographic and MRI radiologic parameters for IAT and postoperative patient-reported outcomes (VISA-A-G and SF-12).

Anterior stand-alone fusion revisited: a prospective clinical, X-ray and CT investigation.

PURPOSE: The purpose of this study was to assess the mid-term clinical and radiological results as well as patient safety in terms of complication and reoperation rates in patients treated with a novel anterior stand-alone fusion (ASAF) device (Synfix-LR, DePuy Synthes, West Chester, PA, USA) in a cohort of patients with predominant and intractable low back pain originating from monosegmental degenerative disc disease at the lumbosacral junction. METHODS: Clinical outcome scores visual analog scale (VAS), Oswestry disability index (ODI) and patient satisfaction rates were acquired within the framework of an ongoing single-center prospective clinical trial. Evaluation of radiological data included segmental and global lumbar lordosis, neuroforaminal height and width. Interbody fusion was assessed from post-operative CT scans. The minimum follow-up (FU) was 12 months. RESULTS: 71 out of an initial 77 patients were available for final FU (92.2 % FU rate) after a mean FU of 35.1 months (range 12.0-85.5 months). The overall results revealed a highly significant improvement from baseline VAS and ODI levels (p < 0.0001). 77.5 % (n = 55/71) of all patients reported a 'highly satisfactory' (n = 37/71; 52.1 %) or a 'satisfactory' (n = 18/71; 25.4 %) outcome; 22.5 % of patients were not satisfied. The overall complication rate was 12.7 % (n = 9/71). Two cases required post-operative revision surgery (2.8 %). Radiographical analysis demonstrated a highly significant increase of segmental lordosis from 16.1° to 26.7° (p < 0.0001). A high rate of solid interbody fusion was confirmed in 97.3 % of all cases (n = 36/37). CONCLUSION: The current study delineates satisfactory clinical results following ASAF at the lumbosacral junction. Patient safety was demonstrated with acceptable complication and low reoperation rates. Radiological data demonstrated a significant reconstruction of lordosis at the lumbosacral junction. Solid interbody fusion was achieved in 97.3 % of all cases in a highly selected cohort with optimal predisposition for fusion. ASAF may serve to avoid a variety of negative side effects for a considerable number of patients which, otherwise, would have been candidates for posterior instrumented fusion techniques.

[Treatment of chronic ruptures and defects of the Achilles tendon]. / Therapie chronischer Rupturen und Defekte der Achillessehne.

BACKGROUND: Achilles tendon ruptures that are older than 4-6 weeks or developed over a more extended period are chronic. Two challenges characterize the treatment. First, defect zones over a length of several centimeters must frequently be bridged. Second, a prolonged loss of function of the muscles leads to an irreversible fatty degeneration of the tissue. So that even if the tendon is restored, significant functional deficits remain. If there are doubts about the ability of the calf muscles to regenerate, regardless of the size of the defect, tendon transfers are recommended to use the power of an additional muscle to support the plantar flexion of the ankle. TREATMENT: Established concepts are the transposition of the flexor hallucis longus or the peroneus brevis muscle. If the muscle is intact, defects of up to 2 cm can be treated with a direct suture. Defects between 2 and 5 cm can be bridged using a VY-plasty or a turndown flap. For larger defects, free tendon transplants can be considered. The technical alternative for larger defects is a tendon transfer of the flexor hallucis longus or the peroneus brevis muscle. Besides bridging the defect, another advantage of tendon transfer is that vital muscle tissue is placed in the bed of the Achilles tendon. Both tendons are covered with muscle tissue over nearly the full length, which offers advantages, especially in patients with critical soft tissue or after infection. FOLLOW-UP TREATMENT AND PROGNOSIS: Follow-up treatment is analogous to an acute Achilles tendon rupture. However, permanent impairments are possible; 75-80% of athletes regain their original performance level.

Influence of lumbar intervertebral disc degeneration on the outcome of total lumbar disc replacement: a prospective clinical, histological, X-ray and MRI investigation.

INTRODUCTION: The role of fusion of lumbar motion segments for the treatment of axial low back pain (LBP) from lumbar degenerative disc disease (DDD) without any true deformities or instabilities remains controversially debated. In an attempt to avoid previously published and fusion-related negative side effects, motion preserving technologies such as total lumbar disc replacement (TDR) have been introduced. The adequate extent of preoperative DDD for TDR remains unknown, the number of previously published studies is scarce and the limited data available reveal contradictory results. The goal of this current analysis was to perform a prospective histological, X-ray and MRI investigation of the index-segment's degree of DDD and to correlate these data with each patient's pre- and postoperative clinical outcome parameters from an ongoing prospective clinical trial with ProDisc II (Synthes, Paoli, U.S.A.). MATERIALS AND METHODS: Nucleus pulposus (NP) and annulus fibrosus (AF) changes were evaluated according to a previously validated quantitative histological degeneration score (HDS). X-ray evaluation included assessment of the mean, anterior and posterior disc space height (DSH). MRI investigation of DDD was performed on a 5-scale grading system. The prospective clinical outcome assessment included visual analogue scale (VAS), Oswestry Disability Index (ODI) scores as well as the patient's subjective satisfaction rates. RESULTS: Data from 51 patients with an average follow-up of 50.5 months (range 6.1-91.9 months) were included in the study. Postoperative VAS and ODI scores improved significantly in comparison to preoperative levels (p < 0.002). A significant correlation and interdependence was established between various parameters of DDD preoperatively (p < 0.05). Degenerative changes of NP tissue samples were significantly more pronounced in comparison to those of AF material (p < 0.001) with no significant correlation between each other (p > 0.05). Preoperatively, the extent of DDD was not significantly correlated with the patient's symptomatology (p > 0.05). No negative influence was associated with increasing stages of DDD on the postoperative clinical outcome parameters following TDR (p > 0.05). Increasing stages of DDD in terms of lower DSH scores were not associated with inferior clinical results as outlined by postoperative VAS or ODI scores or the patient's subjective outcome evaluation at the last FU examination (p > 0.05). Conversely, some potential positive effects on the postoperative outcome were observed in patients with advanced stages of preoperative DDD. Patients with more severe preoperative HDS scores of NP samples demonstrated significantly lower VAS scores during the early postoperative course (p = 0.02). CONCLUSION: Increasing stages of DDD did not negatively impact on the outcome following TDR in a highly selected patient population. In particular, no preoperative DDD threshold value was identified from which an inferior postoperative outcome could have been deduced. Conversely, some positive effects on the postoperative outcome were detected in patients with advanced stages of DDD. Combined advantageous effects of progressive morphological structural rigidity of the index segment and restabilizing effects from larger distraction in degenerated segments may compensate for increasing axial rotational instability, one of TDR's perceived disadvantages. Our data reveal a "therapeutic window" for TDR in a cohort of patients with various stages of DDD as long as preoperative facet joint complaints or degenerative facet arthropathies can be excluded and stringent preoperative decision making criteria are adhered to. Previously published absolute DSH values as contraindication against TDR should be reconsidered.

Clinical and radiological mid- to long-term investigation of anterior lumbar stand-alone fusion: Incidence of reoperation and adjacent segment degeneration.

Introduction: Anterior stand-alone fusion (ASAF) devices have been developed in an attempt to reduce adjacent segment degenerative changes observed with posterior instrumented fusion techniques. Research question: The purpose of this study was to assess mid- to long-term clinical and radiological results following ASAF at the lumbosacral junction with special emphasis on the assessment of adjacent level pathologies.Materials & Methods: Clinical outcome scores and radiological data were acquired within an ongoing single-center prospective cohort study. Progression of adjacent level degeneration was evaluated based on MRI scans according to the Pfirrmann and Weishaupt classification system by two independent radiologists. Results: The results from 37 patients (FU â€‹≥ â€‹5 years) demonstrated high satisfaction rates and significant improvements in VAS and ODI scores. N â€‹= â€‹8 patients (21.6%) had to undergo subsequent surgery at the cranially adjacent level. The incidence of adjacent level disc degeneration and adjacent facet joint degeneration was 24.3% and 35.1%, respectively. More pronounced degenerative changes of the adjacent level discs (p â€‹= â€‹0.005) and facet joints (p â€‹= â€‹0.042) prior to surgery and a lower segmental lordosis reconstruction at the lumbosacral junction (p â€‹= â€‹0.0084) were identified as potential risk factors for the development of subsequent adjacent level pathologies. Discussion & Conclusion: The study revealed satisfactory clinical results at a mid-to long-term FU of ≥5 years. The incidence of adjacent level degeneration was higher than initially expected. Patients with preexisting radiographic signs of degenerative adjacent level changes have a higher risk for subsequent deterioration necessitating reoperation at the adjacent segment at later stages. Furthermore, adequate intraoperative segmental lordosis reconstruction at the index segment is paramount as the present data reveal this to be a key protective factor for adjacent segment preservation.

Magnetic resonance imaging signs of iliotibial band friction in patients with isolated medial compartment osteoarthritis of the knee.

BACKGROUND: The purpose of this retrospective study was to assess the frequency of magnetic resonance imaging (MRI) signs of iliotibial band friction (ITBF) in patients with advanced medial compartment knee osteoarthritis. MATERIAL AND METHODS: Proton density-weighted (PDw) fat-saturated (fatsat) MR images (1.5 T, slice thickness (SL) 2.5-3 mm, eight-channel phased array coil) of 128 patients with isolated advanced osteoarthritis of the medial knee compartment and complete or subtotal (>80%) loss of cartilage were evaluated. There were 41 men and 87 women. Mean age was 63 years, range 34-89 years. The control group consisted of 94 patients with medial meniscus degeneration without cartilage loss (56 men and 38 women, mean age 50 years, range 16-89 years). MRI signs of ITBF were evaluated in both groups [poorly defined abnormalities of signal intensity and localized fluid collection lateral, distal or proximal to the lateral epicondyle; signal intensity abnormalities superficial to or deep by the iliotibial band (ITB)]. Transverse images were evaluated separately. Consensus evaluation using all imaging planes was performed. RESULTS: Of 128 patients with osteoarthritis, 95 had moderate or advanced MRI signs of ITBF (74.2%). Eighty-nine patients (69.5%) had advanced degeneration of the meniscus. In the control group, 26 of 94 patients had only moderate MRI signs of ITBF. There was a statistically significant difference between both groups for the presence of MR signs of ITBF (P

Treatment of Bone Marrow Edema of the Foot and Ankle With the Prostacyclin Analog Iloprost.

BACKGROUND: Bone marrow edema (BME) of the foot and ankle is challenging to treat. One approach is intravenous Iloprost treatment, which is a vasoactive prostacyclin analog. The aim of this study was to evaluate the early and intermediate outcome of intravenous Iloprost therapy on BME of the foot and ankle and to analyze the influence of its etiology and Association Research Circulation Osseous (ARCO) stage on the outcome. METHODS: This was a retrospective study with prospective follow-up. All patients treated by intravenous Iloprost for BME of the foot and ankle (ARCO I-III) at a single orthopedic reference center were included. Demographics, medical history, and MRIs were assessed prior to treatment (t0). MRIs were used to assess the BMEs' etiology (idiopathic/ischemic/metabolic, mechanical/degenerative, traumatic) and severity (ARCO). Complications as well as changes in pain, treatment, and MRI were evaluated after 3 months (t1). The following patient-rated outcome measures (PROMs) were assessed prospectively (t2): 12-Item Short Form Health Survey (SF-12), Visual Analog Scale Foot and Ankle (VAS FA), and the Foot Function Index (FFI) (also at t0). The descriptive outcomes and the influence of the etiology and ARCO on the outcome parameters were evaluated. Out of 70 eligible patients, 42 patients (60%; 47 ± 15 years; 30% female) with a mean follow-up of 28 ± 19 months were included. RESULTS: Twelve patients reported minor complications during Iloprost therapy. At t1, pain decreased significantly in 56%, and the amount of BME decreased in 83% of patients. Both parameters correlated moderately (r = -0.463, P = .015). The PROMs at t2 revealed moderate results. The overall FFI improved from 59 ± 21 to 30 ± 22 ( P < .001), the overall VAS FA was 68 ± 20, the SF-12 Physical Component Summary 42 ± 12 and Mental Component Summary 50 ± 9. Subgroup analysis revealed no significant influence of the etiology or ARCO stage on any outcome measure. CONCLUSION: Iloprost therapy for BME of the foot and ankle resulted in a 60% pain and 80% edema decrease after 3 months. After 2 years, patient-rated outcome measures showed residual impairment. Neither the etiology nor ARCO stage significantly influenced the outcome. LEVEL OF EVIDENCE: Level III, comparative study.

Molecular analysis of skeletal tuberculosis in an ancient Egyptian population.

A paleomicrobiological study was performed on 37 skeletal tissue specimens from cadavers in the necropolis of Thebes-West, Upper Egypt, (2120-500 BC) and four from the necropolis of Abydos (3000 BC). The subjects had typical macromorphological evidence of osseous tuberculosis (n = 3), morphological alterations that were not specific, but probably resulted from tuberculosis (n = 17), or were without morphological osseous changes (n = 21). DNA was extracted from these bone samples and amplified by PCR with a primer pair that recognised the Mycobacterium tuberculosis complex insertion sequence IS6110. To confirm specificity of the analysis, the amplification products of several samples were subjected to restriction enzyme digestion, or direct sequencing, or both. In 30 of the 41 cases analysed, ancient DNA was demonstrated by amplification by the presence of the human beta-actin or the amelogenin gene and nine of these cases were positive for M. tuberculosis DNA. The results were confirmed by restriction endonuclease digestion and sequencing. A positive result for M. tuberculosis DNA was seen in two of the three cases with typical morphological signs of tuberculosis and amplifiable DNA, in five of 13 non-specific, but probable cases (including two cases from c. 3000 BC), but also in two of 14 cases without pathological bone changes. These observations confirm that tuberculosis may be diagnosed unequivocally in skeletal material from ancient Egypt, even dating back to c. 3000 BC. As a positive molecular reaction was observed in most of the typical cases of skeletal tuberculosis, in about one-third of non-specific, but probable tuberculous osseous changes and, surprisingly, in about one-seventh of unremarkable samples, this suggests that infection with M. tuberculosis was relatively frequent in ancient Egypt.

Extraluminal gastrointestinal stromal tumour in the second portion of the duodenum.

The preoperative diagnosis of extraluminal gastrointestinal stromal tumours in the duodenum is difficult to establish due to their rare occurrence and the lack of pathognomonic signs. This report describes the case of a 61-year-old woman who suffered from an immunohistologically confirmed gastrointestinal stromal tumour in the second portion of the duodenum. Preoperative, abdominal, multislice computed tomography showed an extraluminal but intramural tumour located between the head of the pancreas and the duodenum. Rapid postprocessing analysis by three-dimensional, volume-rendered images revealed a strong arterial blood supply and an early draining vessel into the superior mesenteric vein during the portal-venous phase. The combination of endoscopic ultrasonography and non-invasive multislice computed tomography provided an early suggestion of gastrointestinal stromal tumour.

The fate of facet joint and adjacent level disc degeneration following total lumbar disc replacement: a prospective clinical, X-ray, and magnetic resonance imaging investigation.

STUDY DESIGN: Prospective clinical, x-ray, and magnetic resonance imaging investigation following total lumbar disc replacement (TDR) with ProDisc II (Synthes, Paoli, PA). OBJECTIVE: To examine the progression of adjacent level degeneration (ALD), facet joint degeneration (FJD) as well as associated risk factors following TDR. SUMMARY OF BACKGROUND DATA: Fusion procedures have been associated with adjacent level morbidities and facet joint pathologies in a considerable number of patients. Whether the incidence of these negative side effects can be reduced with TDR remains unestablished. METHODS: Clinical outcome scores Visual Analogue Scale (VAS), Oswestry Disability Index (ODI) and patient satisfaction rates were acquired within the framework of an ongoing prospective study with ProDisc II. The mean index-level ROM was established for every patient over the entire postoperative period from multiple flexion/extension x-ray images. The progression of ALD and FJD was evaluated from pre- and postoperative magnetic resonance images by 2 independent radiologists. RESULTS: Results from 93 patients with an average follow-up of 53.4 months (range, 24.1-98.7 months) were included in this study. The overall results revealed a significant improvement from preoperative VAS and ODI levels (P < 0.0001).The incidence of ALD was 10.2% (n = 11/108 levels). The degenerative changes were mild and occurred late after surgery (mean, 65.2 months; range, 37.9-85.6 months). There was no significant correlation between index-level ROM and the occurrence of ALD (P > 0.05).Progression of FJD was observed in 20.0% of all facet joints (n = 44/220). FJD occurred significantly more often following TDR at the lumbosacral junction in comparison to the level above the lumbosacral junction (P < 0.02) and was observed more frequently at index-levels than at nonindex levels (P < 0.001).The degenerative changes were associated with a negative influence on postoperative outcome parameters VAS and ODI (P < 0.03) that were already detected early after surgery. The mean postoperative ROM was significantly lower in patients with progression of FJD in comparison to the remaining cohort (P < 0.0001). CONCLUSION: TDR proved to have a beneficial effect with respect to adjacent level disc preservation. The degenerative changes were mild, occurred late after surgery and did not reveal a negative effect on postoperative clinical outcome. There was no significant correlation between index-level ROM and the occurrence of ALD (P > 0.05).TDR was, however, associated with a progression of index-level FJD in a considerable number of patients, particularly at the lumbosacral junction. Lower segmental mobility and less favorable clinical results point to the fact that a particular cohort of patients may predominantly be affected in which TDR shows inferior compatibility with the index-segment's biomechanics.