Comparing the MRI-based Goutallier Classification to an experimental quantitative MR spectroscopic fat measurement of the supraspinatus muscle.

BACKGROUND: The Goutallier Classification is a semi quantitative classification system to determine the amount of fatty degeneration in rotator cuff muscles. Although initially proposed for axial computer tomography scans it is currently applied to magnet-resonance-imaging-scans. The role for its clinical use is controversial, as the reliability of the classification has been shown to be inconsistent. The purpose of this study was to compare the semi quantitative MRI-based Goutallier Classification applied by 5 different raters to experimental MR spectroscopic quantitative fat measurement in order to determine the correlation between this classification system and the true extent of fatty degeneration shown by spectroscopy. METHODS: MRI-scans of 42 patients with rotator cuff tears were examined by 5 shoulder surgeons and were graduated according to the MRI-based Goutallier Classification proposed by Fuchs et al. Additionally the fat/water ratio was measured with MR spectroscopy using the experimental SPLASH technique. The semi quantitative grading according to the Goutallier Classification was statistically correlated with the quantitative measured fat/water ratio using Spearman's rank correlation. RESULTS: Statistical analysis of the data revealed only fair correlation of the Goutallier Classification system and the quantitative fat/water ratio with R = 0.35 (p < 0.05). By dichotomizing the scale the correlation was 0.72. The interobserver and intraobserver reliabilities were substantial with R = 0.62 and R = 0.74 (p < 0.01). CONCLUSION: The correlation between the semi quantitative MRI based Goutallier Classification system and MR spectroscopic fat measurement is weak. As an adequate estimation of fatty degeneration based on standard MRI may not be possible, quantitative methods need to be considered in order to increase diagnostic safety and thus provide patients with ideal care in regard to the amount of fatty degeneration. Spectroscopic MR measurement may increase the accuracy of the Goutallier classification and thus improve the prediction of clinical results after rotator cuff repair. However, these techniques are currently only available in an experimental setting.

Significant pain reduction and improved functional outcome after surgery for displaced midshaft clavicular fractures.

PURPOSE: Displaced midshaft clavicular fractures can be treated conservatively as well as operatively by titan elastic nail (TEN) or plate fixation. This survey was performed to evaluate the clinical results of each treatment method and elaborate advantages or possible complications of each modality. METHODS: Between 2008 and 2013, 102 patients were prospectively included in our study-37 patients for conservative treatment with a rucksack bandage for 4 to 6 weeks, 41 patients for plate osteosynthesis, and 24 for intramedullary stabilization with TEN. Disabilities of the Arm, Shoulder and Hand (DASH), Constant Murley Score (CMS), and visual analog scale (VAS) for pain and function as well as time of invalidity were recorded over a 1-year period. RESULTS: The clinical data collected reveals that all three different therapies lead to good or excellent clinical results after 1 year. However, one can observe advantages of operative treatment in comparison to conservative therapy in some characteristics. CONCLUSION: Our data shows that there are several indications where operative treatment has advantages compared to conservative treatment. In special fracture types (Robinson 2B1), TEN gives the best results. Plate fixation is extraordinarily sufficient in pain reduction within the first 5 weeks and indicated in more-part fractures (Robinson 2B2). Nevertheless, conservative treatment is always a good and promising way to treat clavicular fractures, so that individual indications and thorough patient informative talks are inevitable.

Biomechanical comparison of the Locking Compression superior anterior clavicle plate with seven and ten hole reconstruction plates in midshaft clavicle fracture stabilisation.

PURPOSE: The purpose of this study was to characterise the biomechanical properties of the seven hole superior anterior clavicle LCP (locking compression plate) and to compare these with the properties of commonly applied implants used for the stabilisation of clavicular midshaft fractures such as the locking 7- and ten hole reconstruction plate. METHODS: Twenty-four synthetic clavicles were used. A transverse midshaft fracture was induced. The clavicles were fixed with angle stable clavicle LCPs, seven hole and ten hole reconstruction plates (n = 8 each). Twenty cycles of axial compression and torsion were performed for each sample, which was followed by 1,000 cycles of three point bending and ultimately bending to failure. Axial, torsional and cantilever bending stiffness were calculated from the data recorded. RESULTS: The clavicle LCP showed the highest overall stiffness compared to the seven and ten hole reconstruction plate. Significantly higher stiffness values were found for axial compression and external rotation. In the load-to-failure tests, the ten hole reconstruction plate especially showed early signs of plastic deformation, which might account for early plate insufficiency so frequently observed clinically. CONCLUSION: The results indicate that the clavicle LCP, as compared to the reconstruction plates, leads to superior biomechanical stability in the treatment of midshaft clavicle fractures.

Fluoroscopic and magnetic resonance cross-sectional imaging assessments of radial and ulnar torsion profiles in volunteers.

PURPOSE: Planning an osteotomy to correct rotational malunions of the forearm is difficult because the uninvolved side is the only available reference to assess radial and ulnar torsions. This study was designed to compare the reliability of 2 methods for the determination of the torsion profile of both forearm bones and to assess side differences further in volunteers. METHODS: Fluoroscopy in combination with goniometry and magnetic resonance (MR) cross-sectional imaging were used to determine torsion profiles of the radius and the ulna in 24 asymptomatic volunteers. Interrater and interside reliabilities were assessed. RESULTS: For the radius, interclass correlation coefficients were less than 0.65 with fluoroscopy and greater than 0.80 with magnetic resonance imaging (MRI). For the ulna, both methods had an interclass correlation coefficient of greater than 0.90. Maximum side-to-side differences assessed with fluoroscopy and MRI were 25 degrees and 34.5 degrees for the radius and 20 degrees and 32 degrees for the ulna, respectively. There were no statistical differences between sides using both methods for both forearm bones. CONCLUSIONS: Fluoroscopy coupled with goniometry is a valuable method for assessing the torsion profile of the ulna. MR cross-sectional imaging is better to assess the torsion profile of the radius; however, a side difference in torsion profile of up to 35 degrees for the radius and of up to 20 degrees for the ulna should be considered physiologic. Hence, only side differences greater than these limits may serve as an indication for an axial osteotomy in the clinical setting.

Assessment of radial and ulnar torsion profiles with cross-sectional magnetic resonance imaging. A study of volunteers.

BACKGROUND: We determined whether the torsion profiles of the radius and ulna could be reliably assessed with cross-sectional magnetic resonance imaging and whether these torsion profiles were comparable on the two sides of volunteers. METHODS: We assessed magnetic resonance imaging cross sections of the left and right forearms of twenty-four asymptomatic volunteers. The torsion profile of the ulna was defined as the angle formed between a line tangential to the volar cortical surface of the distal part of the humerus and a line connecting the center of the ulnar head and the center of the ulnar styloid. Use of paired proximal and distal landmarks resulted in five different methods of assessment of the radial torsion profile. Intrarater and interrater reliabilities and side-to-side variability were assessed. RESULTS: This method of assessment of the ulnar torsion profile had intraclass and interclass coefficients of 0.95 and 0.91, respectively. A method previously described by Bindra et al. had the best combined intrarater and interrater reliabilities for assessment of the radius. The mean differences between the right and left sides of the volunteers were the lowest with the use of these two methods; nevertheless, the maximum side-to-side difference was > 30 degrees with techniques. CONCLUSIONS: Torsion-profile assessment with cross-sectional magnetic resonance imaging had high intrarater and interrater reliabilities. However, individual side-to-side variations in the radial and ulnar profiles are important considerations. CLINICAL RELEVANCE: Cross-sectional magnetic resonance imaging is currently the only available method to quantify rotational malunion of the radius and ulna. Its low side-to-side reliability warrants comparison between the imaging results and the clinical findings. A side-to-side difference in the rotation profile may serve as a reason to perform an axial osteotomy when the results of the clinical and magnetic resonance imaging assessments are consistent with each other.

Avascular necrosis of the femoral head in sickle-cell disease: restoration of sphericity and congruency following triple pelvic osteotomy. A case report.

A 9-year-old boy, originally from Zaire, presented with homozygous sickle-cell disease and a unilateral avascular necrosis of the femoral head. He was treated with a triple pelvic osteotomy to improve containment and stimulate remodelling of the head following prior partial reduction in a spica cast. Four and a half years postoperatively the patient was pain free with normal hip function. Radiography revealed a well-centred hip with a mild coxa magna and a nearly spherical femoral head. In geographic regions with a small black population, sickle cell disease and related orthopaedic problems are rarely encountered, but one must be prepared for the occasional patient. Triple pelvic osteotomy for the treatment of femoral head necrosis associated with sickle cell disease has not yet been reported and has led in this case to a highly satisfying improvement of the hip.