Reliability and Accuracy of the Outerbridge Classification in Staging of Cartilage Defects.

OBJECTIVE: The decision on whether or not and how to treat a local cartilage defect is still made intraoperatively based on the visual presentation of the cartilage and findings from indentations with an arthroscopic probe. The treatment decision is then usually based on grading according to established classifications systems, which, therefore, need to have high reliability and accuracy. The aim of the present study was to evaluate the reliability and accuracy of the Outerbridge classification in staging cartilage defects. METHODS: We performed an observer arthroscopic study using the Outerbridge classification on seven fresh-frozen human cadaveric knees, which collectively exhibited nine cartilage defects. To evaluate accuracy, defect severity was verified through histological examination. Interrater and intrarater reliabilites were calculated using Cohen's kappa and the intra-class correlation coefficient (ICC 3.1). RESULTS: The interrater and intrarater reliability for the Outerbridge classification ranged from poor to substantial, with 0.24 ≤ κ ≤ 0.70 and κ = 0.55 to κ = 0.66, respectively. The accuracy evaluated by comparison with the histological examination was 63% overall. The erroneous evaluations were, however, still often at the discrimination of grade 2 and 3. We did not find any relationship between higher experience and accuracy or intraobserver reliability. Taken together, these results encourage surgeons to further use diagnostic arthroscopy for evaluating cartilage lesions. Nevertheless, especially in grade 2 and 3, deviations from the histology were observed. This is, however, the point where a decision is made on whether to surgically address the defect or not. CONCLUSION: Diagnostic arthroscopy is the standard for cartilage lesion assessment, yet interobserver reliability is fair to substantial. Caution is warranted in interpreting varied observer results. The accuracy of the "simpler" Outerbridge classification is insufficient compared to histological examinations, highlighting the need for improved techniques in guideline-based intraoperative decision-making.

Knee Diameter and Cross-Section Area Measurements in MRI as New Promising Methods of Chondromalacia Diagnosis-Pilot Study.

Background and Objectives: Chondromalacia often affects the knee joint. Risk factors for the development of cartilage degenerative changes include overweight, female sex and age. The use of radiological parameters to assess the knee joint is rarely reported in the literature. Materials and Methods: The study involved 324 patients, including 159 (49%) women and 165 (51%) men, with an age range between 8−87 years (mean: 45.1 ± 20.9). The studied group had a body mass index (BMI) in the range of 14.3−47.3 (mean: 27.7 ± 5.02). A 1.5 Tesla and 3.0 Tesla (T) MRI scanner was used to assess the cartilage of the knee joint using the Outerbridge scale. The radiological parameters analyzed were the Insall−Salvati index, knee surface area, knee AP (antero-posterior) maximal diameter and knee SD (sinistro-dexter) maximal diameter. Results: Parameters such as the knee surface area, knee AP maximal diameter and knee SD maximal diameter showed a significant correlation with Outerbridge Scale (p < 0.014). The age of the patients showed a significant correlation with each knee parameter (p < 0.004). Results of knee AP and SD maximal diameter measurements strongly depended on BMI level. Conclusions: A significant relationship was found between the knee surface area, knee AP maximal diameter and knee SD maximal diameter and the advancement of chondromalacic changes in the knee joint, age and BMI.

Radiographic vs. MRI vs. arthroscopic assessment and grading of knee osteoarthritis - are we using appropriate imaging?

PURPOSE: Radiographs and MRI scans are commonly used imaging techniques in the assessment of knee osteoarthritis. However, it currently remains uncertain how good a representation of the actual condition of the knee joint these investigations provide. By comparing them against arthroscopic findings the aim of our study was to conclude how accurate these imaging techniques are at grading knee osteoarthritis. METHODS: This was a retrospective study looking at knee arthroscopies performed at a tertiary centre over a 5 year period. The Outerbridge grade given at arthroscopy was correlated with pre-operative radiograph and MRI scores, so as to assess the reliability of these imaging techniques at predicting the actual severity of knee osteoarthritis seen. RESULTS: Kellgren-Lawrence (KL) grading of radiographs was moderately correlated with Outerbridge grades from arthroscopy for the medial compartment of the knee (Spearman's rho (SR) 0.483, p < 0.001), with a milder correlation in the lateral compartment (SR 0.218, p = 0.003). MRI reporting of knee osteoarthritis was moderately correlated with Outerbridge grades in the medial compartment (SR 0.451, p < 0.001), mildly correlated for both the lateral (SR 0.299, p < 0.001) and patellofemoral joint compartments (SR 0.142, p = 0.054). KL and MRI grading was moderately correlated for the medial compartment (SR 0.475, p < 0.001) and mildly correlated for the lateral compartment (SR 0.277, p < 0.001). CONCLUSION: The ability of radiographs to represent the actual condition of knee osteoarthritis is underestimated. KL grading especially best represents the disease seen in the medial compartment of the knee joint, with a moderate correlation to Outerbridge scores given on arthroscopic assessment. We suggest that whilst MRI is a useful tool in the investigation of knee symptoms, it is often unnecessarily used in patients with OA, when in fact, radiographs alone would be sufficient. EVIDENCE LEVEL: III.

Knee Diameter and Cross-Sectional Area as Biomarkers for Cartilage Knee Degeneration on Magnetic Resonance Images.

Background and Objectives: Osteoarthritis (OA) of the knee is a degenerative disorder characterized by damage to the joint cartilage, pain, swelling, and walking disability. The purpose of this study was to assess whether demographic and radiologic parameters (knee diameters and knee cross-sectional area from magnetic resonance (MR) images) could be used as surrogate biomarkers for the prediction of OA. Materials and Methods: The knee diameters and cross-sectional areas of 481 patients were measured on knee MR images, and the corresponding demographic parameters were extracted from the patients' clinical records. The images were graded based on the modified Outerbridge arthroscopic classification that was used as ground truth. Receiver-operating characteristic (ROC) analysis was performed on the collected data. Results: ROC analysis established that age was the most accurate predictor of severe knee cartilage degeneration (corresponding to Outerbridge grades 3 and 4) with an area under the curve (AUC) of the specificity-sensitivity plot of 0.865 ± 0.02. An age over 41 years was associated with a sensitivity and specificity for severe degeneration of 82.8% (CI: 77.5-87.3%), and 76.4% (CI: 70.4-81.6%), respectively. The second-best degeneration predictor was the normalized knee cross-sectional area, with an AUC of 0.767 ± 0.04), followed by BMI (AUC = 0.739 ± 0.02), and normalized knee maximal diameter (AUC = 0.724 ± 0.05), meaning that knee degeneration increases with increasing knee diameter. Conclusions: Age is the best predictor of knee damage progression in OA and can be used as surrogate marker for knee degeneration. Knee diameters and cross-sectional area also correlate with the extent of cartilage lesions. Though less-accurate predictors of damage progression than age, they have predictive value and are therefore easily available surrogate markers of OA that can be used also by general practitioners and orthopedic surgeons.

Outcomes of rotator cuff repair with concurrent microfracture of focal glenohumeral osteoarthritis.

BACKGROUND: The benefit of rotator cuff repair (RCR) in patients with concurrent osteoarthritic changes remains unclear. RCR has the theoretical potential to increase the compressive force across the glenohumeral joint, further exacerbating osteoarthritis pain. The purpose of this study is to investigate pain relief and patient-reported outcomes of patients undergoing simultaneous RCR and microfracture of focal glenohumeral osteoarthritis. METHODS: Thirty-four patients undergoing simultaneous RCR and microfracture were retrospectively reviewed at a minimum 1-year follow-up. Patient demographics, preoperative range of motion, functional outcomes (visual analog scale [VAS], Single Assessment Numeric Evaluation [SANE], American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form [ASES], and Simple Shoulder Test [SST]), and operative metrics were recorded. The patients were then contacted to obtain postoperative functional outcome scores (VAS, SANE, ASES, and SST). RESULTS: Twenty-seven patients (11 male/16 female [79%]) were evaluated at a mean follow-up of 25.8 months (range, 12-46). The average age at surgery was 64.9 years (range, 56-78). Chronic tears were more common than acute tears (57.7% vs. 42.3%). The majority of patients had a full rotator cuff tear (89%) involving a mean 1.7 ± 0.8 tendons (range, 1-3). Eighty-eight percent of the humeral lesions were Outerbridge 4 compared with 84% on the glenoid. The mean estimated involvement between the 2 groups with 38.4% ± 18.4% of the humeral head involved and 34.6% ± 18.4% of the glenoid involved. PRO scores improved postoperatively with a reduction in mean VAS (6.6-2.0, P < .01), SANE (33.8-79.8, P < .01), ASES (38.0-80.9, P < .01), and SST (3.07-9.70, P < .01) scores. Cumulatively, only 52% (14/27) of the patients improved, however, by the MCID for all collected PROs. CONCLUSIONS: Our results demonstrate modest improvements in postoperative pain and functional scores at a minimum of 1-year follow-up in a cohort of patients who have undergone RCR and glenohumeral microfracture. In cases of small focal lesions of full-thickness cartilage loss, RCR with microfracture is a reasonable treatment option; however, patients should be counseled on expectations accordingly.

Femoral Cartilage Ultrasound Echo Intensity Associates with Arthroscopic Cartilage Damage.

This study compared quantitative cartilage ultrasound metrics between people with (n = 12) and without (n = 12) arthroscopic cartilage damage after anterior cruciate ligament injury (age, 24.9 ± 3.7 y; sex, 33% female, 67% male; days since injury = 50 ± 52). A transverse suprapatellar ultrasound assessment imaged the femoral cartilage in participants' injured knees before a clinical arthroscopy. A custom program automatically separated a manual cartilage segmentation into standardized medial and lateral femoral regions and calculated mean thickness (i.e., cross-sectional area/length of cartilage-bone interface), mean echo intensity and echo-intensity heterogeneity. An orthopedic surgeon assessed arthroscopic cartilage damage in the medial and lateral femoral condyles using the Outerbridge grading system (cartilage damage = Outerbridge ≥ 1). Separate logistic regressions for medial and lateral femoral cartilage were used to determine the association between each ultrasound metric and arthroscopic cartilage damage. In medial femoral cartilage, for every 1 standard deviation decrease in echo-intensity mean and heterogeneity, there is, respectively, a 91% (adjusted odds ratio, 0.09; 95% confidence interval, 0.01-0.69) and 97% (adjusted odds ratio, 0.03; 95% confidence interval, 0.002-0.50) increase in the odds of having arthroscopic cartilage damage. Lateral cartilage ultrasound metrics are not associated with lateral arthroscopic cartilage damage. This study provides preliminary evidence that femoral cartilage ultrasound echo intensity is a non-invasive measure associated with medial femoral cartilage health after anterior cruciate ligament injury.

Clinical outcomes of a combined arthroscopic and mini-open Outerbridge-Kashiwagi procedure for elbow osteoarthritis.

BACKGROUND: To evaluate the short-term clinical outcomes of a modified Outerbridge-Kashiwagi (O-K) procedure in the treatment of elbow osteoarthritis. METHODS: Between January 2012 and December 2016, 27 patients with elbow osteoarthritis were treated with a modified O-K procedure combining mini-open and arthroscopic technique in our institution. All patients with primary osteoarthritis and post-traumatic degenerative osteoarthritis of the elbow were included in the study if they had undergone the modified O-K procedure. Clinical outcomes were assessed using the visual analog scale (VAS), degree of flexion, extension loss, arc of motion, Mayo Elbow Performance Score (MEPS), and radiographs. RESULTS: Twenty-five patients with a mean age of 47.2 years (range, 21-69 years) at surgery were followed up for a mean of 54.5 months (range, 27-86 months). The VAS improved from 8.0 ± 1.4 (range, 6-10) preoperatively to 1.3 ± 1.1 (range, 0-3) at the final follow-up (P < .001), degree of flexion from 115.2° ± 12.0° (range, 90°-135°) to 130.6° ± 6.3° (range, 120°-140°) (P < .001), extension loss from 31.2° ± 15.0° (range, 10°-60°) to 10.2° ± 7.7° (range, 0°-30°) (P < .001), arc of motion from 84.0° ± 18.8° (range, 55°-120°) to 120.4° ± 9.3° (range, 105°-135°) (P < .001), and MEPS from 55.8 ± 8.1 (range, 40-70) to 88.4 ± 7.2 (range, 70-100) (P < .001). Radiographs at the final follow-up showed that 9 patients (36%) had significant recurrence of bone formation within the fenestration of the olecranon fossa. One patient developed delayed-onset ulnar neuropathy, with only slight numbness in the ulnar nerve distribution 6 months after surgery. CONCLUSIONS: The modified O-K procedure is safe and effective in pain relief and function restoration in patients with elbow osteoarthritis.

Size of Initial Bone Bruise Predicts Future Lateral Chondral Degeneration in ACL Injuries: A Radiographic Analysis.

BACKGROUND: Bone marrow contusions are common after an acute anterior cruciate ligament (ACL) injury. It is unknown whether the severity of this initial bruise can predict the potential of developing chondral changes even after ACL reconstructive surgery (ACLR). PURPOSE: To investigate whether the initial bone bruise area could be predictive of progressive chondral defects. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: A retrospective chart review was performed to capture patients with an acute ACL injury with pre- and post-ACLR magnetic resonance imaging (MRI) between January 2000 and December 2017. Lesion areas were measured on initial MRI, and chondral wear was graded on final imaging by use of the modified Outerbridge classification. An ordinal model was created to determine whether the initial area was a significant predictor for future chondral degeneration. RESULTS: A total of 40 patients with a mean age of 34.5 ± 12.6 years were included for analysis. All patients underwent ACLR at a mean 139 ± 64 days from initial injury. A lateral tibial and femoral bone bruise was most commonly present in patients (77.5% and 62.5%, respectively). A medial femoral bone bruise was found in only 12.5% (5/40) of patients. The initial contusion area significantly correlated with increasing chondral wear over time in the tibia and lateral femoral condyle (P < .001). Patients with a bone bruise encompassing 100% of the lateral femoral compartment on MRI had a 74% chance of having grade 3 or 4 chondral changes at 5 years (P = .001). Absence of a bone bruise on initial MRI was the greatest predictor of no cartilage wear at 5 years in all compartments (P < .001). The presence of a concomitant lateral meniscal injury increased the risk of developing type 3 or 4 chondral wear in the lateral tibial plateau (P = .012) but did not pose increased risk of femoral wear (P = .23). CONCLUSION: A significant relationship between area of initial bone bruise at the time of injury and progressive posttraumatic chondral disease was found in the tibial and lateral femoral compartments.

[Diagnostic accuracy of conventional X-ray imaging for assessment of trapeziometacarpal joint osteoarthritis]. / Genauigkeit der konventionellen Röntgendiagnostik bei der Beurteilung der Daumensattelgelenkarthrose.

BACKGROUND: Osteoarthritis of the trapeziometacarpal joint is a common and painful affliction that can be diagnosed using conventional X­ray imaging as well as arthroscopy and if necessary treated; however, the X­ray classification often does not sufficiently demonstrate the cartilage damage found in arthroscopy. OBJECTIVE: The aim of the study was to evaluate the diagnostic accuracy of conventional X­ray imaging compared to arthroscopy for osteoarthritis of the trapeziometacarpal joint. MATERIAL AND METHODS: The preoperative conventional X­ray images of 23 patients were presented to 10 experienced hand surgeons who were blinded to the arthroscopy results. Their ratings were compared to the results found with arthroscopy. RESULTS: Of the patients 11 were found to have grade 4 cartilage lesions according to the Outerbridge classification, 8 grade 3 lesions, 4 grade 2 lesions and no grade 1 lesions. Overall, 43% (95% confidence interval, CI 37-49%) of the cartilage lesions were diagnosed correctly using conventional X­rays. For grade 4 lesions 73% (95% CI 65-81%) of the surgeons made the correct diagnosis, in the case of grade 3 lesions 38% (95% CI 27-49%) and in grade 2 lesions 13% (95% CI 3-23%). CONCLUSION: This study presents an arthroscopy classification system that is specific for osteoarthritis of the trapeziometacarpal joint and provides an additional method of assessment if the X­ray grading of osteoarthritis according to Eaton and Littler is too unspecific. Arthroscopy can be used to safely differentiate the treatment-relevant stage and also includes treatment options.

A Microarray Study of Articular Cartilage in Relation to Obesity and Severity of Knee Osteoarthritis.

OBJECTIVE: To query the transcript-level changes in the medial and lateral tibial plateau cartilage in tandem with obesity in patients with end-stage osteoarthritis (OA). DESIGN: Cartilage was obtained from 23 patients (20 obese [body mass index > 30 kg/m2], 3 overweight [body mass index < 30 kg/m2]) at the time of total knee replacement. Cartilage integrity was assessed using Outerbridge scale, while radiographic changes were scored on preoperative X-rays using Kellgren-Lawrence (K-L) classification. RNA was probed for differentially expressed transcripts between medial and lateral compartments using Affymetrix Gene 2.0 ST Array and validated via real-time polymerase chain reaction. Gene ontology and pathway analyses were also queried. RESULTS: Scoring of cartilage integrity by the Outerbridge scale indicated that the medial and lateral compartments were similar, while scoring by the K-L classification indicated that the medial compartment was more severely damaged than the lateral compartment. We observed a distinct transcript profile with >50% of transcripts unique between medial and lateral compartments. MMP13 and COL2A1 were more highly expressed in medial versus lateral compartment. Polymerase chain reaction confirmed expression of 4 differentially expressed transcripts. Numerous transcripts, biological processes, and pathways were significantly different between overweight and obese patients with a differential response of obesity on medial and lateral compartments. CONCLUSIONS: Our findings support molecular differences between medial and lateral compartments reflective of the greater severity of OA in the medial compartment. The K-L system better reflected the molecular results than did the Outerbridge. Moreover, the molecular effect of obesity was different between the medial and lateral compartments of the same knee plausibly reflecting the molecular effects of differential biomechanical loading.

Correlación de la Escala de Kellgren-Lawrence con la Clasificación de Outerbridge en Pacientes con Gonalgia Crónica / Correlation of the Kellgren-Lawrence Scale with the Outerbridge Classification in Patients with Chronic Gonalgia

Introducción La correlación entre las escalas radiográficas y artroscópicas para el grado de lesión articular en pacientes con osteoartritis (OA) es inconsistente. El estudio busca determinar la correlación entre el grado de lesión articular según la escala radiográfica de Kellgren-Lawrence (KL) y la clasificación artroscopica de Outerbridge (CO). Materiales y Métodos Se analizaron pacientes adultos (>18 años) con gonalgia crónica realizando una valoración de las radiografía de rodilla según la escala KL. Posteriormente, los mismos pacientes fueron sometidos a artroscopía en donde se valoró el grado de lesión condral de acuerdo a la CO. Se realizó una correlación de Spearman entre las escalas de clasificación. Se calculó la sensibilidad, especificidad, valor predictivo positivo, valor predictivo negativo de la radiografía para diagnosticar OA (grado >1 en la CO). Resultados Se analizaron 80 pacientes, 52.5% fueron mujeres. La clasificación radiográfica KL mostró una sensibilidad promedio de 90.2%, especificidad de 24.6%, VPP de 86.3% y VPN de 32.0% para diagnosticar cualquier grado de OA en relación a la CO. En promedio, se encontró una correlación moderada a baja (Rho 0.40, p<0.001) entre la escala de KL y la CO. El porcentaje de correspondencia entre los grados de KL y CO fue de 17.5% en promedio. Discusión La clasificación KL es sensible para diagnosticar OA en rodillas, sin embargo, nuestro estudio sugiere que es poco específica y presenta una moderada correlación con los grados de lesión diagnosticados mediante artroscopía utilizando la CO. Nivel de evidencia

Background The correlation between radiographic and arthroscopic scales for the degree of joint injury in patients with osteoarthritis (OA) is inconsistent. The study seeks to determine the correlation between the degree of joint injury according to the Kellgren-Lawrence (KL) radiographic scale and the Outerbridge (CO) arthroscopic classification. Methods Adult patients (> 18 years) with chronic gonalgia were analyzed by evaluating the knee radiographs according to the KL scale. Subsequently, the same patients underwent arthroscopy where the degree of chondral injury was assessed according to CO. A Spearman correlation was made between the rating scales. Sensitivity, specificity, positive predictive value, negative predictive value of radiography to diagnose OA (grade>1 in CO) were calculated. Results 80 patients were analyzed, 52.5% were women. The KL radiographic classification showed an average sensitivity of 90.2%, specificity of 24.6%, PPV of 86.3% and NPV of 32.0% to diagnose any degree of OA in relation to CO. On average, a moderate to low correlation (Rho 0.40, p <0.001) was found between the KL scale and the CO. The percentage of correspondence between the grades of KL and CO was 17.5% on average. Discussion The KL classification is sensitive for diagnosing OA in the knees, however, our study suggests that it is not very specific and has a moderate correlation with the degrees of injury diagnosed by arthroscopy using CO. Evidence Level IV.

Use of a modified Outerbridge-Kashiwagi procedure for the treatment of posttraumatic elbow sequelae.

BACKGROUND: To review our 10-year experience treating posttraumatic sequelae of the elbow using a modified Outerbridge-Kashiwagi (O-K) procedure. METHODS: Twenty-one patients with posttraumatic sequelae of the elbow treated using the technique were evaluated clinically using the Mayo Elbow Performance Score, range of motion testing, and pain level. We noted the presence of preoperative and postoperative ulnar nerve symptoms, complications, and reoperations. Open contracture release was selected to address either removal of hardware or ulnar nerve pathology. RESULTS: At a mean of 39 months (range, 12-116 months), the Mayo Elbow Performance Score improved from 52 to 84 (P < .0001) and the mean arc of motion improved from 44° to 98° (P < .0001). At the final follow-up, 90% of patients reported no pain or mild pain, and 81% of patients had a satisfactory objective result. In 15 of 21 cases (71%), it was necessary to mobilize the ulnar nerve. After contracture release, 1 patient developed new onset ulnar nerve symptoms. Three patients underwent reoperation: 2 for recalcitrant contracture and 1 for new onset ulnar nerve symptoms. CONCLUSIONS: The mini-open O-K procedure is safe and effective in restoring function in patients with retained hardware and posttraumatic contracture. Posttraumatic arthritic patients often require both removal of hardware and neurolysis of the ulnar nerve. The mini-open O-K procedure allows complete access to the elbow joint, which facilitates release for both intrinsic and extrinsic contracture.

Fracture Risk in Ulnohumeral Arthroplasty-A Biomechanical Study.

PURPOSE: Ulnohumeral arthroplasty, also known as the Outerbridge-Kashiwagi procedure, was popularized after reports of successful results in 1978, and has long been a means of management for ulnohumeral arthritis. However, there are concerns over the loss of integrity of the distal humerus as a result of fenestration. The purpose of this study was to examine the relationship between the size of fenestration and fracture risk. METHODS: Using a validated fourth-generation sawbones model, load to failure and site of fracture were investigated following incrementally increasing distal humeral fenestration sizes. Each sample was subjected to a uniform extension stress on a materials testing system, with 5 samples run for each group. The experimental groups began with a fenestration size of 10 mm and increased by 3 mm increments up to 31 mm. Load at failure and site of fracture were recorded for each sample. RESULTS: Forty-five fourth-generation sawbones samples were tested. Average load at sample failure was equivalent for each fenestration group up to 25 mm. At 28 mm, average load to failure began to decrease, and was statistically significant beginning between 28 mm and 31 mm. At 28 mm, 4 of 5 samples fractured through the fenestration, and at 31 mm, all 5 samples fractured through the fenestration. This change in fracture site became statistically significant between 25 mm and 28 mm. CONCLUSIONS: Distal humeral fenestration does compromise its structural integrity; however, for resection in the range of 10-25 mm, there is no increased risk of fracture. CLINICAL RELEVANCE: On the basis of this biomechanical model, the authors do not recommend any activity limitations after initial surgical recovery, but do recommend against distal humeral fenestrations larger than 25 mm when performing this procedure.

The effect of humeral-fenestration diameter in Outerbridge-Kashiwagi arthroplasty on failure load of the distal humerus: a cadaveric biomechanical study.

INTRODUCTION: Outerbridge-Kashiwagi ulnohumeral arthroplasty is an effective method in treating elbow osteoarthritis; however, distal humerus fracture after surgery can become a critical issue. A previous biomechanical study has shown that the failure load of the distal humerus decreases after a fenestration, but the size of the fenestration hole has not yet been discussed. MATERIALS AND METHODS: 32 fresh-frozen cadaveric distal humeri were obtained. Two drill sizes were chosen for fenestration: 12 and 15 mm in diameter. Two directions of force were applied with a materials testing machine for biomechanical testing: 5° flexion for axial loading and 75° flexion for anterior-posterior (AP) loading. Each specimen randomly received one of the two fenestration sizes, and force directions. All specimens were loaded to failure at a rate of 2 mm/min. RESULTS: The failure loads of the 12 and 15 mm groups were not significantly different in either axial loading(3886 ± 1271 N vs 4286 ± 901 N) or AP loading(2303 ± 803 N vs 1897 ± 357 N). All specimens loaded with axial force failed via the fenestration holes; however, during AP loading, some specimens failed through the fenestration holes, while others at diaphysis (p = 0.28). CONCLUSIONS: The failure load of distal humeri did not differ significantly after fenestration of 12 or 15 mm. The clinical relevance is that as the risk of distal humerus fracture is not exacerbated, a larger-size fenestration hole could be of help to improve the effectiveness of this surgical procedure.

Elbow arthroplasty: where are we today? A narrative review.

Background The elbow joint is a complex compound articulation, with a linking role within the upper limb kinematics. Its hinge function allows for proper placement of our working instrument (the hand) in the space surrounding us, directed by the shoulder joint. Both reliable mobility and stability are essential elements to allow for consistent bridging of the distance we aim to achieve in common daily activities. Sufficient flexion and extension are required to ensure both the patients' independence and the dignity. Next to the hinge, a radio-ulnar rotation with precise co-operation of forearm and wrist spin enhances the linking function with accurate precision instrument manipulation. Arthritis of the elbow joint or cubarthritis, whether primary or secondary, may not be as highly prevalent as hip or knee arthritis, but its impact on daily live certainly cannot be underestimated. Methods Current treatment options for failing cubarthritis are reviewed. Results Surgical techniques to reconstruct or replace the elbow joint are currently increasingly efficient with mounting long-term outcome reports. Debridement techniques including open or arthroscopic Outerbridge-Kashiwaghi procedure often delays joint replacement. Implants for joint arthroplasty focus on the ulna-humeral joint mostly with semi-constrained linked techniques, but there is a trend towards total joint replacement including the radiocapitellar joint. Conclusion In this independent review article, elbow joint failure due to cubarthritis and an overview of its current state-of-the-art orthopaedic treatment algorithm is presented, with its indications, advantages, risks and outcome.

Long-term outcome of grade III and IV chondral injuries of the knee treated with Steadman microfracture technique.

INTRODUCTION: The aim of our study is to demonstrate the effectiveness of Steadman microfracture technique in the management of high-grade chondral defects at the level of the knee by clinical follow-ups at eleven years. MATERIALS AND METHODS: This is a study conducted on fifteen patients suffering from Outerbridge grade III and IV chondral lesions of the knee, who underwent Steadman microfracture surgery between 2003 and 2004. Selective exclusion criteria to prevent that other treatments or comorbidities could invalidate the results were used. Patients were clinically evaluated with Lysholm and IKDC scale scores before surgery and at follow-ups at eleven years. RESULTS: There has been an improvement in the Lysholm scores (59.33 ± 18.2 at time zero vs 82.13 ± 14.16 at time t; p value: 0.0342) and in the IKDC scores (45.13 ± 17.07 at time zero vs 68.66 ± 21.47 at time t; p value: 0.04) that appears statistically significant. DISCUSSION: Currently microfracture surgery is not indicated in patients with high-grade chondral defects, but at the same time, it is a technique of easy execution, low cost and good results. The clinical improvement observed appears statistically significant, but we have also noticed a slight clinical worsening in two patients, possibly caused by: improper treatment, new trauma, incorrect rehabilitation and age at time of surgery. CONCLUSIONS: The study has shown significant clinical improvements in patients, despite the fact that indications to the use of microfracture are still very limited and selective. It's essential to underline the importance of the single patient assessment process, taking into account a variety of aspects including the site, the number and extent of the lesion, the degree of functionality, activity level, age and previous trauma. This shows the importance of a comprehensive assessment of the patient in order to choose the most suitable surgical option, which not necessarily has to strictly adhere to standard practice.

Role of Arthroscopy in the Treatment of Osteoarthritis of Knee.

BACKGROUND: A variety of procedures have been described for treatment of the osteoarthritic knee. Comprehensive Arthroscopic treatment regime has definite role in treating patients with knee Osteoarthritis. AIM: To evaluate the role of arthroscopy in functional and subjective outcomes of patient with moderate to severe osteoarthritis of knee. MATERIALS AND METHODS: Between October 2011 to September 2013, 30 patients were treated with an arthroscopic regimen. Patients with primary osteoarthritis who fulfilled clinical and radiographic classification criteria of American College of Rheumatology for osteoarthritis were included. All patients were followed for 18 months. All patients were subjected to comprehensive arthroscopic treatment. RESULTS: Overall, mean age was 59 years, with 17 females and 13 males. According to Kellgren Lawrence scale, 17 patients had grade 2 osteoarthritis, 10 had grade 3 osteoarthritis and 3 patients had grade 4. The average preoperative Lysholm score was 38.8. According to Outerbridge grading of chondral surface lesions, 14 patients were in grade-1, 5 in grade-2, 8 in grade-3 and 3 patients were in grade-4. The average 18 months postoperative Lysholm score was 83.3 (range 60- 96). 73.33% patients showed good/ excellent outcome. 80% of patients with chondral and meniscal lesions showed excellent/good outcome. CONCLUSION: This arthroscopic treatment regimen can improve function and activity levels in patients with moderate to severe osteoarthritis. Patients with meniscal and chondral pathology will be benefited more by arthroscopic treatment.

Correlation among Radiographic, Arthroscopic and Pain Criteria for the Diagnosis of Knee Osteoarthritis.

INTRODUCTION: Osteoarthritis (OA) is the most common degenerative joint disorder leading to functional impairment and dependency in older adults. Early detection and intervention is of paramount importance in decreasing the morbidity. Radiography is the first investigation of choice for OA patients presenting with knee pain. But, there is a high degree of discordance between clinical and radiographic findings. Arthroscopy aids in accurate diagnosis of OA knee. AIM: In view of the conflicting reports in the literature the present study was undertaken to report the correlation among radiographic, arthroscopic and pain findings in knee OA patients to facilitate early and precise diagnosis. MATERIALS AND METHODS: Twenty eight cases (14 males and 14 females) of primary OA knee (7 each from radiographic grade 1 to 4) were screened and selected for the study. Spearman's rank correlation coefficients (Rho/r estimate) were calculated to determine the relationship between pain, radiographic and arthroscopic grades in patients with knee OA. RESULTS: Among 28 patients, 10.71% had grade 1, 14.28% had grade 2, 25% had grade 3 and 50% had grade 4 arthroscopic findings. Overall Spearman's correlation coefficient (r) for radiographic and arthroscopic grades was 0.8077, 0.8212 for radiographic and pain grades and 0.7634 for arthroscopic and pain grades. Correlation coefficient could not be calculated for individual grades in isolation which would otherwise represent the factual correlation. The Mean arthroscopic grade for radiographic grades 1 to 4 were 1.57, 3.42, 3.57,4.0 respectively and the Mean pain grades for radiographic grades 1 to 4 were1.57, 2.57,3.28, 3.57 respectively. Radiological findings were found to lag behind the arthroscopic findings significantly. CONCLUSION: Arthroscopic findings represent the exact extent and degree of the pathology of OA knee. Kellgren-Lawrence grading read with conventional Antero-posterior standing radiographs of knee underscores the arthroscopic findings significantly in grades 1, 2 and 3. Radiological and clinical findings (Apley's pain grading) in combination should be considered in concluding the final diagnosis and treatment of OA knee. Improvised criteria for precise diagnosis have to be evolved.

MR T(1)ρ quantification of cartilage focal lesions in acutely injured knees: correlation with arthroscopic evaluation.

OBJECTIVE: Quantitative T1ρ MRI has been suggested as a promising tool to detect changes in cartilage composition that are characteristic of cartilage damage and degeneration. The objective of this study was to evaluate the capability of MR T1ρ to detect cartilage lesions as evaluated by arthroscopy in acutely ACL-injured knees and to compare with the Whole-Organ Magnetic Resonance Imaging Score (WORMS) using clinical standard MRI. METHOD: Ten healthy controls (mean age 35) with no ACL injury or history of osteoarthritis (OA) and 10 patients with acute ACL injuries (mean age 39) were scanned at 3 Tesla (3T). ACL patients underwent ACL reconstruction, where focal lesions were graded according to an Outerbridge grading system during arthroscopic evaluation. Normalized MR T1ρ values (T1ρ z-scores normalized to control values in matched regions) in full thickness, and superficial and deep layers of cartilage were compared between defined sub-compartments with and without focal lesions. Intraclass (ICC) correlation and the root mean square coefficient of variation (RMS-CV) were performed to evaluate the inter-observer reproducibility of T1ρ quantification. Sub-compartments of cartilage were also evaluated using WORMS scoring and compared to their Outerbridge score respectively. RESULTS: The inter-observer ICC and the RMS-CV of the sub-compartment T1ρ quantification were 0.961 and 3.9%, respectively. The average T1ρ z-scores were significantly increased in sub-compartments with focal lesions compared to those without focal lesions and to the control cohort (p<0.05). CONCLUSION: Our results indicate that T1ρ provided a better diagnostic capability than clinical standard MRI grading in detecting focal cartilage abnormalities after acute injuries. Quantitative MRI may have great potential in detecting cartilage abnormalities and degeneration non-invasively, which are occult with standard morphological MRI.

Outcomes of the mini-open Outerbridge-Kashiwagi procedure according to preoperative radiocapitellar joint status.

PURPOSE: To compare the clinical and radiological outcomes in patients treated with the mini-open Outerbridge-Kashiwagi procedure according to radiological grading of the radiocapitellar joint. METHODS: Sixty-three patients with primary elbow arthritis diagnosed between March 2004 and February 2010 were enrolled. Patients without and with radiocapitellar arthrosis were assigned to groups 1 (n = 34) and 2 (n = 29), respectively. The mean follow-up period was 51 months. Clinical outcomes were compared between groups using the presence of resting elbow pain; Morrey pain score; the Mayo Elbow Performance Score; the Disabilities of the Arm, Shoulder and Hand score; and active range of motion. Radiological outcomes, including the presence of loose bodies and re-ossification of fenestration, were evaluated. RESULTS: No patient in group 1 and 4 patients in group 2 reported resting elbow pain at the final follow-up examination. All pain was on the radial side, and it was aggravated in 2 patients. The Mayo Elbow Performance Score and Disabilities of the Arm, Shoulder and Hand score and active motion improved in both groups. No significant difference in the Morrey pain score, Mayo Elbow Performance Score, Disabilities of the Arm, Shoulder and Hand score, or active range of motion was observed between groups. Postoperative deterioration of radiological joint status was similar in the ulnohumeral and radiocapitellar joints of both groups. Re-ossification of the fossa fenestration did not differ significantly between groups. CONCLUSIONS: We compared the outcomes of the mini-open Outerbridge-Kashiwagi procedure according to radiocapitellar joint status. Short-term results were satisfactory in both groups, but resting pain associated with newly developed anterior loose bodies led to a poor outcome in group 2. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic III.