Development and application of a proximal hamstring MRI-based scoring tool in patients undergoing proximal hamstring tendon surgical repair.

Purpose: An MRI-based scoring tool assessing surgical repair after proximal hamstring avulsions may provide benefit in the context of research, while serial post-operative MRI will provide insight of what to expect in the clinical context of early re-injury requiring imaging. This study developed and assessed the reliability of a Proximal Hamstring Objective Magnetic Resonance Imaging Score (PHOMRIS), further assessing MRI-based repair status and its correlation with patient-reported outcome. Methods: 15 patients that underwent proximal hamstring surgical repair underwent MRI and clinical review pre-operatively and at 3-, 6- and 12-months. Clinical scores included the Lower Extremity Functional Scale (LEFS), the Perth Hamstring Assessment Tool (PHAT) and Tegner Activity Scale (TAS). The MRI-based tool assessed the conjoint (semitendinosus & biceps femoris) and semimembranosus insertion components based on bone-tendon healing, signal and retraction. Inter- and intra-observer reliability of the tool was assessed. Results: Inter-observer reliability indicated a strong correlation for the semimembranosus (rho = 0.827, p < 0.0001) and conjoint (rho = 0.851, p < 0.0001) components. Intra-observer reliability indicated a strong correlation for the semimembranosus (rho = 0.852, p < 0.0001) and conjoint (rho = 0.996, p < 0.0001) components. All clinical scores and the semimembranosus hamstrings component MRI score significantly improved (p < 0.05) over time, though the conjoint component did not (p = 0.219). At 12 months, a higher LEFS was significantly associated with a better semimembranosus MRI score (r = -0.57, p = 0.042), though no other significant correlations (p > 0.05) were observed between clinical and MRI measures. Conclusions: Excellent reliability was observed for the MRI-based scoring tool, which may prove useful in both a research and clinical setting.

Presentation of multiple painful subcutaneous nodules: Dercum's disease, a rare variant of lipoma.

A woman in her 50s presented to her general practitioner (GP) with an 8-month history of multiple painful subcutaneous nodules of various sizes in her trunk and limbs. Her previous GP made the clinical diagnosis of lipoma when they presented as non-painful nodules 2 years ago. Initial ultrasound demonstrated multiple lipomata with the largest size in the left upper thighs displaying features of subtle internal vascularity, entirely contained within the subcutaneous layer. MRI scan of thigh lesions showed multiple angiolipomas consistent with the entity of Dercum's disease. Subsequent biopsy histology confirmed the image diagnosis of angiolipoma. She was referred to a musculoskeletal oncological surgeon for evaluation and reassurance regarding optimising medical management of her associated obesity. Her angiolipoma and obesity are well managed by her GP. This case highlights the diagnostic workup of a rare variant of lipoma, Dercum's disease. The differential diagnosis of multiple painful lipomas was reviewed and discussed, consequently leading to the discussion of managing the associated obesity in this case.

Arthroscopic Bone Graft and Internal Fixation of Non-Union of the Proximal Pole of the Scaphoid: Surgical Technique and Outcomes.

Background Fractures of the proximal pole of the scaphoid have been associated with delayed union, non-union, and avascular necrosis. This has been attributed to avascularity of the proximal pole of the scaphoid. While proximal pole non-unions can be successfully treated using open techniques, there is little information in the literature regarding arthroscopic bone graft and internal fixation of proximal pole non-unions. Description of Technique After insertion of a 1.2-mm radiolunate K-wire, the scaphoid non-union was arthroscopically excised, bone grafted with iliac crest cancellous bone, and internally fixed with 3 × 1.2 mm K-wires. Patients and Methods This is a retrospective study of patients who had arthroscopic bone graft of non-union of the proximal pole of the scaphoid between 2009 and 2021. Results There were 30 cases in this study; 29 cases united. The one case that did not unite was caused by inadequate fixation of the proximal pole. The size of the proximal pole did not influence the outcome. Conclusion Arthroscopic bone graft and internal fixation is a reliable technique for the treatment of non-union of the proximal pole of the scaphoid.

Double-bundle anterior cruciate ligament reconstruction using autologous hamstrings with LARS augmentation demonstrates comparable outcomes to hamstrings alone, without evidence of synovitis or early osteoarthritis.

PURPOSE: To compare the clinical and radiological outcomes in patients undergoing anterior cruciate ligament reconstruction (ACLR) with, or without, LARS augmentation. METHODS: One-hundred and thirty-six patients that underwent double-bundle ACLR with (DB Hams/LARS, n = 67), or without (DB Hams, n = 69), LARS augmentation, were assessed clinically and with Magnetic Resonance Imaging (MRI) at a minimum of 7-years post-surgery. Patients were assessed via patient-reported outcome measures (PROMs), KT-1000 (laxity), isokinetic knee extensor and flexor strength and a 4-hop test battery. Limb symmetry indices (LSIs) were calculated. The Whole-Organ Magnetic Resonance Imaging Score (WORMS) evaluated knee status via MRI. Sport participation, secondary operations, ACL re-tears and contralateral ACL tears were reported. RESULTS: No differences (n.s.) were observed in demographics, PROMs, KT-1000 scores or strength and hop LSIs. Normal (< 3 mm side-to-side differences) KT-1000 scores were observed in 64 (92.8%) and 59 (88.1%) of DB Hams and DB Hams/LARS patients, respectively. Comparative rates of satisfaction were reported. Knee flexor strength and hop test LSIs were all ˃95% in both groups, which was 94.2% and 96.7% for knee extensor strength in the DB Hams and DB Hams/LARS cohorts, respectively. While 53 (76.8%) and 52 (77.6%) of the DB Hams and DB Hams/LARS patients had returned to pivoting sports, 42 (60.9%) and 41 (61.2%) were participating in pivoting sports at the minimum 7-year review. No difference (n.s.) was observed in the WORMS (12.3 DB Hams, 16.7 DB Hams/LARS). Of the cohort assessed, 8 (11%) DB Hams and 11 (16%) DB Hams/LARS patients had undergone secondary surgery. In addition to one patient in each group that demonstrated ACL rupture on MRI, an additional cohort of patients were excluded from the current analysis due to prior re-tear (DB Hams n = 6, DB Hams/LARS n = 8) or contralateral ACL tear (DB Hams n = 4, DB Hams/LARS n = 4). CONCLUSIONS: Comparable outcomes were observed after double-bundle ACLR using autologous hamstrings with, or without, LARS augmentation. Therefore, while these outcomes do not justify the additional use of synthetic augmentation given the lack of further benefit and additional cost, higher rates of graft failure, synovitis and early osteoarthritic change previously reported were not observed. LEVEL OF EVIDENCE: III.

A bio-inductive collagen scaffold that supports human primary tendon-derived cell growth for rotator cuff repair.

BACKGROUND: Rotator Cuff (RC) tendon tearing is a common clinical problem and there is a high incidence of revision surgery due to re-tearing. In an effort to improve patient outcome and reduce surgical revision, scaffolds have been widely used for augmentation of RC repairs. However, little is known about how scaffolds support tendon stem cell growth or facilitate tendon regeneration. The purpose of this study is to evaluate the structural and biological properties of a bioactive collagen scaffold (BCS) with the potential to promote tendon repair. Additionally, we conducted a pilot clinical study to assess the safety and feasibility of using the BCS for repair of RC tears. METHODS: A series of physical, ultrastructural, molecular and in vitro tests determined the biocompatibility and teno-inductive properties of this BCS. In addition, a prospective case study of 18 patients with RC tendon tears (>20 â€‹mm in diameter) was performed in an open-label, single-arm study, involving either mini-open or arthroscopic surgical RC repair with the BCS. Clinical assessment of RC repair status was undertaken by MRI-imaging at baseline, 6 and 12 months and patient evaluated questionnaires were taken at baseline as well as 3, 6 & 12 months. RESULTS: The BCS consists of highly purified type-I collagen, in bundles of varying diameter, arranged in a higher order tri-laminar structure. BCS have minimal immunogenicity, being cell and essentially DNA-free as well as uniformly negative for the porcine α-Gal protein. BCS seeded with human primary tendon-derived cells and exposed to 6% uniaxial loading conditions in vitro, supported increased levels of growth and proliferation as well as up-regulating expression of tenocyte differentiation marker genes including TNMD, Ten-C, Mohawk and Collagen-1α1. To test the safety and feasibility of using the BCS for augmentation of RC repairs, we followed the IDEAL framework and conducted a first, open-label single arm prospective case series study of 18 patients. One patient was withdrawn from the study at 3 months due to wound infection unrelated to the BCS. The remaining 17 cases showed that the BCS is safe to be implanted. The patients reported encouraging improvements in functional outcomes (ASES, OSS and Constant-Murley scores), as well as quality of life assessments (AQoL) and a reduction in VAS pain scores. MRI assessment at 12 months revealed complete healing in 64.8% patients (11/17), 3 partial thickness re-tears (17.6%) and 3 full thickness re-tears (17.6%). CONCLUSION: The BCS is composed of type-I collagen that is free of immunogenic proteins and supports tendon-derived cell growth under mechanical loading in vitro. This pilot study shows that it is safe and feasible to use BCS for RC argumentation and further controlled prospective studies are required to demonstrate its efficacy. THE TRANSLATIONAL POTENTIAL OF THIS ARTICLE: The results of this study indicate that this bioactive collagen scaffold has unique properties for supporting tendon growth and that it is non-immunogenic. The clinical study further confirms that the scaffold is a promising biological device for augment of human rotator cuff repairs.

Association of Preoperative Gluteal Muscle Fatty Infiltration With Patient Outcomes in Women After Hip Abductor Tendon Repair Augmented With LARS.

BACKGROUND: Hip abductor tendon repair has demonstrated encouraging outcomes. The influence of fatty infiltration (FI) on outcome has not been explored. PURPOSE: To investigate the association between preoperative hip abductor FI and clinical outcome after hip abductor tendon repair. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: A total of 84 women underwent hip abductor tendon repair. The mean age was 64.6 years (range, 43-84 years); body mass index, 27.7 (range, 20.0-40.2); and duration of symptoms, 3.4 years (range, 6 months-20 years). The 6-minute walk test, isometric hip abduction strength assessment, and patient-reported outcome measures, including the Harris Hip Score and Oxford Hip Score, were completed presurgery and 2 years after surgery. Patient satisfaction and perceived improvement were assessed 2 years after surgery. All patients underwent preoperative magnetic resonance imaging on the affected hip, and the Goutallier system was used to grade the degree of FI in the anterior, middle, and posterior thirds of the gluteus medius and minimus on a 0-4 ordinal scale. A single FI score for the gluteus medius and minimus was calculated, as was a combined FI score. RESULTS: All clinical scores significantly improved over time (P < .001). Preoperatively, FI was more severe in the gluteus minimus, with the most severe FI (grades 2-4) demonstrated in the middle (n = 56, 66.7%) and anterior (n = 17, 20.2%) portions of the gluteus minimus and the middle (n = 27, 32.1%) and anterior (n = 12, 14.3%) portions of the gluteus medius. Older age was associated with greater FI (combined FI score: r = 0.529, P < .001), although duration of symptoms (r = 0.035, P = .753) and body mass index (r = 0.089, P = .464) were not. Greater FI was associated with less improvement in hip strength of the unaffected leg (coefficient, -1.6, 95% CI: -2.8 to -0.4), although no other significant associations were observed between FI and pre- or postoperative clinical scores. CONCLUSION: Preoperative FI was not associated with pertinent parameters of patient outcome after hip abductor tendon repair, including pain, symptoms, functional capacity, perceived improvement, and satisfaction. Based on these outcomes, surgical repair may be considered in the presence of more severe FI.

Eight-Week Return to Play Following Latarjet Shoulder Reconstruction in an Australian Football Player: A Case Report.

INTRODUCTION: Anterior shoulder dislocation is a common injury in many sports, resulting in extended time lost from play with an extremely high recurrence rate in young athletes playing a high-risk sport. Latarjet shoulder reconstruction is a common surgical procedure used to prevent subsequent dislocation with an expected rehabilitation time frame of between 4 and 6 months before return to play. CASE DESCRIPTION: A 21-year-old male Australian football player experienced 2 left-sided shoulder dislocations before undergoing a left Latarjet shoulder reconstruction. He was assessed clinically and with magnetic resonance imaging, which revealed significant tearing of the anterior labrum. The authors theorized that maximal glenohumeral stability occurs after bony healing of the coracoid onto the glenoid at 6 weeks. The patient then underwent an 8-week structured and graduated rehabilitation program aimed at preventing loss of shoulder range of motion, muscle, and functional capacity and returned to play at 8 weeks postinjury with no complications or recurrence at 12-month follow-up. DISCUSSION: This is the first time an 8-week rehabilitation following Latarjet shoulder reconstruction has been reported. In athletes with anterior glenohumeral dislocation who require accelerated return to play, a Latarjet reconstruction with an 8-week rehabilitation protocol may be considered.

Piriformis-Sparing Minimally Invasive Versus the Standard Posterior Approach for Total Hip Arthroplasty: A 10-Year Follow-Up of a Randomized Control Trial.

BACKGROUND: Despite the popularity of minimally invasive approaches in total hip arthroplasty, studies regarding their impact on soft tissues and long-term benefits are lacking. This study aims to compare the 10-year functional outcome of the piriformis-sparing minimally invasive approach to the standard posterior approach for total hip arthroplasty surgery. METHODS: Hundred patients were randomized, 48 patients to the piriformis-sparing approach and 52 to the standard approach. Primary outcomes were hip function and piriformis muscle volume and grade on magnetic resonance imaging. Secondary outcomes were pain, satisfaction score, and complications. Evaluators were blinded to allocation. Participants were followed up to 10 years. RESULTS: Ten years following surgery, both groups reported excellent pain relief, improved hip function, and high satisfaction. The significant differences were improvement in piriformis muscle volume (P = .001) and muscle grade (P = .007) in the piriformis-sparing group compared to the standard group. There were no significant differences in all other outcomes. CONCLUSION: Aside from being less injurious to the piriformis muscle, the piriformis-sparing approach offered the same long-term functional benefits as the standard posterior approach at 10 years.

Ultrasonography Detects Deep Tissue Injuries in the Subcutaneous Layers of the Buttocks Following Spinal Cord Injury.

Background: Ultrasonography may have potential as an effective diagnostic tool for deep tissue injury (DTI) in tissues overlying bony prominences that are vulnerable when under sustained loading in sitting. Methods: Three cases of DTI in the fat and muscle layers overlying the ischial tuberosity of the pelvis in 3 persons with spinal cord injury (SCI) with different medical histories and abnormal tissue signs are described. Conclusion: There is a need for prospective studies using a reliable standardized ultrasonography protocol to diagnose DTI and to follow its natural history to determine its association with the development of pressure injuries.

Adaptation of a MR imaging protocol into a real-time clinical biometric ultrasound protocol for persons with spinal cord injury at risk for deep tissue injury: A reliability study.

BACKGROUND: High strain in soft tissues that overly bony prominences are considered a risk factor for pressure ulcers (PUs) following spinal cord impairment (SCI) and have been computed using Finite Element methods (FEM). The aim of this study was to translate a MRI protocol into ultrasound (US) and determine between-operator reliability of expert sonographers measuring diameter of the inferior curvature of the ischial tuberosity (IT) and the thickness of the overlying soft tissue layers on able-bodied (AB) and SCI using real-time ultrasound. MATERIAL AND METHODS: Part 1: Fourteen AB participants with a mean age of 36.7 ± 12.09 years with 7 males and 7 females had their 3 soft tissue layers in loaded and unloaded sitting measured independently by 2 sonographers: tendon/muscle, skin/fat and total soft tissue and the diameter of the IT in its short and long axis. Part 2: Nineteen participants with SCI were screened, three were excluded due to abnormal skin signs, and eight participants (42%) were excluded for abnormal US signs with normal skin. Eight SCI participants with a mean age of 31.6 ± 13.6 years and all male with 4 paraplegics and 4 tetraplegics were measured by the same sonographers for skin, fat, tendon, muscle and total. Skin/fat and tendon/muscle were computed. RESULTS: AB between-operator reliability was good (ICC = 0.81-0.90) for 3 soft tissues layers in unloaded and loaded sitting and poor for both IT short and long axis (ICC = -0.028 and -0.01). SCI between-operator reliability was good in unloaded and loaded for total, muscle, fat, skin/fat, tendon/muscle (ICC = 0.75-0.97) and poor for tendon (ICC = 0.26 unloaded and ICC = -0.71 loaded) and skin (ICC = 0.37 unloaded and ICC = 0.10). CONCLUSION: A MRI protocol was successfully adapted for a reliable 3 soft tissue layer model and could be used in a 2-D FEM model designed to estimate soft tissue strain as a novel risk factor for the development of a PU.

A Midterm Evaluation of Postoperative Platelet-Rich Plasma Injections on Arthroscopic Supraspinatus Repair: A Randomized Controlled Trial.

BACKGROUND: Platelet-rich plasma (PRP) has been applied as an adjunct to rotator cuff repair to improve tendon-bone healing and potentially reduce the incidence of subsequent tendon retears. PURPOSE: To investigate whether the midterm clinical and radiographic outcomes of arthroscopic supraspinatus repair are enhanced after repeated postoperative applications of PRP. STUDY DESIGN: Randomized controlled trial; Level of evidence, 1. METHODS: A total of 60 patients (30 control; 30 PRP) were initially randomized to receive 2 ultrasound-guided injections of PRP to the tendon repair site at 7 and 14 days after double-row arthroscopic supraspinatus repair or not. A total of 55 patients (91.7%) underwent a clinical review and magnetic resonance imaging (MRI) at a mean of 3.5 years after surgery (range, 36-51 months). Patient-reported outcome measures (PROMs) included the Constant score, Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH) questionnaire, Oxford Shoulder Score (OSS), and visual analog scale (VAS) for pain. Global rating of change (GRC) scale and patient satisfaction scores were evaluated. Structural integrity of the surgical repair was assessed via MRI using the Sugaya classification system. RESULTS: At the midterm review, there was no difference between the groups for any of the PROMs. No differences between the groups were demonstrated for the subjective and range of motion subscales of the Constant score, although a significantly higher Constant strength subscale score was observed in the PRP group (3.3 points; 95% CI, 1.0-5.7; P = .006). There was no evidence for any group differences in MRI scores or retear rates, with 66.7% of PRP patients and 64.3% of control patients rated as Sugaya grade 1. Two control patients had symptomatic retears (both full thickness) within the first 16 weeks after surgery compared with 2 PRP patients, who suffered symptomatic retears (both partial thickness) between 16 weeks and a mean 3.5-year follow-up. CONCLUSION: Significant postoperative clinical improvements and high levels of patient satisfaction were observed in patients at the midterm review after supraspinatus repair. While pain-free, maximal abduction strength was greater in the midterm after PRP treatment, repeated applications of PRP delivered at 7 and 14 days after surgery provided no additional benefit to tendon integrity.

Cortical desmoid of the humerus: radiographic and MRI correlation.

Cortical desmoids are self-limiting fibro-osseous lesions commonly occurring at the medial supracondylar femur in active adolescents, at either the origin of the medial head of the gastrocnemius or at the insertion of the adductor magnus aponeurosis. Less commonly, in a similar demographic, cortical desmoids may occur in the proximal humerus medially at the insertion of the pectoralis major muscle or laterally at the insertion of the deltoid. The radiographic appearance of the proximal humerus cortical desmoid has been described previously, but not the MRI appearance. We present the radiographic and MRI appearances of a proximal humerus cortical desmoid in a young adolescent who presented for investigation of right shoulder pain.

Autologous Tenocyte Injection for the Treatment of Chronic Recalcitrant Gluteal Tendinopathy: A Prospective Pilot Study.

BACKGROUND: Gluteal tendinopathy is a common cause of lateral hip pain, and existing conservative treatment modalities demonstrate high symptom recurrence rates. Autologous tenocyte injection (ATI) is a promising cell therapy that may be useful for the treatment of gluteal tendinopathy. PURPOSE: To investigate the safety and effectiveness of ATI, specifically in patients with chronic recalcitrant gluteal tendinopathy. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: Twelve female patients with a clinical and radiological diagnosis of gluteal tendinopathy were recruited. Patients demonstrated a mean duration of symptoms of 33 months (range, 6-144 months), had undergone a mean 3.2 prior corticosteroid injections (range, 2-5), and had failed to respond to existing conservative treatments including physiotherapy and injections. In an initial procedure, tendon cells were harvested from a needle biopsy of the patella tendon and propagated in a certified Good Manufacturing Practice (GMP) laboratory. In a secondary procedure, a single injection of 2 mL autologous tenocytes (2-5 × 106 cells/mL) suspended in patient serum was injected into the site of the pathological gluteal tendons under ultrasound guidance. Patients were assessed pre- and postinjection (3, 6, 12, and 24 months) using the Oxford Hip Score (OHS), a visual analog pain scale (VAS), the Short Form-36 (SF-36), and a satisfaction scale. Magnetic resonance imaging (MRI) was undertaken at 8.7 months (range, 6-12 months) postinjection. RESULTS: Molecular characterization of autologous tendon cells showed a profile of growth factor production in all cases, including platelet-derived growth factor α, fibroblast growth factor ß, and transforming growth factor ß. The OHS (mean, 24.0 preinjection to 38.9 at 12 months [14.9-point improvement]; 95% CI, 10.6-19.2; P < .001), VAS (mean, 7.2 preinjection to 3.1 at 12 months [4.1-point improvement]; 95% CI, 2.6-5.6; P < .001), and SF-36 (mean, 28.1 preinjection to 43.3 at 12 months [15.2-point improvement]; 95% CI, 9.8-20.5; P < .001) significantly improved to 12 months postinjection, sustained to 24 months. Eight patients were satisfied with their outcomes. Significant MRI-based improvement could not be demonstrated in the majority of cases. CONCLUSION: ATI for gluteal tendinopathy is safe, with improved and sustained clinical outcomes to 24 months.

Early postoperative repair status after rotator cuff repair cannot be accurately classified using questionnaires of patient function and isokinetic strength evaluation.

BACKGROUND: This study investigated if patients with an intact tendon repair or partial-thickness retear early after rotator cuff repair display differences in clinical evaluations and whether early tendon healing can be predicted using these assessments. METHODS: We prospectively evaluated 60 patients at 16 weeks after arthroscopic supraspinatus repair. Evaluation included the Oxford Shoulder Score, 11-item version of the Disabilities of the Arm, Shoulder and Hand, visual analog scale for pain, 12-item Short Form Health Survey, isokinetic strength, and magnetic resonance imaging (MRI). Independent t tests investigated clinical differences in patients based on the Sugaya MRI rotator cuff classification system (grades 1, 2, or 3). Discriminant analysis determined whether intact repairs (Sugaya grade 1) and partial-thickness retears (Sugaya grades 2 and 3) could be predicted. RESULTS: No differences (P < .05) existed in the clinical or strength measures. Although discriminant analysis revealed the 11-item version of the Disabilities of the Arm, Shoulder and Hand produced a 97% true-positive rate for predicting partial thickness retears, it also produced a 90% false-positive rate whereby it incorrectly predicted a retear in 90% of patients whose repair was intact. The ability to discriminate between groups was enhanced with up to 5 variables entered; however, only 87% of the partial-retear group and 36% of the intact-repair group were correctly classified. CONCLUSIONS: No differences in clinical scores existed between patients stratified by the Sugaya MRI classification system at 16 weeks. An intact repair or partial-thickness retear could not be accurately predicted. Our results suggest that correct classification of healing in the early postoperative stages should involve imaging.

Incidence, degree, and development of graft hypertrophy 24 months after matrix-induced autologous chondrocyte implantation: association with clinical outcomes.

BACKGROUND: Graft hypertrophy is a common occurrence after periosteal, collagen-covered and matrix-induced autologous chondrocyte implantation (MACI). PURPOSE/HYPOTHESIS: The purpose of this study was to investigate the incidence, development, and degree of graft hypertrophy at 24 months after MACI. The hypothesis was that graft hypertrophy would not be associated with clinical outcome at 24 months. STUDY DESIGN: Case series, Level of evidence, 4. METHODS: This study was undertaken in 180 consecutive patients (113 male, 67 female) after MACI in the knee. All patients were assessed clinically using the Knee injury and Osteoarthritis Outcome Score (KOOS) and underwent magnetic resonance imaging (MRI) at 3, 12, and 24 months after surgery. The incidence of hypertrophy relevant to anatomic graft site was investigated, as was the progressive change in hypertrophic studies postoperatively. The degree of tissue overgrowth in hypertrophic cases was investigated, as was its association with patient clinical outcome at 24 months after surgery. RESULTS: Of the 180 patients, 50 demonstrated a hypertrophic graft at 1 or more postoperative time points. This included 9 grafts (5.0%) at 3 months and 32 grafts (18.7%) at 12 months. At 24 months, 47 grafts (26.1%)-43 (32.1%) tibiofemoral and 4 (8.7%) patellofemoral-were hypertrophic. Patients with hypertrophic grafts at 24 months (n = 47) were younger (P = .051), they had a lower body mass index (BMI; P = .069), and significantly fewer of them had patellofemoral grafts (P = .007) compared with patients who had grafts with full (100%) tissue infill (n = 61). There were no significant differences in any of the KOOS subscales between patients with graft hypertrophy or full (100%) tissue infill at 24 months after surgery, while the severity of graft hypertrophy was not associated with KOOS subscales at 24 months. CONCLUSION: Hypertrophic grafts after MACI were common and continued to develop through to 24 months after surgery. Hypertrophic growth was associated with being younger and having a lower BMI, was more common on the femoral condyles, and overall was not associated with clinical outcome at 24 months after surgery. However, further research with longer term follow-up is required to evaluate the effect of persistent hypertrophy on graft stability and to assess the use of early surgical intervention to prevent such failure.

The existence of cords in olecranon bursae.

BACKGROUND: The purpose of this study was to document the existence of transverse cords in olecranon bursae in patients undergoing excision of the bursa and to describe the unique clinical presentation of patients with these cords. METHODS: A retrospective study was performed on 24 patients who had surgery to excise an olecranon bursa between 2006 and 2011. The patient's history, preoperative radiographs, ultrasound images, intraoperative photographs, and findings on histologic analysis were reviewed in all cases. RESULTS: Nine olecranon bursae had cords (cord group) and 15 did not have cords (noncord group). All patients in the cord group were male manual laborers, and nearly all had olecranon enthesophytes (n = 8). Patients in the noncord group had associated medical conditions or an infection. A higher level of satisfaction was reported in the noncord group after surgical excision. CONCLUSION: This study documents the existence of transverse cords oriented at right angles to the long axis of the olecranon. Olecranon bursae with cords have a unique presentation and are found in male manual workers, are nearly always associated with an olecranon enthesophyte, and do not present with infections.

Evidence for the Durability of Autologous Tenocyte Injection for Treatment of Chronic Resistant Lateral Epicondylitis: Mean 4.5-Year Clinical Follow-up.

BACKGROUND: Chronic lateral epicondylitis (LE) induces cell apoptosis and autophagy, which lead to the reduction of tendon-derived cells in the torn tendon. Our previous study has shown that ultrasound-guided autologous tenocyte injection (ATI) to the torn tendon in patients with chronic resistant LE significantly improves pain, function, and structural repair at 1 year. This report is the continued assessment of the clinical outcomes of these patients at mean 4.5-year follow-up. HYPOTHESIS: Improvements in LE clinical function and structural repair after ATI will be maintained at mean 4.5-year follow-up. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: Patients with severe refractory LE underwent clinical evaluation and MRI before intervention. A patellar tendon needle biopsy was performed under local anesthetic, and tendon cells were expanded by in vitro culture. Autologous tenocytes were injected into the central tendinopathy identified at the common extensor tendon origin under ultrasound guidance on a single occasion. Patients underwent serial clinical evaluations for up to 5 years after ATI, including the visual analog scale (VAS) for pain, Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH), Upper Extremity Functional Scale (UEFS), and grip strength. Post-ATI MRI scanning was performed at 1 year and final follow-up. RESULTS: A total of 16 patients (9 male, 7 female), aged between 37 and 63 years, were included in the study. The mean duration of symptoms before study recruitment was 29.24 months (range, 6-240 months). One patient elected to proceed to surgery 3 months after ATI due to reinjury at work, and 1 patient died of prostate cancer with metastases during the follow-up period. The mean final follow-up time for the remaining 15 patients was 4.51 years (range, 3.08-5.17 years). No complications were observed at the patellar tendon biopsy site for any patient. No adverse events, infection, or excessive fibroblastic reactions were observed in any patient at the injection site. Clinical evaluation revealed significant (P < .001) improvement in mean VAS pain score from 5.73 at initial assessment to 1.21 (78% improvement) at final follow-up. Mean QuickDASH, UEFS, and grip strength scores also significantly (P < .001) improved from initial assessment to final follow-up (from 45.88 to 6.61 [84%], from 31.73 to 9.20 [64%], and from 19.85 to 46.60 [208%], respectively). There was no difference in mean QuickDASH and UEFS scores at 1 year and final follow-up (P > .05); however, grip strength continued to improve (P < .001). A validated MRI scoring system indicated that the mean grade of tendinopathy at the common extensor origin improved significantly (P < .001) from initial assessment (4.31) to 1 year (2.88) and was maintained (P > .05) at final follow-up (2.87). At final follow-up, 93% of patients were either highly satisfied or satisfied with their ATI treatment. CONCLUSION: ATI significantly improved clinical function and MRI tendinopathy scores for up to 5 years in patients with chronic resistant LE who had previously undergone unsuccessful nonsurgical treatment. This study provides evidence for the midterm durability of ATI for treatment of LE tendinopathy.

MRI and clinical analysis of hip abductor repair.

INTRODUCTION: Hip abductor insufficiency is often associated with lateral hip pain, movement disorder and Trendelenburg gait. The aims of this study are to predict if preoperative radiological findings correlate with postoperative outcomes and if pre and postoperative radiological findings correlate with postoperative function. METHODS: Patients with clinical and MRI evidence of hip abductor tears that had failed to nonoperative treatment underwent surgical repair. Pre and postoperative MRI analysis was carried out by an experienced musculo-skeletal radiologist. Clinical analysis consisted of Harris Hip Score, a measure of patient satisfaction, pre and postoperative walking aids and Trendelenburg test. RESULTS: This study shows no real improvement in the MRI appearances of the tendons after surgery. Preoperative MRI absence of gluteus minimus was 100% predictive of a poor outcome, whilst thickening of the posterior gluteus medius was 83% predictive of a poor outcome. Postoperative MRI absence of posterior gluteus medius was 75% predictive of a poor outcome. Thickening of anterior gluteus medius and posterior gluteus medius were 71% and 83% predictive of a poor outcome respectively. Absence of posterior gluteus medius correlated with poor outcome in 75% of cases. DISCUSSION: The MRI appearance of the tendon does not normalise after surgery and there is limited correlation between the MRI appearances pre and postoperatively with the postoperative outcome.

Reliability of a 3 T MRI protocol for objective grading of supraspinatus tendonosis and partial thickness tears.

BACKGROUND: Partial thickness supraspinatus tears and tendonosis can be managed either nonoperatively or by various arthroscopic techniques. New biologic treatment approaches are currently being investigated. MRI is commonly used for objective imaging outcome evaluation but there is a lack of reliability studies. We propose a novel MRI classification of partial supraspinatus tears and tendonosis and evaluate its inter-observer and intra-observer reliability. METHODS: Digital MRI scans (3 Tesla) of 65 patients investigated for assessment of supraspinatus pathology or subacromial impingement were evaluated by three independent and experienced musculoskeletal (MSK) radiologists. Tendonosis (absent, focal, generalized), partial thickness (PT) tears (absent, 0%-25% PT, 25%-50% PT, 50%-100% PT, and full thickness tears), and anteroposterior extent of tears (less than 5 mm, 5-10 mm, greater than 10 mm) were scored by each radiologist on two separate occasions (t1, t2), 2 months apart. The inter-observer and intra-observer agreement and weighted kappa values for each parameter were calculated. RESULTS: The range of weighted intra-observer kappa (IAK) was 0.84-0.93 for evaluation of tendonosis; 0.84 (all raters) for depth of partial thickness, 0.74-0.84 for AP tear size, and 0.83-0.85 for the total score. The range of weighted inter-observer kappa (IEK) over two time points (t1, t2) was 0.55-0.74 for tendonosis, 0.69-0.84 for depth for partial thickness tears, 0.57-0.80 for AP tear size, and 0.63-0.80 for the total score. CONCLUSION: A comprehensive MRI grading protocol is proposed and is reliable for the evaluation of supraspinatus tendonosis and partial thickness tears with good to excellent kappa values. This rotator cuff MRI protocol can be applied to evaluate morphological tendon outcomes after different treatment modalities.

Serial MRI and clinical assessment of cyclops lesions.

PURPOSE: 'Clinical cyclops syndrome' is associated with pain and a palpable 'clunk' at terminal extension with the loss of full extension. The aims of this prospective controlled study were: (1) to assess whether the minimal debridement of the ACL stump and notch is associated with an increased incidence of clinical cyclops lesions, (2) to look at the incidence and natural history of 'MRI cyclops' lesions using serial MRI's and (3) to assess whether 'MRI cyclops' lesions are associated with the loss of extension. METHODS: Forty-eight patients were randomized for ACL reconstruction into standard (23) and minimal debridement (24) techniques. One patient was excluded from the study. All patients underwent MR scanning postoperatively at 2, 6 and 12 months, together with the clinical assessment using a KT-1000 arthrometer and International Knee Documentation Committee evaluation. All observations were made by investigators blinded to the surgical technique. RESULTS: There was no statistical difference in the incidence of cyclops lesions between the two groups (n.s.). The overall incidence of cyclops lesions was 46.8% (22 of 47). The natural history is variable with some getting larger, smaller or remaining static in size. Of patients with cyclops lesions, 17 patients (77%) had cyclops lesions in the setting of full extension. Five patients (23%) had loss of extension at 12 months with no MRI cyclops detected at 2 months. CONCLUSIONS: The natural history is variable; although once present, the majority of cyclops remain static or regress in size. The onset of cyclops lesions is usually between 6- and 12-month post-ACL reconstruction. Minimal debridement does not lead to an increased incidence of clinical cyclops lesions. The authors conclude that loss of extension is multi-factorial, and there is a discrepancy between what we term 'MRI cyclops' and true 'clinical cyclops'. LEVEL OF EVIDENCE: Case-control study, Level II.