A comprehensive analysis of the pre- and postoperative responses to each of the 12 Oxford knee score questions one year following knee arthroplasty.

AIMS: To assess the pre- and postoperative responses to each of the 12 individual Oxford Knee Score (OKS) questions and percentages of those that were better, same or worse after primary knee arthroplasty (KA). METHODS: A single centre retrospective cohort study conducted over a 24-month period which included 3259 patients with completed OKS preoperatively and 1-year after KA. There were 1286 males and 1973 females, with an overall mean age of 70.0 (range 34-94). The mean scores for each question of the OKS were compared between baseline and 1-year. The percentage of patients who reported better, the same or worse postoperative symptoms for each question were calculated and represented on a heatmap. RESULTS: There were significant (p < 0.001) improvements in all 12 questions, all of which demonstrated moderate (Q2, Q7) or large effect sizes. Improvements in individual question responses varied. Symptoms of pain and limping demonstrated the greatest improvement, with 86% of patients enjoying a positive change in their symptoms. Despite this improvement 1067 (41.4%) continued to have mild to severe pain in their knee, and 442 (17.3%) patients limped often to all the time when walking postoperatively. Whereas other questions that did not improve to the same extent for example washing and drying only improved in 53% of patients but only 347 (13.5%) had moderate/extreme trouble or found it impossible to do this postoperatively. Preoperatively four questions (Q1, Q6, Q7, Q8) demonstrated floor effects, postoperatively all questions apart from question 7 (kneeling) demonstrated ceiling effects. CONCLUSION: The mean improvement and outcome at 1-year for each of the 12 questions varied according to the patient's preoperative response. As a clinical tool, the heatmap (improvement, same and worse) will enable communication to patients about their potential change in their knee specific symptoms according to their preoperative responses. LEVEL OF EVIDENCE: Retrospective study, Level III.

Posterior stabilised total knee arthroplasty is associated with improved post-operative knee specific function, health related quality of life and greater satisfaction when compared to cruciate retaining protheses.

PURPOSE: To assess whether there were differences in knee specific function, health related quality of life (HRQoL), and satisfaction between patients with a cruciate retaining (CR) or a posterior stabilised (PS) total knee arthroplasty (TKA) at 1 and 2 years postoperatively. METHODS: A retrospective review of TKA (CR and PS) patients from a prospectively collected arthroplasty database. Patient demographics, body mass index and ASA grade, Oxford knee score (OKS) and EuroQol 5-dimension (EQ-5D) 3-level, which was used to assess HRQoL, were collected preoperatively and 1 year and 2 years postoperatively. Regression was used to adjust for confounding factors. RESULTS: The sample included 3122 TKA, of which 1009 (32.3%) were CR and 2112 (67.7%) were PS. The PS group were more likely to be female (odd ratio (OR) 1.26, p = 0.003) and undergo resurfacing of the patella (OR 6.63, p < 0.001). There was a significantly greater improvement in the 1 year OKS in the PS group (mean difference (MD) 0.9, p = 0.016). The PS TKA was independently associated with a greater 1 year (MD 1.1, 95% CI 0.4 to 1.9, p = 0.001) and 2 years (MD 0.8, p = 0.037) post-operative improvements in OKS. PS TKA was also independently associated with a greater 1 year (MD 0.021, p = 0.024) and 2 years (MD 0.022, p = 0.025) post-operative and change in EQ-5D utility compared to the CR group. The PS group was more likely to be satisfied with their outcome at 1 year (OR 1.75, p < 0.001) and at 2 years (OR 1.38, p = 0.001) when adjusting for confounders. CONCLUSION: PS TKA was associated with a better knee specific function and HRQoL when compared to CR, but the clinical significance of this is not clear. However, the PS group was more likely to be satisfied with their outcome compared to the CR group.

Factors associated with a clinically significant improvement in health-related quality of life after total knee arthroplasty.

BACKGROUND: The aim was to identify independent preoperative factors associated with changes in health-related quality of life (HRQoL) following total knee arthroplasty (TKA), and whether these could be used as indicators for surgery. METHODS: A retrospective study of 3127 TKA patients was undertaken that included 1194 (38.2%) male and 1933 (61.8%) female patients, with a mean age of 70.5 years (standard deviation 9.0). Patient demographics, body mass index and ASA grade, Oxford Knee Score (OKS) and EuroQol 5-dimension (EQ-5D) 3-level, which was used to assess HRQoL, were collected preoperatively and 2 years postoperatively. RESULTS: When adjusting for confounding factors, obesity grade II (p = 0.002), ASA grade 3 (p = 0.002), and a better preoperative OKS (p < 0.001) or EQ-5D score (p < 0.001) were associated with a decreased improvement in the HRQoL at 2-years. A preoperative EQ-5D of < 0.8 (95.7% specific, AUC ≥ 67.0%) or an OKS of < 36 (97.1% specific, AUC ≥ 58.1%) was associated with a clinically significant improvement HRQoL. Patella resurfacing (n = 1454, 46.5%) was not independently associated with a clinical or statistically significant improvement in HRQoL. According to preoperative factors, no subgroup of patients benefited more from patella resurfacing according to improvement in their HRQoL. CONCLUSION: ASA grade 3, grade II obesity, a better preoperative EQ-5D or OKS were independently associated with a lesser improvement in HRQoL. The thresholds identified in the EQ-5D or OKS for a clinically significant improvement in HRQoL may be used as potential indicators for referral for TKA. Patella resurfacing was not independently associated with a clinically important improvement in HRQoL. LEVEL OF EVIDENCE: Retrospective diagnostic study, Level III.

The effect of Nickel hypersensitivity on the outcome of total knee arthroplasty and the value of skin patch testing: a systematic review.

BACKGROUND: To assess the Nickel sensitizing potential of total knee arthroplasty (TKA), explore the relationship between hypersensitivity and clinical outcomes, and evaluate the utility of skin patch testing pre- and/or postoperatively. MATERIALS AND METHODS: A literature search was performed through EMBASE, Medline and PubMed databases. Articles were screened independently by two investigators. The level of evidence of studies was assessed using the Oxford Centre for Evidence-Based Medicine Criteria and the quality evaluated using the Methodological Index for Non-randomized Studies and Cochrane risk-of-bias tools. RESULTS: Twenty studies met the eligibility criteria, reporting on 1354 knee arthroplasties. Studies included patients undergoing primary or revision TKA, pre- and/or postoperatively, and used patch testing to identify Nickel hypersensitivity. Prevalence of Nickel hypersensitivity ranged from 0% to 87.5%. One study compared the prevalence of Nickel hypersensitivity in the same patient group before and after surgery and noted newly positive patch test reactions in three patients (4.2%). Three studies reported lower prevalence of Nickel hypersensitivity in postoperative patients compared to preoperative ones. Seven studies suggested that hypersensitivity might cause adverse clinical outcomes, but six did not support any relationship. Seven studies recommended preoperative patch testing in patients with history of metal allergy, and nine concluded that testing may be valuable postoperatively. CONCLUSIONS: Patients undergoing TKA with no prior history of metal hypersensitivity do not seem to be at an increased risk of developing Nickel hypersensitivity, and there is conflicting evidence that patients with pre-existing hypersensitivity are more likely to experience adverse outcomes. Patch testing remains the most commonly used method for diagnosing hypersensitivity, and evidence suggests preoperative testing in patients with history of metal allergy to aid prosthesis selection, and postoperatively in patients with suspected hypersensitivity once common causes of implant failure have been excluded, since revision with hypoallergenic implants may alleviate symptoms.

The Oxford Knee Score is a reliable predictor of patients in a health state worse than death and awaiting total knee arthroplasty.

BACKGROUND: The health-related quality of life of patients awaiting a total knee arthroplasty (TKA) deteriorates with increasing time to surgery and identification of those with the worst quality of life may help to prioritize patients. The aims were to identify and validate independent variable(s) associated with a health state worse than death (WTD) in patients awaiting a TKA and whether these variables influenced patients-reported outcome measures. METHODS: A retrospective cohort of 5857 patients undergoing a primary TKA was identified from an established arthroplasty database. Patient demographics, body mass index (BMI), index of multiple deprivation, Oxford Knee Score (OKS), EuroQoL five dimension (EQ-5D) 3 level, and visual analogue scale (EQ-VAS) were collected preoperatively and one year postoperatively. An EQ-5D utility of less than zero was defined as WTD. A randomly selected subset of patients (n = 3076) was used to validate the variable that was most predictive of a state WTD and to assess the influence on patient-reported outcomes. RESULTS: There were 771 (13.2%) patients with a health state WTD. Increasing social deprivation (P = 0.050), worse preoperative OKS (P < 0.001), or EQ-VAS (P < 0.001) were independently associated with a health state WTD. The OKS was the most reliable predictor (area under curve 88.9%, 95% CI 87.8 to 90.1, P < 0.001) of a health state WTD. A threshold value of 16 or less, 80% sensitive and specific, was validated and confirmed to have a negative predictive value of 97.5%. Patients with an OKS of 16 or less had a significantly greater improvement in their OKS (difference 6.9, P < 0.001) and EQ-5D score (difference 0.257, P < 0.001). When adjusting for confounding factors, a health status WTD was not associated with worse postoperative OKS (difference -0.6, 95% CI -1.4 to 0.3, P = 0.177), EQ-5D (difference -0.016, 95% CI -0.036 to 0.003, P = 0.097) or patient satisfaction (difference -1.8, 95% CI -4.3 to 0.7, P = 0.162). CONCLUSION: A threshold score 16 or less in OKS was a reliable predictor of a health status WTD and was associated with a greater improvement in knee-specific and health-related quality of life following TKA.

There is no clinically important difference in the Oxford knee scores between one and two years after total knee arthroplasty: The one-year score could be used as the benchmark timepoint to assess outcome.

BACKGROUND: The aim was to assess the whether there was a clinically important change in the Oxford knee score (OKS) between one and two years after total knee arthroplasty (TKA), and to identify predictors associated with a clinically important change. METHODS: A retrospective cohort study was undertaken using an established arthroplasty database of 5857 primary TKA. Patient demographics, body mass index, social deprivation, OKS and EuroQoL five-domain (EQ-5D) score were collected preoperatively and at one and two years postoperatively. A clinically important change in the OKS was defined as ≥5 points. RESULTS: There was a 0.2 point increase in the OKS between one and two years, which was statistically significant (95% confidence interval (CI) 0.1 to 0.4, p < .0001), but not clinically important. A better preoperative OKS (p < .001) and in contrast a worse one year OKS (p < .001) were independently associated with a greater improvement from one to two years. There were 1006 (17.3%) patients that had a clinically important improvement in the OKS between one and two years. Receiver operating characteristic curve analysis showed that a one year OKS of less than 35 was a reliable predictor of a clinically important improvement between one and two years (area under the curve 0.77, 95% CI 0.76 to 0.78, p < .001). CONCLUSION: There was not a clinically important change in the OKS from one to two years after TKA when assessed as a group. However, individual patients with a one year OKS of less than 35 may demonstrate a clinically important improvement at two years. LEVEL OF EVIDENCE: Retrospective diagnostic study, Level III.

[Epidemic meningitis in 2013 in Republic of Guinea: Nesseria meningitidis W135 emergence]. / Epidémie de méningite en République de Guinée en 2013 : émergence de Nesseria meningitidis W135.

A prospective study conducted from 1 January to 31 December 2013 described a meningitis epidemic in Republic of Guinea. The identification of the germs was based on Gram stain, latex agglutination and culture. During the study period, 480 suspected cases of meningitis were reported by 21 health districts. The average age was 18±8 years and 62.5% were men. The vaccination status was unknown in all patients. The largest attack rates were found in Siguiri (3.2 per 10,000), Kankan (2.6 per 10,000) and Dabola (3.9 per 10,000). The locality of Kintinian in Siguiri was the only one to cross the epidemic threshold. The identified microorganisms were Haemophilus influenzae (1 time), Pneumococcus (2 times), Neisseria meningitidis A (4 times) and W135 (10 times) with a total of 17 positive samples. All of these germs were sensitive to chloramphenicol, ceftriaxone and ciprofloxacin. The average hospital stay was 6.5±2 days. The lethality was 13.8%. This meningitis epidemic was characterized by the emergence of Neisseria meningitidis W135. The monitoring of this serogroup should be increased and future vaccination strategies must include it presence.

The accuracy of magnetic resonance imaging (MRI) in detecting meniscal pathology.

AIMS: The purpose of this study was to determine the accuracy of Magnetic Resonance Imaging (MRI) scanning in the detection of meniscal pathology in a district general hospital. METHODS: We retrospectively analysed a single-surgeon series of 240 knee arthroscopic investigations for all indications. The arthroscopic reports included an outline diagram of the meniscus upon which the surgeon could record his operative findings. 112 of these patients had also had a recent MRI scan. We compared the MRI findings with the arthroscopy findings. RESULTS: 66 patients had a positive MRI scan. 64 of these were found to have a meniscal tear at surgery. 37 MRI scans were reported as "no tear", of which four were found to have a meniscal tear at surgery. Nine MRI scans were descriptive, e.g. "signal change, possible tear", or "tear cannot be ruled out." These tended to correspond with equivocal arthroscopic findings of "degeneration" or "fibrillation". In our series of 112 patients with meniscal pathology, MRI scanning was 90.5% sensitive, 89.5% specific and 90.1% accurate. CONCLUSIONS: False positive MRI scans may lead to unnecessary surgery. Patients with negative MRI scans had a mean delay to surgery of 33 weeks compared to 18 weeks for patients with positive MRI scans. Patients with false negative MRI results may wait longer for their surgery. Two of the false negative MRI scan reports clearly showed meniscus tears, which were not identified by the reporting radiologist. In our series, the MRI scan itself was more accurate than the reporting. It is important to have an experienced musculoskeletal radiologist to minimise the number of missed meniscal tears. It is also important for the surgeon to review the MRI scan itself, as well as the report.

The effect of total hip and hip resurfacing arthroplasty on vertical ground reaction force and impulse symmetry during a sit-to-stand task.

BACKGROUND: The aim of this study was to determine the influence of total hip arthroplasty and hip resurfacing arthroplasty on limb loading symmetry before, and after, hip reconstruction surgery during a sit-to-stand task. METHODS: Fourteen patients were recruited that were about to receive either a total hip prosthesis (n=7) or a hip resurfacing prosthesis (n=7), as well as matched controls. Patients performed a sit-to-stand movement before, 3 months after, and 12 months after surgery. Peak vertical ground reaction force and impulse were measured for each leg, from which ground reaction force and impulse symmetry ratios were calculated. FINDINGS: Before surgery, hip resurfacing patients showed a small asymmetry which was not different to normal for ground reaction force (0.88(0.28) vs. 1.00(0.11); p=0.311) or impulse (0.87(0.29) vs. 0.99(0.09); p=0.324) symmetry ratios. Total hip patients offloaded their affected hip by 30% in terms of impulse symmetry ratio (0.71(0.36) vs. 0.99(0.23); p=0.018). At 3 months following surgery asymmetries were seen that were different to normal in both hip resurfacing patients for ground reaction force (0.77(0.16); p=0.007), and total hip patients for ground reaction force (0.70(0.15); p=0.018) and impulse (0.72(0.16); p=0.011) symmetry ratios. By 12 months after surgery total hip patients regained a symmetrical loading pattern for both ground reaction force (0.95(0.06); p=0.676) and impulse (1.00(0.06); p=0.702) symmetry ratios. Hip resurfacing patients, however, performed the task by overloading their operated hip, with impulse symmetry ratio being larger than normal (1.16(0.16); p=0.035). INTERPRETATION: Physiotherapists should appreciate the need for early recovery of limb loading symmetry as well as subsequent differences in the responses observed with different prostheses.

Is tibial tuberosity-trochlear groove distance an appropriate measure for the identification of knees with patellar instability?

PURPOSE: Tibial tuberosity-trochlear groove distance (TT-TG) has been regarded as a useful tool for establishing therapeutic choices for patellar instability. Recently, it has been shown that TT-TG negatively correlated with the quadriceps angle, suggesting that if used individually, neither provide a valid measure of instability. This study aimed to compare TT-TG distance between both knees in patients with unilateral instability to assess whether this measurement is a decisive element in the management decisions for patellar instability. METHODS: Sixty-two patients (18 male and 44 female), reporting to a specialist patella clinic for recurrent unilateral patellar instability, were included in the study. Patients underwent bilateral long leg computed tomography scan to determine TT-TG distance in both knees. Tibial TT-TG in symptomatic and asymptomatic knees in the same individual was compared statistically. RESULTS: Mean TT-TG distance in the symptomatic knee was 16.9 (±4.9) mm, compared to 15.6 (±5.6) mm in the asymptomatic knee. Tibial TT-TG was not significantly different between stable and unstable knees (n.s.). CONCLUSIONS: The lack of difference in TT-TG distance between stable and unstable knees suggests that TT-TG distance alone may not be a decisive element in establishing therapeutic choices for patellar instability. It should, therefore, be interpreted with caution during clinical evaluations. LEVEL OF EVIDENCE: II.

Clinically insignificant association between anterior knee pain and patellofemoral lesions which are found incidentally.

BACKGROUND: Patellofemoral chondral lesions are frequently identified incidentally during the arthroscopic treatment of other knee pathologies. A role has been described for arthroscopic debridement when symptoms are known to originate from pathology of the patellofemoral joint. However, it remains unclear how to manage lesions which are found incidentally whilst tackling other pathologies. The purpose of this study was to establish the strength of association between anterior knee pain and patellofemoral lesions identified incidentally in a typical arthroscopic population. METHODS: A consecutive series of patients undergoing arthroscopy for a range of standard indications formed the basis of this cross section study. We excluded those with patellofemoral conditions in order to identify patellofemoral lesions which were solely incidental. Pre-operative assessments were performed on 64 patients, where anterior knee pain was sought by three methods: an annotated photographic knee pain map (PKPM), patient indication with one finger and by palpated tenderness. A single blinded surgeon, performed standard arthroscopies and recorded patellofemoral lesions. Statistical correlations were performed to identify the association magnitude. RESULTS: Associations were identified between incidental patellofemoral lesions and tenderness palpated on the medial patella (P = 0.007, χ(2) = 0.32) and the quadriceps tendon (P = 0.029, χ(2) = 0.26), but these associations were at best fair, which could be interpreted as clinically insignificant. CONCLUSION: Incidental patellofemoral lesions are not necessarily associated with anterior knee pain, we suggest that they could be left alone. This recommendation is only applicable to patellofemoral lesions which are found incidentally whilst addressing other pathology.

Combined pubic rami and sacral osteoporotic fractures: a prospective study.

BACKGROUND: Pelvic osteoporotic fractures (POFs) are often associated with considerable morbidity and mortality mainly as a result of infections and cardiovascular events. Patients usually need prolonged institutionalization, rehabilitation, and follow-up, with a high rate of dependency and cost. The most common sites of POFs include the pubic rami, sacrum, ilium, and acetabulum. Combined pubic rami (PROFs) and sacral osteoporotic fractures (SOFs) have been reported, mostly in retrospective studies, describing the mechanism of injury and incidence. The aim of this study was to evaluate the association between PROFs and SOFs and to assess the effect of combined PROFs and SOFs on patients' mobility, discharge destination, and length of stay. MATERIALS AND METHODS: We prospectively studied 67 patients with low-impact PROFs and/or SOFs. There were 54 (80.4%) female and 13 (19.6%) male patients, and the average age was 87.5 (range 65-96) years. All patients were assessed by the fracture liaison service. Patients had magnetic resonance imaging or bone scan when there was history of low back pain following the injury or lumbosacral tenderness on clinical examination. RESULTS: The mean length of stay for all patients was 45 (± 35) days. Mortality rate was 10.4%. A significant relationship was found between low back pain and a positive finding of sacral fracture. Patients with combined PROFs and SOFs showed significantly longer length of stay than those with isolated PROFs. CONCLUSIONS: The presence of low back pain and tenderness in patients who had low-impact pelvic injuries was highly suggestive of the presence of an associated SOF. There was a high association between sacral and PROFs. The length of stay of patients with PROFs associated with sacral osteoporotic fractures was significantly longer than that of patients with PROFs only. Therefore, we recommend considering the high association between SOFs and PROFs in planning the management and rehabilitation of patients with POFs.

The relationship between quadriceps angle and tibial tuberosity-trochlear groove distance in patients with patellar instability.

PURPOSE: The quadriceps angle (Q-angle) represents the angle between the vector of action of the quadriceps and the patellar tendon. An increased Q-angle has been associated with an increased risk of patellar instability, although there is disagreement on its reliability and validity as it is affected by the position of the limb and contraction of the quadriceps. Tibial tuberosity-trochlear groove distance (TT-TG) is ascertained by axial CT scanning, with an increased value associated with patellar instability. This study aimed to determine whether the Q-angle correlates with the TT-TG distance in patients with patellar instability. METHODS: Q-angles were measured in 34 knees that had previously undergone CT scanning for assessment of patellar instability. Measurements were made with the patient supine, the knee extended and the lower limbs in neutral rotation with the quadriceps relaxed and contracted. TT-TG distance was measured on CT scanning in an identical position. RESULTS: Of the 34 knees measured, 24 had symptoms of patellar instability, and 10 were normal. A significant negative correlation between relaxed Q-angle and TT-TG in all knees was demonstrated (p = 0.028). In symptomatic knees, contracted Q-angle also demonstrated a significant negative correlation with TT-TG (p = 0.037). CONCLUSIONS: If TT-TG distance is regarded as the gold standard measurement, Q-angle is not a reliable indicator of patellar instability. There is a clear need to develop methods to more fully characterise the knee and factors contributing to patellar instability. LEVEL OF EVIDENCE: II.

Interactions between severity and location of chondral lesions and meniscal tears found at arthroscopy.

PURPOSE: This study reports the specific interactions between the different grades and locations of chondral lesions found in symptomatic knees requiring arthroscopy. The associations between meniscal tears and chondral lesions were also investigated. METHODS: Data were analysed for 141 knee arthroscopies (87 males and 54 females), with a mean patient age of 45.9 years. Chondral lesions were defined according to the modified Outerbridge classification system by a single surgeon immediately following arthroscopic surgery. RESULTS: The most common clinical findings were medial meniscal tears (47%) and medial femoral condyle lesions (57%). Compared to other locations within the knee, the medial femoral condyle was the most commonly affected location for a chondral lesion and 75% of these lesions were graded as III (32%) or IV (43%). Similarly, 77% of knees with a trochlea lesion were affected by high-grade chondral lesions (grade III = 12%; grade IV = 65%). The trochlea presented with the greatest percentage of grade IV chondral lesions. Eighty percent of patients with a meniscal tear also had a chondral lesion. Medial meniscal tears were most commonly observed with medial femoral condyle lesion. Lateral meniscal tears were most commonly observed with lateral tibial plateau lesions. Twenty-nine percent of patients had corresponding lesions on the medial femoral condyle and medial tibial plateau, and this was the most commonly found interaction between chondral lesion locations. CONCLUSION: Patients with medial meniscal tears are likely to also have a chondral lesion on the same side of the knee. LEVEL OF EVIDENCE: II.

The photographic knee pain map: locating knee pain with an instrument developed for diagnostic, communication and research purposes.

Pain maps are used to determine the location of pain. Knee pain maps have previously been described, but only one study has reported on reliability and none report validity. The present study describes the generation of a photographic knee pain map (PKPM) together with its validity and reliability. A photographic representation of a pair of knees was chosen by 26 patients, (66.7%) from a group of 39. The selected photograph was modified and a template of anatomical zones was generated. The opinions of 25 independent subject matter experts were canvassed and validity ratios calculated for these zones, ranged from 0.28 to 0.84. Hypothetical comparisons were made between the PKPM and an alternative knee pain map, in a cross-sectional group of 26 patients (35 knees). Convergent patterns of validity were found where hypothesised. Reliability was determined using a different cohort of 44 patients (58 knees) who completed the PKPM before and after a sampling delay. Four of these patients were excluded with a short sampling delay. Calculated agreement of test-retest reproducibility was fair to good. All of the completed PKPM (151 knees) were then subject to further analysis where inter-rater reproducibility was good to very good and intra-rater reproducibility was very good. The PKPM is readily accessible to patients with low completion burden. It is both valid and reliable and we suggest it can be used in both clinical and research settings. Further studies are planned to explore its predictive ability as a diagnostic tool. The PKPM can be found at www.photographickneepainmap.com.

Achilles tendinopathy: some aspects of basic science and clinical management.

Achilles tendinopathy is prevalent and potentially incapacitating in athletes involved in running sports. It is a degenerative, not an inflammatory, condition. Most patients respond to conservative measures if the condition is recognised early. Surgery usually involves removal of adhesions and degenerated areas and decompression of the tendon by tenotomy or measures that influence the local circulation.

Correlation between the MRI changes in the lumbar multifidus muscles and leg pain.

AIM: In the assessment of the lumbar spine by magnetic resonance imaging (MRI), changes in the paraspinal muscles are frequently overlooked. In this study, our objective was to investigate the relationships between lumbar multifidus (MF) muscle atrophy and low back pain (LBP), leg pain and intevertebral disc degeneration. METHODS: A retrospective study of 78 patients (aged 17-72) with LBP presenting with back pain with or without associated leg pain was undertaken. Their MR images were visually analysed for signs of lumbar MF muscle atrophy, disc degeneration and nerve root compression. The clinical history in each case was obtained from their case notes and pain drawing charts. RESULTS: MF muscle atrophy was present in 80% of the patients with LBP. The correlation between MF muscle atrophy and leg pain was found to be significant (P < 0.01). However, the relationships between muscle atrophy and radiculopathy symptoms, nerve root compression, herniated nucleus pulposus and number of degenerated discs were statistically not significant. CONCLUSION: Examination of the paraspinal muscles looking for atrophy of MF muscle should be considered when assessing MR images of lumbar spine. This may explain the referred leg pain in the absence of other MR abnormalities.

Ultrasound-detected hepatic periportal thickening in patients with prolonged pyrexia.

Hepatic periportal thickening (HPT) detected by ultrasonography has been established as a reliable tool for measuring hepatic morbidity due to schistosomiasis. During ultrasonographic examination of patients with prolonged pyrexia, we frequently noticed minimal grades of HPT in patients without a history of schistosomiasis. This led to ultrasonographic studies of conditions other than schistosomiasis in which HPT may occur. Subjects included 460 patients with Schistosoma haematobium infection, 107 urban patients with prolonged pyrexia without previous exposure to schistosomiasis, and 288 healthy controls unexposed to schistosomiasis. Grade I HPT was more prevalent (P < 0.001) in patients with pyrexia (56.1%) than in those with S. haematobium (32.2%) and was more frequent (P < 0.001) in patients with S. haematobium than in controls (11.1%). Typhoid fever was the most common febrile illness causing HPT. Grade II lesions were rare in patients with pyrexia (2.8%) or schistosomiasis (0.9%). Grade III lesions were present in only one patient with S. haematobium. Mild grades of HPT can occur in infectious diseases other than schistosomiasis. Cellular infiltration in the portal tract from chronic infectious diseases can frequently give the ultrasonographic appearance of grade I HPT.

Meniscal regeneration in the long-term after total meniscectomy?

A cohort of 39 patients (28 male, 11 female) that had undergone total meniscectomy as adolescents (mean age 16 years) underwent FISP 3D Magnetic Resonance Imaging at a mean follow up of 30 years. The presence of meniscal tissue was assessed by two independent observers blinded to the operation details. The volume of any meniscal tissue present was calculated. A posterior horn remnant was seen in 57% of medial and 45% of lateral meniscectomy cases. The mean volume of an operated medial meniscal remnant was 0.29 mL compared with a mean volume of 1.15 mL for an intact medial meniscus. The mean volume of an operated lateral meniscal remnant was 0.30 mL compared with 1.07 mL for an intact lateral meniscus. We have shown that the incidence of incomplete excision of the posterior horn is more common after total medial meniscectomy, and that at a mean follow up of 30 years there is no convincing in vivo MRI evidence of long-term meniscal regeneration.