MRI quantification of femoral neck version using the posterior lesser trochanteric line: a comparison of three measurements.

OBJECTIVE: To validate MRI for the quantification of the femoral neck version (FNV) using posterior lesser trochanteric Line (PLTL) and to compare reliability of the PLTL to the epicondylar and retrocondylar measurements. MATERIALS AND METHODS: A retrospective review of 3 T MRI scans performed for femoroacetabular impingement (FAI). Two musculoskeletal radiologists performed the measurements. MRI measurements of the PLTL were compared to CT using Bland Altman, Lin's concordance, and Lin's correlation coefficients. Interobserver reliability was determined using Bland Altman, Lin's concordance, and Lin's correlation coefficients. Intraobserver reliability was determined using Lin's concordance and Lin's correlation coefficients. RESULTS: Forty-five patients (90 lower extremities) met the inclusion criteria. Ages ranged from 20 to 41 years, with a mean of 31.5 years. There were 22 females and 23 males. Lin's concordance correlation coefficient for MRI and CT measurements of PLTL was substantial: 0.96 (95% CI: 0.94-0.98). PLTL Lin's correlation coefficient was 0.825 (95% CI 0.732-0.918) and indicated good interobserver reliability. Epicondylar and retrocondylar methods Lin's correlation coefficients demonstrated moderate interobserver reliability at 0.601 (0.415-0.786) and 0.632 (0.456-0.807), respectively. There was moderate 95% confidence interval overlap between the PLTL and the other measurements. Bland-Altman plots for each measurement were similar and demonstrated no bias. There was excellent intraobserver reliability (> 0.900) with significant 95% confidence interval overlap. CONCLUSION: MRI measurements of the PLTL are comparable to CT. The PLTL has good reliability between readers for the quantification of FNV using MRI, which could help avoid unnecessary radiation exposure using CT and reduce MRI scan time.

Exploration of a quality improvement process to standardised preoperative tests for a surgical procedure to reduce waste.

BACKGROUND: Preoperative tests are done to determine a patient's fitness for anaesthesia and surgery. LOCAL PROBLEM: Although routine tests before surgery in the absence of specific clinical indications are not recommended, we observed high volumes of routine preoperative tests were performed in our institution. We describe a process to implement a standardised preoperative investigational approach to reduce unnecessary testing before surgeries. METHODS: A series of six Plan-Do-Study-Act (PDSA) cycles was conducted for root cause analysis and process mapping, development of standardised tool (GRID), collection of baseline data, education and feedback, pilot testing and implementation and uptake of GRID.Root cause analysis revealed a lack of awareness of guidelines and a lack of a standardised tool to guide preoperative testing. We undertook a pilot quality improvement project to reduce unnecessary testing before knee and hip arthroplasty by developing and implementing a standardised tool (GRID) and engaging all stakeholders. INTERVENTIONS: A clinical development team (CDT) was formed, including all the stakeholders. Our CDT focused on a continuous rapid cycle improvement strategy. RESULTS: After implementation of the tool in a subgroup of patients undergoing elective hip or knee arthroplasty, unnecessary coagulation tests (activated partial thromboplastin time and the international normalised ratio), electrolyte/renal panel tests and electrocardiograms were reduced by 81% (91%-17%), 81% (41%-7%) and 68% (35%-11%), respectively. No surgery was delayed or cancelled due to tests not performed before surgery. CONCLUSIONS: A standardised preoperative investigational approach based on patients' medical conditions rather than routine testing can reduce unnecessary tests before surgery. Further, implementing guidelines is more complex than developing guidelines. Hence, continuous PDSA cycles are essential to evaluate the processes in a quality improvement project. It can take time to build teams and have shared goals; however, once this is achieved, the success of a quality improvement project is certain.

Bone-cartilage mismatch in the medial tibial plateau: A MRI study.

BACKGROUND: Bone-cartilage mismatch is a variation in which the surface curvature of the articular cartilage is incongruent with the curvature of the underlying subchondral bone. The purpose of this study is to investigate the prevalence of this variant in the medial tibial plateau (MTP) and examine potential association with clinical findings and intra-articular derangements using MRI. METHODS: A quantitative and qualitative retrospective analysis of 98 knee MRI studies was performed. Bone and cartilage depths of the MTP were measured to assess bone-cartilage morphology and classified into congruent (concave bone-concave cartilage) and incongruent (concave bone-convex cartilage) patterns. Associations between bone-cartilage mismatch and clinical findings and other MRI changes were assessed using Fisher's exact test. RESULTS: By quantitative assessment, four individuals (4%) had MTP incongruent morphology (bone-cartilage mismatch). The mean bone depth ± standard deviation (SD) was 2.3 ± 0.6 mm concave in the congruent group, and 1.4 ± 0.6 mm concave in the incongruent group. The mean cartilage depth ± SD was 0.7 ± 0.7 mm concave in the congruent group, and 0.9 ± 0.5 mm convex in the incongruent group. By qualitative assessment, three individuals (3%) had incongruent morphology. Although not statistically significant, a higher proportion of individuals (3 of 4; 75%) with incongruent cartilage demonstrated chondromalacia patellae compared to those with congruent cartilage (38 of 94; 40%). CONCLUSION: Bone-cartilage mismatch was present in 3-4% of the knees. Individuals with incongruent cartilage demonstrated a trend of a higher proportion of chondromalacia patellae. Larger studies are needed to evaluate this further.

Proximal femoral epiphyseal spurs and their association with acetabular labral tears on MRI in symptomatic patients.

OBJECTIVE: Femoral epiphyseal spurs are developmental projections that form at the edge of the physis. Although considered incidental, their association with acetabular labral tears has never been examined. Our aim was to assess the prevalence of femoral epiphyseal spurs in symptomatic patients with mechanical hip pain and explore if they are associated with labral tears on MRI. MATERIALS AND METHODS: Hip MRI scans performed on a Siemens 3 T MRI using femoroacetabular impingement protocol were retrospectively reviewed. All patients were referred by orthopaedic surgeons for mechanical hip pain. Two musculoskeletal radiologists blinded to initial reports evaluated MRI images for the presence of an epiphyseal spur and acetabular labral changes. A consensus was achieved on all cases by the two readers. The association between epiphyseal spurs and labral changes was assessed using Fisher's exact test. RESULTS: A total of 115 patients (178 hip MRI scans) were reviewed; the mean age was 28.8 years (SD 7.1). There were 52 females (45.2%) and 63 males (54.8%). There were 115 hips with labral tears (64.6%). Fourteen hips (7.8%) in ten patients (8.7%) demonstrated epiphyseal spurs and all of them showed labral tears (100%). There was statistically significant association between epiphyseal spurs and labral tears on MRI (p value = 0.0024). CONCLUSION: Femoral epiphyseal spurs were observed in 8.7% of our defined patient population, and all patients with epiphyseal spurs demonstrated labral tears. Epiphyseal spurs should be documented on imaging reports due to their potential association with labral tears. Future research is needed to further delineate and guide management of these entities.

Serum and synovial fluid cytokine profiling in hip osteoarthritis: distinct from knee osteoarthritis and correlated with pain.

BACKGROUND: Inflammation is associated with the onset and progression of osteoarthritis in multiple joints. It is well known that mechanical properties differ between different joints, however, it remains unknown if the inflammatory process is similar/distinct in patients with hip vs. knee OA. Without complete understanding of the role of any specific cytokine in the inflammatory process, understanding the 'profile' of inflammation in a given patient population is an essential starting point. The aim of this study was to identify serum cytokine profiles in hip Osteoarthritis (OA), and investigate the association between cytokine concentrations and clinical measurements within this patient population and compare these findings to knee OA and healthy control cohorts. METHODS: In total, 250 serum samples (100 knee OA, 50 hip OA and 100 control) and 37 synovial fluid samples (8 knee OA, 14 hip OA and 15 control) were analyzed using a multiplex ELISA based approach. Synovial biopsies were also obtained and examined for specific cytokines. Pain, physical function and activity within the hip OA cohort were examined using the HOOS, SF-36, HHS and UCLA outcome measures. RESULTS: The three cohorts showed distinct serum cytokine profiles. EGF, FGF2, MCP3, MIP1α, and IL8 were differentially expressed between hip and knee OA cohorts; while FGF2, GRO, IL8, MCP1, and VEGF were differentially expressed between hip OA and control cohorts. Eotaxin, GRO, MCP1, MIP1ß, VEGF were differentially expressed between knee OA and control cohorts. EGF, IL8, MCP1, MIP1ß were differentially expressed in synovial fluid from a sub-set of patients from each cohort. Specifically within the hip OA cohort, IL-6, MDC and IP10 were associated with pain and were also found to be present in synovial fluid and synovial membrane (except IL-6) of patients with hip OA. CONCLUSION: OA may include different inflammatory subtypes according to affected joints and distinct inflammatory processes may drive OA in these joints. IL6, MDC and IP10 are associated with hip OA pain and these proteins may be able to provide additional information regarding pain in hip OA patients.