Calcific tendonitis of the quadriceps tendon.

A 61-year-old woman presented with chronic anterior pain and stiffness in the distal left thigh. Examination revealed swelling and tenderness immediately proximal to the patella. Radiographs showed opacities in the distal anterior thigh whilst MRI identified enlargement of the distal quadriceps tendon with splayed fibres separated by solid conglomerates. Dystrophic calcification of the quadriceps tendon was diagnosed. Blood tests revealed no systemic abnormalities in calcium handling. Arthroscopy of the left knee identified calcific deposits in the supra-patella pouch with surrounding synovitis. An open debridement of the tendon was performed; biopsy of the excised tendon showed chronic tenosynovitis with dystrophic calcification without evidence of malignancy. Post-operatively her knee was braced in extension enabling progressive flexion over 4 weeks. Anterior knee pain diminished post-operatively and 10 months following surgery the patient was pain free, able to walk normally and scored 99/100 on the Fulkerson modification of the Lysholm score.

Radiation risk from fluoroscopically-assisted anterior cruciate ligament reconstruction.

INTRODUCTION: Precise tunnel positioning is crucial for success in anterior cruciate ligament (ACL) reconstruction. The use of intra-operative fluoroscopy has been shown to improve the accuracy of tunnel placement. Although radiation exposure is a concern, we lack information on the radiation risk to patients undergoing fluoroscopically-assisted ACL reconstruction with a standard C-arm. The aim of our study was to determine the mean radiation doses received by our patients. PATIENTS AND METHODS: Radiation doses were recorded for 18 months between 1 April 2007 and 30 September 2008 for 58 consecutive patients undergoing ACL reconstruction assisted by intra-operative fluoroscopy. Dose area product (DAP) values were used to calculate the entrance skin dose (ESD), an indicator of potential skin damage and the effective dose (ED), an indicator of long-term cancer risk, for each patient. RESULTS: The median age of 58 patients included in data analysis was 28 years (range, 14-52 years), of whom 44 were male (76%). The mean ESD during intra-operative fluoroscopy was 0.0015 +/- 0.0029 Gy. The mean ED was 0.001 +/- 0.002 mSv. No results exceeded the threshold of 2 Gy for skin damage, and the life-time risk of developing new cancer due to intra-operative fluoroscopy is less than 0.0001%. CONCLUSIONS: Radiation doses administered during fluoroscopically-assisted ACL reconstruction were safe and do not represent a contra-indication to the procedure.

Osteochondritis dissecans of the knee; long-term clinical outcome following arthroscopic debridement.

We reviewed 32 knees in 26 patients who had previously undergone arthroscopic debridement for symptomatic osteochondritis dissecans (OCD) of the knee. The patients were followed up at a minimum of 11 years following surgery and were evaluated clinically using the American Knee Society Clinical Rating Score. Additional evaluation was performed using the Hughston Scale to include radiographic assessment. The mean American Knee Society Score was 179 (out of 200), indicating good clinical function. Radiographically, however, only 29% scored excellent or good on the Hughston Scale. Younger patients with a small, stable (and therefore preserved), medial femoral condyle lesion had the best prognosis. Whilst more novel and complex options such as chondrocyte implantation are being assessed for the treatment of OCD, it is clear that within this study group careful debridement with removal of loose tissue can achieve good clinical results in the long term. There was however radiographic evidence of early degenerative joint disease in 17/24 (71%) of patients reviewed. Patients undergoing excision of OCD fragments did worse than those in whom the fragment was preserved, however the risk of further surgery is raised if a fragment is left in situ at initial surgery.

Hydroxyapatite-coated, cementless total knee replacement in patients aged 75 years and over.

We have carried out a prospective study comparing the results at five years in patients older than 75 years of age undergoing hydroxyapatite-coated, cementless total knee replacement (TKR) with those who were younger. The Knee Society clinical rating scores were recorded before and after operation. Of 559 patients undergoing TKR, 135 were in the elderly age group. The knee scores at five years or more showed comparable results, with patients under 75 years of age reaching a score of 183 and those aged 75 years or over reaching 174. These differences were predominantly due to the functional component of the score. We conclude that elderly patients do just as well as the younger group using this prosthesis.

End-stage coxarthrosis and gonarthrosis. Aetiology, clinical patterns and radiological features of idiopathic osteoarthritis.

OBJECTIVES: To determine and compare the aetiological background, clinical patterns and radiological features of idiopathic osteoarthritis (OA) of the hip and the knee warranting arthroplasty. METHODS: A total of 402 Caucasians consecutively undergoing total hip replacement (THR) or total knee replacement (TKR) for idiopathic OA at a major centre was surveyed. RESULTS: Previous joint injury was more common in the TKR group (P < 0.0001). However, both groups manifested a mixed occupational background, body mass indices similar to the general population and a predominance of females (F:M = 1.3-1.4:1). The TKR group had a significantly younger age of symptom onset (56 yr) than the THR group (61 yr) but both groups had a tendency to bilateral arthroplasty (33%), nodal involvement (54-59%), a significant excess of right-sided replacements (1.8:1, THR; 2.2:1, TKR) and similar levels of pre-operative pain and disability. Up to 40% of hips manifested acetabular dysplasia and 10% possible previous slipped upper femoral epiphyses. Eighty-five per cent with end-stage coxarthrosis or gonarthrosis had an identical pattern of radiographic disease contralaterally. CONCLUSIONS: Our data suggest the importance of a constitutional tendency to idiopathic, end-stage OA, a disorder traditionally associated with environmental factors leading to 'wear and tear'.

Linkage analysis of chromosome 2q in osteoarthritis.

BACKGROUND: In independent linkage studies chromosome 2q11-q24 and chromosome 2q23-35 have previously been implicated as regions potentially harbouring susceptibility loci for osteoarthritis (OA). OBJECTIVE: To test chromosome 2q for linkage to idiopathic osteoarthritis. METHODS: Using a cohort of 481 OA families that each contained at least one affected sibling pair with severe end-stage disease (ascertained by hip or knee joint replacement surgery), we conducted a linkage analysis of chromosome 2q using 16 polymorphic microsatellite markers at an average spacing of one marker every 8.5 cM. RESULTS: Our results provide suggestive evidence for a locus at 2q31 with a maximum multipoint logarithm of the odds score (MLS) of 1.22 which increased to 2.19 in those families concordant for hip-only disease (n = 311). This suggestive linkage was greater in male-hip families (MLS = 1.57, n = 71) than in female-hip families (MLS = 0.71, n = 132). CONCLUSIONS: Chromosome 2q is likely to contain at least one susceptibility locus for OA.

Linkage analysis of candidate genes as susceptibility loci for osteoarthritis-suggestive linkage of COL9A1 to female hip osteoarthritis.

OBJECTIVE: To examine 11 candidate genes as susceptibility loci for osteoarthritis (OA). METHODS: A total of 481 families have been ascertained in which at least two siblings have had joint replacement surgery of the hip, or knee, or hip and knee for idiopathic OA. Each candidate gene was targeted using one or more intragenic or closely linked microsatellite marker. The linkage data were analysed unstratified and following stratification by sex and by joint replaced (hip or knee). RESULTS: The analyses revealed suggestive linkage of the type IX collagen gene COL9A1 (6q12-q13) to a subset of 132 families that contained affected females who were concordant for hip OA (female-hip) with a P-value of 0.00053 and logarithm of the odds (LOD) score of 2.33 [corrected P-value of 0. 0016, corrected LOD score of 1.85]. CONCLUSIONS: COL9A1 may therefore be a susceptibility locus for female hip OA. In addition, there was weak evidence of linkage to HLA/COL11A2 (6p21.3) in female hip OA with a corrected P-value of 0.016.

Association analysis of the vitamin D receptor gene, the type I collagen gene COL1A1, and the estrogen receptor gene in idiopathic osteoarthritis.

OBJECTIVE: Evidence has accumulated supporting a role for genes in the etiology of osteoarthritis (OA). Several candidates have been targeted as potential susceptibility loci including genes that are involved in the regulation of bone density. Genetic association analysis has suggested a role for the vitamin D receptor gene (VDR) and the estrogen receptor gene (ER) in susceptibility. Such findings must be tested in additional independent cohorts. We tested for association of these 2 genes, plus a third gene implicated in bone density, COL1A1, with idiopathic OA. METHODS: A case-control cohort of 371 affected probands and 369 unaffected spouses was used. Association was tested using 4 intragenic single nucleotide polymorphisms (SNP), one each for the VDR and COL1A1 genes, and 2 for the ER gene. The VDR and ER SNP are the same SNP that have been associated with OA. All 4 SNP affect restriction enzyme sites and were genotyped using polymerase chain reaction and enzyme digestion. Allele and genotype distributions for each SNP were compared between cases and controls and analyzed using Fisher's exact test. RESULTS: There was no evidence of association of the VDR or the ER gene SNP to OA. There was weak evidence of association of the COL1A1 SNP in female cases (p = 0.017), reflected by a difference in the distribution of genotypes at this SNP between female cases and controls (p = 0.027). However, when corrected for multiple testing, these results were not significant. CONCLUSION: If the VDR, ER, or COL1A1 genes do encode predisposition to OA then the 4 SNP tested are not associated with major susceptibility alleles at these 3 loci.

Osteoarthritis-susceptibility locus on chromosome 11q, detected by linkage.

We present a two-stage genomewide scan for osteoarthritis-susceptibility loci, using 481 families that each contain at least one affected sibling pair. The first stage, with 272 microsatellite markers and 297 families, involved a sparse map covering 23 chromosomes at intervals of approximately 15 cM. Sixteen markers that showed evidence of linkage at nominal P

Genetic influences in end-stage osteoarthritis. Sibling risks of hip and knee replacement for idiopathic osteoarthritis.

From a prospective, cross-sectional survey of 402 patients who had a total hip (THR) or a total knee (TKR) replacement for idiopathic osteoarthritis (OA) at a major centre, we determined the prevalence of these replacements for idiopathic OA in their 1171 siblings and 376 spouses. Using spouses as controls, the relative risk of THR in siblings was 1.86 (95% CI 0.93 to 3.69). The relative risk for TKR in siblings v spouses was 4.8 (95 % CI 0.64 to 36.4) whereas the risk for the combined outcome measure of THR or TKR was 2.32 (95% CI 1.22 to 4.43) when siblings and spouses over 64 years of age were compared. Using a threshold liability model (Falconer), the heritability of end-stage OA of the hip was estimated at 27%. The increased risks of joint replacement for severe, idiopathic OA which we found in siblings suggest that genetic influences are important in end-stage OA of the hip and knee.

Accidents with horses: what has changed in 20 years?

Horse riding is a dangerous pastime with more accidents occurring per hour than during motor-cycling. Since a prospective survey of horse-related injuries conducted at a major centre in 1971-1972, equestrian groups and the medical profession have encouraged improvements in training and protective riding wear. By conducting a similar study at the same centre 20 years later we hoped to assess the effects of these measures on the pattern of injuries resulting from contact with horses. Patient and injury details were recorded prospectively for all those presenting to the Accident Service at Oxford during the whole of 1991. Total admissions fell by 46 per cent on average. Most of the decrease was due to a near fivefold fall in those admitted with head injuries (P < 0.001). A reduction in the severity of such injuries was associated with an increased use of riding helmets. However, the most commonly injured group remained amateur young female riders suggesting the need for increasing awareness and training of this group. In seven cases, severe digital injuries were caused by the habit of entwining reins around the fingers. This practice should be discouraged. Up to 12 per cent of all injuries might have been prevented if adequate footwear had been worn.

Complete supernumerary leg in association with mesodermal abnormalities - a 16-year follow-up and literature review.

A male with a complete third leg in association with genito-urinary, anorectal, and colonic defects and an Arnold-Chiari malformation is described at birth and at 16 years of age following surgery. A short review of similar cases over the last century is presented and reference made to reported induction of similar abnormalities in vertebrates.

Examination of the breasts for surgical short cases.

For patients, examination of the breasts is a sensitive and sometimes anxious situation. Candidates should therefore display a thorough and confident technique aimed at reassuring both the patient and the examiner.