Hip joint range of motion is restricted by pain rather than mechanical impingement in individuals with femoroacetabular impingement syndrome.

INTRODUCTION: Discerning whether range of motion (ROM) is restricted by morphology or other pain sources is challenging in patients with femoroacetabular impingement syndrome (FAIS). Computed tomography (CT) motion simulation provides a hypothetical ROM based on morphology. This study aimed to explore associations between ROM measured using CT motion simulation and maximum passive ROM measured clinically using three dimensional (3D) motion analysis in patients with FAIS, prior to and post arthroscopic hip surgery. MATERIALS AND METHODS: Eight males with FAIS (in total 12 hip joints) were included in this explorative feasibility study. Participants were examined using CT according to a low-dose protocol prior to and 7-months post arthroscopic surgery. Software was used to simulate at which ROM the impingement would occur. With the hip in 90 degrees' flexion, maximum passive range of internal hip rotation, and maximum passive internal hip rotation coupled with adduction was examined clinically using 3D motion analysis pre- and postoperatively. Spearman rank correlation coefficients and linear regressions examined associations between methods. RESULTS: Preoperatively, the correlation between maximum internal hip rotation measured using CT motion simulation and 3D motion analysis was strong (r = 0.71, p = 0.009). Linear regressions demonstrated that maximal internal rotation measured using CT motion simulation was predominantly larger than when measured using 3D motion analysis. Postoperatively, and when maximum internal rotation was coupled with adduction, no correlations were found between the two methods. CONCLUSIONS: The hypothetical morphology restricted ROM is larger than clinically assessed pain restricted ROM, both prior to and post hip arthroscopy. These findings suggest that ROM is restricted by pain rather than mechanical, morphology-based impingement in individuals with FAIS.

Can Na18F PET/CT bone scans help when deciding if early intervention is needed in patients being treated with a TSF attached to the tibia: insights from 41 patients.

PURPOSE: To demonstrate the usefulness of positron emission tomography (PET)/computed tomography (CT) bone scans for gaining insight into healing bone status earlier than CT or X-ray alone. METHODS: Forty-one prospective patients being treated with a Taylor Spatial Frame were recruited. We registered data obtained from successive static CT scans for each patient, to align the broken bone. Radionuclide uptake was calculated over a spherical volume of interest (VOI). For all voxels in the VOI, histograms and cumulative distribution functions of the CT and PET data were used to assess the type and progress of new bone growth and radionuclide uptake. The radionuclide uptake difference per day between the PET/CT scans was displayed in a scatter plot. Superimposing CT and PET slice data and observing the spatiotemporal uptake of 18F- in the region of healing bone by a time-sequenced movie allowed qualitative evaluation. RESULTS: Numerical evaluation, particularly the shape and distribution of Hounsfield Units and radionuclide uptake in the graphs, combined with visual evaluation and the movies enabled the identification of six patients needing intervention as well as those not requiring intervention. Every revised patient proceeded to a successful treatment conclusion. CONCLUSION: Numerical and visual evaluation based on all the voxels in the VOI may aid the orthopedic surgeon to assess a patient's progression to recovery. By identifying slow or insufficient progress at an early stage and observing the uptake of 18F- in specific regions of bone, it might be possible to shorten the recovery time and avoid unnecessary late complications.

Experience and Availability of Pelvic Binders at Swedish Trauma Units; A Nationwide Survey.

OBJECTIVE: To assess availability, experience, and knowledge about the Pelvic Circumferential Compression Device (PCCD) in Sweden. METHODS: A telephone interview with the current on-call trauma doctors at all trauma units in Sweden was conducted. After a short presentation and oral consent, the doctors were asked to answer four short questions. We asked the doctors to answer whether they knew if they had PCCDs available in their emergency room, how many times had they applied a PCCD, which is the correct level of application for a PCCD, and if a PCCD can stop arterial bleeding. RESULTS: The on-call trauma doctors at the nine University hospitals, twenty-two General hospitals and twenty-one District General hospitals, with response rate of 100%, were interviewed. Availability of PCCD was 85 % and there was no difference between hospital types (p=0.546). In all hospitals 29/52 (56%) of those interviewed had used a PCCD at least once. There were significantly more doctors that had used a PCCD at least once in the University hospitals (8/9), compared to General hospitals (13/22) and District General hospitals (8/21) (p=0.034). A total of 43/52 (83 %) doctors defined the greater trochanters as the correct level of application for a PCCD. No difference was found when comparing hospitals (p=0.208). Only 22/52 (42 %) of doctors answered that a PCCD could not stop an arterial bleeding. No difference was found between hospitals (p=0.665). CONCLUSION: Less than half of the doctors knew that a PCCD cannot stop arterial bleeding, while the majority knew the correct level of application of a PCCD.

Factors affecting mortality and reoperations in high-energy pelvic fractures.

AIM: Factors affecting mortality during the first year following high-energy pelvic fractures has not been reported previously. Nor has surgical complications leading to reoperations been reported in a cohort with only high-energy pelvic trauma patients. OBJECTIVES: The aim of this study was to report and analyse factors affecting outcome, in terms of mortality and reoperations, up to 1 year after the injury in patients with a traumatic pelvic ring injury due to a high-energy trauma. MATERIALS AND METHODS: Data from the SweTrau (Swedish National Trauma Registry) on patients admitted to the Trauma Centre Karolinska in Stockholm, Sweden, were collected. Inclusion criteria were adults (age ≥ 18), trauma with a high-energy mechanism, alive on arrival, Swedish personal identification number, reported pelvic fracture on CT scan. Patient records and radiographies were reviewed. The study period was 2011-2015 with 1-year follow-up time. Univariate and regression analysis on factors affecting mortality was performed. Risk of reoperation was analysed using univariate and case-by-case analysis. RESULTS: We included 385 cases with mean age 47.5 ± 20.6 years (38% females): 317 pelvic fractures, 48 acetabular fractures and 20 combined injuries. Thirty-day mortality was 8% (30/385), and 1-year mortality was 9% (36/385). The main cause of death at 1 year was traumatic brain injury (14/36) followed by high age (> 70) with extensive comorbidities (8/36). Intentional fall from high altitude (OR 6, CI 2-17), GCS < 8 (OR 12, CI 5-33) and age > 70 (OR 17, CI 6-51) were factors predicting mortality. Thirty patients (22%, 30/134) were further reoperated due to hardware-related (n = 18) or non-hardware-related complications (n = 12). Hardware-related complications included: mal-placed screws (n = 7), mal-placed plate (n = 1), implant failure (n = 6), or mechanical irritation from the implant (n = 4). Non-hardware-related reasons for reoperations were: infection (n = 10), skin necrosis (n = 1), or THR due to post-traumatic osteoarthritis (n = 1). CONCLUSION: Non-survivors in our study died mainly because of traumatic brain injury or high age with extensive comorbidities. Most of the mortalities occurred early. Intentional injuries and especially intentional falls from high altitude had high mortality rate. Reoperation frequency was high, and several of the hardware-related complications could potentially have been avoided.

Prosthetic liner wear in total hip replacement: a longitudinal 13-year study with computed tomography.

This case report follows a woman who had a total hip replacement in 1992 when she was 45 years old. Six serial computed tomography (CT) examinations over a period of 13 years provided information that allowed her revision surgery to be limited to liner replacement as opposed to replacement of the entire prosthesis. Additionally, they provided data that ruled out the presence of osteolysis and indeed none was found at surgery. In 2004, when the first CT was performed, the 3D distance the femoral head had penetrated into the cup was determined to be 2.6 mm. By 2017, femoral head penetration had progressed to 5.0 mm. The extracted liner showed wear at the thinnest part to be 5.5 mm, as measured with a micrometer. The use of modern CT techniques can identify problems, while still correctable without major surgery. Furthermore, the ability of CT to assess the direction of wear revealed that the liner wear changed from the cranial to dorsal direction.

T2 mapping and post-contrast T1 (dGEMRIC) of the patellar cartilage: 12-year follow-up after patellar stabilizing surgery in childhood.

BACKGROUND: Cartilage degeneration has been reported after recurrent patellar dislocation. However, effects of surgical stabilization in childhood have not yet been described. PURPOSE: To examine the cartilage quality in very young adults operated with a patellar stabilizing procedure due to recurrent patellar dislocation in childhood, and evaluate if cartilage quality correlates with clinical parameters and patient-reported outcomes. MATERIAL AND METHODS: Seventeen patients were investigated ≥ 5 years (mean = 11.6 years) after patellar stabilizing surgery in childhood. Pre-contrast T2 relaxation times were analyzed in four superficial and four deep patellar cartilage regions of both knees. Two hours after 0.2 mM/kg Gd-DTPA2 i.v., post-contrast T1 (T1(Gd)) was analyzed in the same regions. Patient-reported outcomes (KOOS, Kujala, and Tegner scores) and recurrence rates were evaluated. RESULTS: Comparing operated to healthy side, neither T2 nor dGEMRIC differed between the operated and the reference knee regarding the superficial half of the cartilage. In the deep half of the cartilage, T1(Gd) was shorter in the central part of the cartilage, whereas T2 was longer medially (P < 0.05). A low score in the KOOS subscales Symptom and Sports & Recreation, was correlated to the degenerative changes detected by T1(Gd) (r = 0.5, P = 0.041). CONCLUSION: In general, our findings demonstrate good cartilage quality 12 years after patellar stabilizing surgery during childhood. The subtle changes in T2 and T1(Gd) in the deep cartilage layer may be a result of altered biomechanics, although very early degenerative changes cannot be excluded. The short T1(Gd) centrally may reflect lower glycosaminoglycan content, whereas the increase in T2 medially indicates increased cartilage hydration.

Can Spatiotemporal Fluoride (18F-) Uptake be Used to Assess Bone Formation in the Tibia? A Longitudinal Study Using PET/CT.

BACKGROUND: When a bone is broken for any reason, it is important for the orthopaedic surgeon to know how bone healing is progressing. There has been resurgence in the use of the fluoride (18F-) ion to evaluate various bone conditions. This has been made possible by availability of positron emission tomography (PET)/CT hybrid scanners together with cyclotrons. Absorbed on the bone surface from blood flow, 18F- attaches to the osteoblasts in cancellous bone and acts as a pharmacokinetic agent, which reflects the local physiologic activity of bone. This is important because it shows bone formation indicating that the bone is healing or no bone formation indicating no healing. As 18F- is extracted from blood in proportion to blood flow and bone formation, it thus enables determination of bone healing progress. QUESTIONS/PURPOSES: The primary objective of this study was to determine whether videos showing the spatiotemporal uptake of 18F- via PET bone scans could show problematic bone healing in patients with complex tibia conditions. A secondary objective was to determine if semiquantification of radionuclide uptake was consistent with bone healing. METHODS: This study investigated measurements of tibia bone formation in patients with complex fractures, osteomyelitis, and osteotomies treated with a Taylor Spatial FrameTM (TSF) by comparing clinical healing progress with spatiotemporal fluoride (18F-) uptake and the semiquantitative standardized uptake value (SUV). This procedure included static and dynamic image acquisition. For intrapatient volumes acquired at different times, the CT and PET data were spatially registered to bring the ends of the bones that were supposed to heal into alignment. To qualitatively observe how and where bone formation was occurring, time-sequenced volumes were reconstructed and viewed as a video. To semiquantify the uptake, the mean and maximum SUVs (SUVmean, SUVmax) were calculated for the ends of the bones that were supposed to heal and for normal bone, using a spherical volume of interest drawn on the registered volumes. To make the semiquantitative data comparable for all patients with multiple examinations, the SUVmean and SUVmax difference per day (SUVmeanDPD and SUVmaxDPD) between the first PET/CT scan and each subsequent one was calculated. Indicators of poor healing progress were (1) uneven distribution of the radionuclide uptake between ends of the bones that were supposed to heal as seen in the video or, (2) low absolute magnitude of the SUV difference data. Twenty-four patients treated between October 2013 and April 2015 with a TSF gave informed consent to be examined with 18F- PET/CT bone scans. Twenty-two patients successfully completed treatment, one of whom had only one PET/CT scan. RESULTS: Observation of 18F- uptake was able to identify three patients whose healing progress was poor, indicated by uneven distribution of radionuclide uptake across the ends of the bones that were supposed to heal. An absolute magnitude of the SUVmaxDPD of 0.18 or greater indicated good bone formation progress. This was verified in 10 patients by the days between the operation to attach and to remove the TSF being less than 250 days, whereas other SUVmaxDPD values were ambiguous, with 11 patients achieving successful completion. CONCLUSIONS: Observation of the spatiotemporal uptake of 18F- appears to be a promising method to enable the clinician to assess the progress of bone formation in different parts of the bone. Bone uptake which is uneven across the ends of bone that were supposed to heal or very low bone uptake might indicate impaired bone healing where early intervention may then be needed. However, semiquantification of 18F- uptake (SUVmaxDPD), SUVmeanDPD) was ambiguous in showing consistency with the bone-healing progress. LEVEL OF EVIDENCE: Level III, diagnostic study.

A CT method for following patients with both prosthetic replacement and implanted tantalum beads: preliminary analysis with a pelvic model and in seven patients.

BACKGROUND: Radiostereometric analysis (RSA) is often used for evaluating implanted devices over time. Following patients who have had tantalum beads implanted as markers in conjunction with joint replacements is important for longitudinal evaluation of these patients and for those with similar implants. As doing traditional RSA imaging is exacting and limited to specialized centers, it is important to consider alternative techniques for this ongoing evaluation. This paper studies the use of computed tomography (CT) to evaluate over time tantalum beads which have been implanted as markers. METHODS: The project uses both a hip model implanted with tantalum beads, acquired in several orientations, at two different CT energy levels, and a cohort of seven patients. The model was evaluated twice by the same observer with a 1-week interval. All CT volumes were analyzed using a semi-automated 3D volume fusion (spatial registration) tool which provides landmark-based fusion of two volumes, registering a target volume with a reference volume using a rigid body 3D algorithm. The mean registration errors as well as the accuracy and repeatability of the method were evaluated. RESULTS: The mean registration error, maximum value of repeatability, and accuracy for the relative movement in the model were 0.16 mm, 0.02° and 0.1 mm, and 0.36° and 0.13 mm for 120 kVp and 0.21 mm, 0.04° and 0.01 mm, and 0.39° and 0.12 mm for 100 kVp. For the patients, the mean registration errors per patient ranged from 0.08 to 0.35 mm. These results are comparable to those in typical clinical RSA trials. This technique successfully evaluated two patients who would have been lost from the cohort if only RSA were used. CONCLUSIONS: The proposed technique can be used to evaluate patients with tantalum beads over time without the need for stereoradiographs. Further, the effective dose associated with CT is decreasing.

A New CT Method for Assessing 3D Movements in Lumbar Facet Joints and Vertebrae in Patients before and after TDR.

This study describes a 3D-CT method for analyzing facet joint motion and vertebral rotation in the lumbar spine after TDR. Ten patients were examined before and then three years after surgery, each time with two CT scans: provoked flexion and provoked extension. After 3D registration, the facet joint 3D translation and segmental vertebral 3D rotation were analyzed at the operated level (L5-S1) and adjacent level (L4-L5). Pain was evaluated using VAS. The median (±SD) 3D movement in the operated level for the left facet joint was 3.2 mm (±1.9 mm) before and 3.5 mm (±1.7 mm) after surgery and for the right facet joint was 3.0 mm (±1.0 mm) before and 3.6 mm (±1.4 mm) after surgery. The median vertebral rotation in the sagittal plane at the operated level was 5.4° (±2.3°) before surgery and 6.8° (±1.7°) after surgery and in the adjacent level was 7.7° (±4.0°) before and 9.2° (±2.7°) after surgery. The median VAS was reduced from 6 (range 5-8) to 3 (range 2-8) in extension and from 4 (range 2-6) to 2 (range 1-3) in flexion.

Using PET/CT Bone Scan Dynamic Data to Evaluate Tibia Remodeling When a Taylor Spatial Frame Is Used: Short and Longer Term Differences.

Eighteen consecutive patients, treated with a Taylor Spatial Frame for complex tibia conditions, gave their informed consent to undergo Na(18)F(-) PET/CT bone scans. We present a Patlak-like analysis utilizing an approximated blood time-activity curve eliminating the need for blood aliquots. Additionally, standardized uptake values (SUV) derived from dynamic acquisitions were compared to this Patlak-like approach. Spherical volumes of interest (VOIs) were drawn to include broken bone, other (normal) bone, and muscle. The SUV m (t) (m = max, mean) and a series of slopes were computed as (SUV m (t i ) - SUV m (t j ))/(t i - t j ), for pairs of time values t i and t j . A Patlak-like analysis was performed for the same time values by computing ((VOI p (t i )/VOI e (t i ))-(VOI p (t j )/VOI e (t j )))/(t i - t j ), where p = broken bone, other bone, and muscle and e = expected activity in a VOI. Paired comparisons between Patlak-like and SUV m slopes showed good agreement by both linear regression and correlation coefficient analysis (r = 84%, r s = 78%-SUVmax, r = 92%, and r s = 91%-SUVmean), suggesting static scans could substitute for dynamic studies. Patlak-like slope differences of 0.1 min(-1) or greater between examinations and SUVmax differences of ~5 usually indicated good remodeling progress, while negative Patlak-like slope differences of -0.06 min(-1) usually indicated poor remodeling progress in this cohort.

Pre- and postcontrast T1 and T2 mapping of patellar cartilage in young adults with recurrent patellar dislocation.

PURPOSE: To examine the cartilage quality in young adults with recurrent patellar dislocation in childhood using different magnetic resonance imaging parameters. METHODS: Sixteen young adults with unilateral recurrent patellar dislocation were investigated ≥5 y (mean, 8.5 y) after the first dislocation. Pre- and postcontrast T1 and precontrast T2 relaxation times were analyzed in four superficial and four deep patellar cartilage regions of both knees. Two hours after intravenous injection of 0.2 mM/kg Gd-DTPA(2-), postcontrast T1 [T1(Gd)] and ΔR1 [1/T1 (precontrast) - 1/T1 (postcontrast)] were analyzed in the regions. Muscle performance and patient-reported outcome were evaluated. RESULTS: When comparing the injured side with the noninjured side, differences were seen in the superficial half but not the deep half of the cartilage. T1(Gd) was shorter in the central part, whereas T2 was shorter in the periphery of the patellar cartilage (P < 0.05). ΔR1 demonstrated similar differences between healthy and diseased cartilage as T1(Gd) alone. The knee function was not correlated to the degenerative changes. CONCLUSION: The short T1(Gd) centrally indicates degenerative cartilage changes consistent with loss of glycosaminoglycans. Precontrast and ΔR1 calculations may be excluded in clinical dGEMRIC, which simplifies the procedure. A decrease in T2 may be a very early sign of joint pathology but warrants further investigation.

Risk factors for periacetabular osteolysis and wear in asymptomatic patients with uncemented total hip arthroplasties.

Osteolysis is a silent disease leading to aseptic loosening. This has not been studied in a cohort of asymptomatic patients. The aim of this study was to detect factors that might be associated with the development of periacetabular osteolysis and wear around an uncemented cup. We assessed 206 patients with an uncemented cup, measuring wear and periacetabular osteolysis using computed tomography with a median follow-up of 10 years after surgery (range 7-14 years). EQ5D, pain from the hip, and satisfaction were assessed. The association between periacetabular osteolysis and wear, age, gender, activity, BMI, cup type, cup age, positioning of the cup, and surface coating was investigated with a proportional odds model. Wear and male gender were associated with an increased risk for periacetabular osteolysis. There was no association with periacetabular osteolysis for time from operation, patient age, UCLA Activity Score, liner thickness at time of operation, BMI, cup positioning, and type of implant. A thin liner at time of operation is correlated to increased wear. Linear wear rate was 0.18 mm/year and 46 of 206 patients had large periacetabular osteolysis. Asymptomatic patients with these implants should be followed up on a regular basis with a sensitive method such as CT in order to detect complications early.

Long-term follow-up of nonoperatively and operatively treated acute primary patellar dislocation in skeletally immature patients.

PURPOSE: The present study reports a long-term follow-up of acute primary patellar dislocation in patients with open physes. The purpose of the study was to evaluate knee function and recurrence rates after surgical and nonsurgical treatment of patellar dislocation. METHODS: A total of 51 patients, including 29 girls and 22 boys, who were 9-14 years of age at the time of injury, were retrospectively evaluated. The minimum follow-up time was 5 years. Thigh muscle torque, range of motion, the squat test, the knee injury and osteoarthritis outcome score (KOOS), the Kujala score, and the recurrence rate were registered. Radiological predisposing factors at the time of injury were determined. RESULTS: Quality of life and sports/recreation were the most affected subscales, according to KOOS, and a reduced Kujala score was also observed in all treatment groups. The surgically treated patients had a significantly lower recurrence rate. Those patients also exhibited reduced muscle performance, with a hamstring to quadriceps ratio (H/Q) of 1.03. The recurrence rate was not correlated with knee function. CONCLUSIONS: Patellar dislocation in children influences subjective knee function in the long term. Surgery appears to reduce the recurrence rate, but subjective knee function was not restored.

In vivo and ex vivo measurement of polyethylene wear in total hip arthroplasty: comparison of measurements using a CT algorithm, a coordinate-measuring machine, and a micrometer.

BACKGROUND: Determination of the amount of wear in a polyethylene liner following total hip arthroplasty (THA) is important for both the clinical care of individual patients and the development of new types of liners. PATIENTS AND METHODS: We measured in vivo wear of the polyethylene liner using computed tomography (CT) (obtained in the course of regular clinical care) and compared it to coordinate-measuring machine (CMM) readings. Also, changes in liner thickness of the same retrieved polyethylene liner were measured using a micrometer, and were compared to CT and CMM measurements. The distance between the centers of the acetabular cup and femoral head component was measured in 3D CT, using a semi-automatic analysis method. CMM readings were performed on each acetabular liner and data were analyzed using 3D computer-aided design software. Micrometer readings compared the thickest and thinnest regions of the liner. We analyzed 10 THA CTs and retrievals that met minimal requirements for CT slice thickness and explanted cup condition. RESULTS - For the 10 cups, the mean difference between the CT readings and the CMM readings was -0.09 (-0.38 to 0.20) mm. This difference was not statistically significant (p = 0.6). Between CT and micrometer, the mean difference was 0.11 (-0.33 to 0.55) mm. This difference was not statistically significant (p = 0.6). INTERPRETATION - Our results show that CT imaging is ready to be used as a tool in clinical wear measurement of polyethylene liners used in THA.

Can Na18F PET/CT be used to study bone remodeling in the tibia when patients are being treated with a Taylor Spatial Frame?

Monitoring and quantifying bone remodeling are of interest, for example, in correction osteotomies, delayed fracture healing pseudarthrosis, bone lengthening, and other instances. Seven patients who had operations to attach an Ilizarov-derived Taylor Spatial Frame to the tibia gave informed consent. Each patient was examined by Na(18)F PET/CT twice, at approximately six weeks and three months after the operation. A validated software tool was used for the following processing steps. The first and second CT volumes were aligned in 3D and the respective PET volumes were aligned accordingly. In the first PET volume spherical volumes of interest (VOIs) were delineated for the crural fracture and normal bone and transferred to the second PET volume for SUVmax evaluation. This method potentially provides clinical insight into questions such as, when has the bone remodeling progressed well enough to safely remove the TSF? and when is intervention required, in a timelier manner than current methods? For example, in two patients who completed treatment, the SUVmax between the first and second PET/CT examination decreased by 42% and 13%, respectively. Further studies in a larger patient population are needed to verify these preliminary results by correlating regional Na(18)F PET measurements to clinical and radiological findings.

A new automated way to measure polyethylene wear in THA using a high resolution CT scanner: method and analysis.

As the most advantageous total hip arthroplasty (THA) operation is the first, timely replacement of only the liner is socially and economically important because the utilization of THA is increasing as younger and more active patients are receiving implants and they are living longer. Automatic algorithms were developed to infer liner wear by estimating the separation between the acetabular cup and femoral component head given a computed tomography (CT) volume. Two series of CT volumes of a hip phantom were acquired with the femoral component head placed at 14 different positions relative to the acetabular cup. The mean and standard deviation (SD) of the diameter of the acetabular cup and femoral component head, in addition to the range of error in the expected wear values and the repeatability of all the measurements, were calculated. The algorithms resulted in a mean (± SD) for the diameter of the acetabular cup of 54.21 (± 0.011) mm and for the femoral component head of 22.09 (± 0.02) mm. The wear error was ± 0.1 mm and the repeatability was 0.077 mm. This approach is applicable clinically as it utilizes readily available computed tomography imaging systems and requires only five minutes of human interaction.

A prospective randomized controlled trial of plantar versus dorsal incisions for operative treatment of primary Morton's neuroma.

BACKGROUND: There are a great number of studies on the outcome of surgery for Morton's neuroma. However, there is a lack of controlled trials to determine the outcome in general and for the 2 most used surgical approaches. This prospective and randomized trial studied the outcome and adverse events of resected primary Morton's neuromas, comparing plantar and dorsal incisions. METHODS: Seventy-six patients were randomized to treatment with either a plantar or a dorsal incision by 2 senior surgeons. Questionnaires were evaluated and physical examinations performed at baseline and at 3 and 12 months postoperatively by the treating surgeon and at a mean of 34 months (range, 28-42 months) by an independent surgeon. The follow-up rate was 93%. RESULTS: Histological examination of specimens verified resection of nerves in all cases except 1, which was in the dorsal group (artery). The main outcome variable, pain at daily activities, was significantly reduced by 96% (plantar) and 97% (dorsal) and restrictions in daily activities were reduced by 77% (plantar) and 67% (dorsal) at the final follow-up. Scar tenderness was noted by 3% (plantar) and 0% (dorsal) at the final evaluation. Clinically good results with surgery were noted in 87% (plantar) and 83% (dorsal) of cases. There were 5 complications in the plantar group and 6 in the dorsal group, with a difference in type of complications. CONCLUSIONS: This study demonstrated 87% (plantar) and 83% (dorsal) clinically good outcomes and no significant differences between the procedures in regard to pain, restrictions in daily activities, and scar tenderness. However, there was a difference between the groups in the type of complications. LEVEL OF EVIDENCE: Level I, prospective randomized trial.

Computed tomography vs. digital radiography assessment for detection of osteolysis in asymptomatic patients with uncemented cups: a proposal for a new classification system based on computer tomography.

Digital radiographic images in the anterior-posterior and lateral view have been gold standard for evaluation of peri-acetabular osteolysis for patients with an uncemented hip replacement. We compared digital radiographic images and computer tomography in detection of peri-acetabular osteolysis and devised a classification system based on computer tomography. Digital radiographs were compared with computer tomography on 206 hips, with a mean follow up 10 years after surgery. The patients had no clinical signs of osteolysis and none were planned for revision surgery. On digital radiographs, 192 cases had no osteolysis and only 14 cases had osteolysis. When using computer tomography there were 184 cases showing small or large osteolysis and only 22 patients had no osteolysis. A classification system for peri-acetabular osteolysis is proposed based on computer tomography that is easy to use on standard follow up evaluation.

Is arthroscopic surgery beneficial in treating non-traumatic, degenerative medial meniscal tears? A five year follow-up.

PURPOSE: The aim of this prospective randomized intervention study was to evaluate the outcome at a 2 and 5 year follow-up whether combined arthroscopic surgery followed by exercise therapy was superior to the same exercise therapy alone when treating non-traumatic, degenerative medial meniscal tears. METHODS: Ninety-six middle-aged patients with MRI-verified degenerative medial meniscus tear and radiographic osteoarthritis grade ≤1 (Ahlbäck) participated in the study. Radiographic examination was done before randomization and after 5 years. The patients were randomly assigned to either arthroscopic treatment followed by exercise therapy for 2 months or to the same exercise therapy alone. At the start of the study and at the follow-ups at 24 and 60 months the patients answered three questionnaires KOOS, Lysholm Knee Scoring Scale and Tegner Activity Scale and made pain ratings on the Visual Analogue Scale (VAS). RESULTS: Both groups showed highly significant clinical improvements from baseline to the follow-ups at 24 and 60 months on all subscales of KOOS, Lysholm Knee Scoring Scale and VAS (p < 0.0001). No group differences were found at any of the testing occasions. One third of the patients that were treated with exercise therapy alone did not feel better after the treatment but were improved after arthroscopic surgery. According to radiographic findings two patients from each group had a slight progression of their osteoarthritis after 5 years. CONCLUSION: The findings indicate that arthroscopic surgery followed by exercise therapy was not superior to the same exercise therapy alone for this type of patients. Consequently, exercise therapy can be recommended as initial treatment. However, one third of the patients from the exercise group still had disabling knee symptoms after exercise therapy but improved to the same level as the rest of the patients after arthroscopic surgery with partial meniscectomy. LEVEL OF EVIDENCE: I.

Incidence of osteolysis in total knee arthroplasty: comparison between radiographic and retrieval analysis.

Detection of polyethylene wear and osteolysis in total knee arthroplasty using radiographs is imprecise. To correlate radiographic findings with retrieved tibial component analysis, we reviewed knee revision cases. A joint registry was used to identify all knee revisions. Radiographic scoring systems were developed. Radiographs were analyzed for osteolysis and implant alignment. Polyethylene liner retrievals were visually and optically graded for surface damage. Statistical analyses that included correlation analysis and Mann-Whitney U test were used. When osteolysis was found, radiographic scores and delamination score were significantly higher (P = .047 and P = .014, respectively). Delamination is a good indicator for polyethylene wear and osteolysis. There is a need to develop in vivo methods to identify polyethylene changes and thereby prevent severe clinical outcomes.