Relationship of disc degeneration after pubertal growth spurt to future low back pain: a longitudinal cohort study.

PURPOSE: In this longitudinal cohort study, we investigated the relationship of disc degeneration (DD) after pubertal growth spurt to future low back pain (LBP). METHODS: A group of healthy volunteers underwent a semi-structured interview about LBP without trauma and a 1.5T lumbar MRI at ages 18 and 34. A Pfirrmann Summary Score (PSS) was calculated by adding up the Pfirrmann grades of the three lowest lumbar discs of each subject (range 3-15). The relationship of PSS at age 18 to LBP at age 34 was analyzed. RESULTS: Forty-one participants had full data at both time points. Mean PSS at age 18 was 6.8 (SD 1.1) and 5.6 (SD 1.2) for participants with or without LBP at age 34, respectively (p = 0.009). The OR (95% CI) of PSS at age 18 for LBP at age 34 was 5.46 (1.22 to 24.47) when adjusted for sex, BMI, smoking and physical activity. All participants but one with PSS greater than 6 at age 18 reported LBP at age 34. CONCLUSION: This is the first study to suggest that DD may be associated with future LBP and the critical time frame seems to be the pubertal growth spurt. Every 1-point increase in Pfirrmann grade at age 18 increased the risk of LBP 5.5-fold at age 34 when adjusted for sex, BMI, smoking and physical activity at age 34. All participants but one with at least one disc with Pfirrmann grade 3 or higher at age 18 reported LBP at age 34.

The intervertebral disc during growth: Signal intensity changes on magnetic resonance imaging and their relevance to low back pain.

Life-time prevalence of low back pain (LBP) in children and adolescents varies from 7% to 72%. Disc changes on magnetic resonance imaging (MRI) have been reported in up to 44% of children with earliest observations around pre-puberty. In this longitudinal cohort study, our objective was to determine the natural history of disc changes from childhood to early adulthood, and the possible association of these changes to LBP. Healthy 8-year-old schoolchildren were recruited for this longitudinal study consisting of a semi-structured interview, a clinical examination, and an MRI investigation at the age of 8-9 (Y8), 11-12 (Y12) and 18-19 (Y19) years. The interview inquired about LBP without trauma. T2-weighted sagittal MRI of the lumbar spine was acquired. Life-long prevalence of LBP was determined, and the disc signal intensity (SI) at the three lowest lumbar levels was assessed both visually using the Schneiderman classification (Bright-Speckled-Dark), and digitally using the disc to cerebrospinal fluid -SI ratio. Possible associations between SI changes and LBP were analyzed. Ninety-four of 208 eligible children were included at Y8 in 1994, 13 and 23 participants were lost to follow-up at Y12 and Y19, respectively. Prevalence of LBP increased after the pubertal growth spurt reaching 54% at Y19. On MRI, 18%, 10% and 38% of participants had disc SI changes at Y8, Y12 and Y19, respectively. No significant associations between self-reported LBP and either qualitative or quantitative disc SI changes were observed at any age. Life-time prevalence of LBP reached 54% by early adulthood. Disc SI changes on MRI traditionally labeled as degenerative were seen earlier than previously reported. Changes in disc SI were not associated with the presence of LBP in childhood, adolescence or early adulthood.

ISSLS prize in clinical science 2022: accelerated disc degeneration after pubertal growth spurt differentiates adults with low back pain from their asymptomatic peers.

PURPOSE: In this prospective observational cohort study, the development of lumbar intervertebral discs (LIVD) on magnetic resonance imaging (MRI) was investigated from childhood to adulthood with emphasis on the possible association of disc degeneration (DD) to low back pain (LBP). METHODS: In 2021, 89 subjects who were enrolled in 1994 in a longitudinal study with lumbar spine MRI at ages 8, 11 and 18 were invited to participate in a long-term follow-up comprising a clinical examination, selected patient-reported outcome measures and a lumbar spine MRI. We assessed all MRIs (three lowest LIVDs) with the Pfirrmann summary score, and the ratio of signal intensity of nucleus pulposus to signal intensity of cerebrospinal fluid (SINDL). We further analyzed whether disc changes at any age were associated with self-reported LBP at age 34. RESULTS: Of the 48 subjects in the follow-up, 35 reported LBP at age 34. The Pfirrmann summary score significantly increased with age (p < 0.001). Subjects reporting LBP at age 34 demonstrated statistically significantly higher summary scores at age 18 and 34 compared to asymptomatic subjects (p = 0.004 at age 18, and p = 0.039 at age 34). SINDL significantly decreased with age (p < 0.001 for all levels separately), but no significant differences between subjects with or without LBP at age 34 were noticed. CONCLUSION: Subjects with LBP at age 34 had more widespread or severe DD already at age 18 compared to those without LBP.

[Pseudotumors caused by hip prostheses]. / Lonkkaproteesien aiheuttamat pseudotuumorit.

More than 100000 hip replacements have been performed in Finland. In the hip replacement operations performed due to osteoarthritis, the artificial joint surfaces are made of metal, plastic or ceramics. Pseudotumors associated with metal-on-metal (MoM) sliding surfaces have received worldwide attention. Soft issue lesions, not always symptomatic, may develop around the joint replacements. These may even require joint revision surgery.

Unusually severe hypophosphatemic rickets caused by a novel and complex re-arrangement of the PHEX gene.

X-linked hypophosphatemia (XLH) is caused by mutations in PHEX. Several other genetic forms of hypophosphatemia have also been described. These disorders share variable clinical presentation ranging from mild hypophosphatemia to severe lower extremity bowing. We report on a 43-year-old woman with short stature, painful leg deformities, and poor dentation. Her biochemical profile showed hypophosphatemia with renal phosphate wasting. Due to unusually severe clinical presentation and absence of mutations in Sanger sequencing of the PHEX gene, quantitative multiplex ligation-dependent probe amplification was performed. A large deletion within the PHEX gene encompassing exons 8 to 11 was identified. We generated a specific junction fragment using long-range PCR and sequenced the junction fragment to determine the exact deletion breakpoints. We found a heterozygous novel complex re-arrangement involving gross deletions, insertions, and inversion of PHEX (hg19:g.22,115,003_22,141,395del;g:22,145,536_22,150,789delinsCins22,114,640_22,114,698invinsA). Thus, the complex re-arrangement including a deletion of coding exons 8 to 11 of the PHEX can be regarded as the cause of XLH in the patient reported here. Phosphate and active vitamin D treatment was initiated with subsequent relief in bone pain and physical improvement. This report expands the spectrum of clinical severity underlying genetic defects in XLH and highlights the importance of conventional medical therapy even at adult age. Furthermore, our findings underscore the importance of search for gene deletions in patients with suspected XLH.

Tibial fractures in children. A retrospective 27-year follow-up study.

BACKGROUND: Tibial fracture is the third most common long-bone fracture in children. Traditionally, most tibial fractures in children have been treated non-operatively, but there are no long-term results. METHODS: 94 children (64 boys) were treated for a tibial fracture in Aurora City Hospital during the period 1980-89 but 20 could not be included in the study. 58 of the remaining 74 patients returned a written questionnaire and 45 attended a follow-up examination at mean 27 (23-32) years after the fracture. RESULTS: 89 children had been treated by manipulation under anesthesia and cast-immobilization, 4 by skeletal traction, and 1 with pin fixation. 41 fractures had been re-manipulated. The mean length of hospital stay was 5 (1-26) days. Primary complications were recorded in 5 children. The childrens' memories of treatment were positive in two-thirds of cases. The mean subjective VAS score (range 0-10) for function appearance was 9. Leg-length discrepancy (5-10 mm) was found clinically in 10 of 45 subjects and rotational deformities exceeding 20° in 4. None of the subjects walked with a limp. None had axial malalignment exceeding 10°. Osteoarthritis of the hip and/or knee was seen in radiographs from 2 subjects. INTERPRETATION: The long-term outcome of tibial fractures in children treated non-operatively is generally good.

Quality of chest radiograph reports.

BACKGROUND: Examination requests and imaging reports are the most important communication instruments between clinicians and radiologists. An accurate and clear report helps referring physicians make care decisions for their patients. PURPOSE: To evaluate the contents of initial and re-reported chest reports, assess the inter-observer agreement, and evaluate the clarity of the report contents from the viewpoint of the referring physicians. MATERIAL AND METHODS: The content and agreement of the reports were analyzed by comparing the initial reports with re-reports prepared by a chest radiologist. The referring physicians evaluated the contents of 50 reports regarding their medical facts, clarity, and intelligibility. The results were analyzed using cross-over tables, the Pearson Chi-Square, and kappa statistics. RESULTS: Radiologists mostly addressed the questions posed by the referring physicians. General radiologists included separate conclusions in their reports more frequently (22%) than the chest radiologist in her re-reports. Reports prepared by the chest radiologist contained nearly 50% more findings than the general radiologists' reports. Inter-observer agreement between the initial and specialist re-reported reports was 66%, but the kappa value was 0.31. The reports were considered clear/intelligible by the referring physicians in 68% of the initial reports by the general radiologists and in 94% of the re-reported studies by the chest radiologist. CONCLUSION: Radiology report quality was rather high despite their contents varying depending on the radiologist. Inter-observer agreement of the chest radiographs was low due to the non-structured reports containing different quantities of information, thus complicating the comparison. Referring physicians considered both short and long radiology reports to be clear.

Back-side wear in HexLoc cups clinico-radiological, immunohistopathological, finite element, and retrieval analysis studies.

The HexLoc locking system was designed to prevent back-side wear of the polyethylene liner in the modular cementless metal-backed acetabular cup, but failed. Back-side wear was analyzed using clinico-radiological data, immunohistopathology, finite element modeling (FEM, and retrieval analysis. Screw holes allowed entry of titanium oxide and exit of polyethylene particles. Birefringent polyethylene wear particles were found behind the metal cup in macrophages containing pro-inflammatory tumor necrosis factor-α and interleukin-1ß, whereas fibroblast-like cells stained for osteoclastogenic receptor activator of nuclear factor kappa B ligand (RANKL). Computerized tomography revealed granulomas (83% versus 17 %) and cortical destruction (50% versus 5%) better than radiographs. In FEM, a change of the abduction angle from 45 to 60 deg, and liner thickness from 4.8 mm to 2.5 mm, increased the back-side wear by 90% and 120%, respectively. Screw holes were stress concentration areas; their removal decreased wear by 40%. Modeling results were validated in retrieved implants, which demonstrated extensive back-side wear damage of liners with a high abduction angle. Combined clinico-radiological, immunohistopathological, FEM, and retrieval analysis disclosed that back-side wear in the HexLoc design is sensitive to the abduction angle, liner thickness, and presence of screw holes.

[Imaging of inflammatory back pain]. / Tulehduksellisen selkäkivun kuvantamis- diagnostiikka.

We recommend magnetic resonance imaging of the sacroiliac joints as the first line imaging method in suspected inflammatory back disorder. Plain X-ray can be taken from those over 35 years of age. A nonconclusive finding in plain X-ray should be verified by MR imaging. For the present, diagnostic criteria for spondylarthritis do not take into account spinal changes. Typical spinal findings can, however, be helpful in making treatment decisions. In case the spinal region MR imaging should be utilized if possible, because radiography is particularly insensitive for thoracic spine. After a confirmed diagnosis, the inflammatory nature of the condition can usually be assessed clinically.

Childhood femoral fracture can lead to premature knee-joint arthritis. 21-year follow-up results: a retrospective study.

BACKGROUND AND PURPOSE: During the past decades, treatment of pediatric femoral fractures in Finland has changed from mostly non-operative to more operative. In this retrospective study, we analyzed the long-term results of treatment. PATIENTS AND METHODS: 74 patients (mean age 7 (0-14) years) with a femoral fracture were treated in Aurora City Hospital in Helsinki during the period 1980-89. 52 of 74 patients participated in this clinical study with a mean follow-up of 21 (16-28) years. Fracture location, treatment mode, time of hospitalization, and fracture alignment at union were assessed. Subjective assessment and range of motion of the hip and knee were evaluated. Leg-length discrepancy and alignment of the lower extremities were measured both clinically and radiographically. RESULTS: Of the 52 children, 28 had sustained a shaft fracture, 13 a proximal fracture, and 11 a distal fracture. 44 children were treated with traction, 5 by internal fixation, and 3 with cast-immobilization. Length of the hospital treatment averaged 58 (3-156) days and the median traction time was 39 (3-77) days. 21 of the 52 patients had angular malalignment of more than 10 degrees at union. 20 patients experienced back pain. Limping was seen in 10 patients and leg-length discrepancy of more than 15 mm was in 8 of the 52 patients. There was a positive correlation between angular deformity and knee-joint arthritis in radiographs at follow-up in 6 of 15 patients who were over 10 years of age at the time of injury. INTERPRETATION: Angular malalignment after treatment of femoral fracture may lead to premature knee-joint arthritis. Tibial traction is not an acceptable treatment method for femoral fractures in children over 10 years of age.

Rotator cuff integrity correlates with clinical and functional results at a minimum 16 years after open repair.

BACKGROUND: Recurrent or persistent defects in the rotator cuff after its repair are common. Short- and medium-term surveys have revealed, after open repair, patients with an intact rotator cuff have increased function and ROM. However, no long-term studies have verified cuff integrity on MR arthrography or correlated it with clinical and functional outcomes. QUESTIONS/PURPOSES: We evaluated long-term cuff integrity and fatty infiltration after open repair using MR arthrography and determined whether these findings correlated with clinical and functional results. METHODS: Using MR arthrography, we retrospectively evaluated 67 patients (48 men, 19 women) who underwent open rotator cuff repair between 1980 and 1989. Their mean age at surgery was 52 years. Minimum followup was 16 years (mean, 20 years; range, 16-25 years). RESULTS: The retear rate was 94%, and mean size of rerupture was 3.5 × 3.6 cm (ranges, 0.5-5.0 cm × 0.5-5.2 cm; median, 4 × 4 cm). The remaining four patients had a partial supraspinatus tendon tear. Fatty infiltration was marked in the supraspinatus and infraspinatus tendons. Cuff integrity correlated with clinical results: active external rotation and forward flexion, and flexion, abduction, and external rotation strengths, were better in patients with an intact rotator cuff or a small retear of 4 cm(2) or less than in patients with larger tears. Cuff integrity also correlated with functional results. CONCLUSIONS: Rotator cuff integrity was lost in 94% of patients after a minimum followup of 16 years. Cuff integrity correlates well with clinical and functional results even several years postoperatively. A large retear seems to be the most important factor in deteriorating long-term clinical and functional results after open rotator cuff repair. LEVEL OF EVIDENCE: Level IV, therapeutic study. See Instructions for Authors for a complete description of levels of evidence.

[Thirst and extensive bone lesions in a previously basically healthy woman]. / Aiemmin terveen naisen jano ja laaja-alaiset luustomuutokset.

A previously quite healthy 65-year-old woman sought emergency hospital care due to fatigue, weight loss and sensation of thirst appearing over a couple of months. Further analysis revealed a process affecting the neurohypophysis and extensive lytic sclerotic bone lesions. Eventually a rare generalized underlying disease was unraveled: the diagnosis included both Langerhans cell histiocytosis and Erdheim-Chester disease.

[An unusual etiology for pain in the back, hip and leg in a young woman]. / Nuoren naisen mystinen alaselkä-lonkka-alaraajakipu.

We present a 28-year old woman, suffering from low back and right leg pain for 5 years, with motor and sensory deficits of the leg. Disc herniation, hip related pain, depression, and even an osteoid osteoma were suspected during the years, and several imaging studies had been undertaken. Based on an ENMG-study a lesion affecting the right L5-nerve root distal to the ganglion was suspected. On a pelvic MRI a nonenhancing tumor of the right L5-root was seen. The tumor was resected operatively. On histologic examination an uncommon granulocellular tumor was diagnosed. The patient recovered almost completely.

Changing from analog to digital images: does it affect the accuracy of alignment measurements of the lower extremity?

BACKGROUND AND PURPOSE: Medical imaging has changed from analog films to digital media. We examined and compared the accuracy of orthopedic measurements using different media. METHODS: Before knee arthroplasty, full-length standing radiographs of 52 legs were obtained. The mechanical axis (MA), tibio-femoral angle (TFA), and femur angle (FA) were measured and analyzed twice, by 2 radiologists, using (1) true-size films, (2) short films, (3) a digital high-resolution workstation, and (4) a web-based personal computer. The agreement between the 4 media was evaluated using the Bland-Altman method (limits of agreement) using the true-size films as a reference standard. RESULTS: The mean differences in measurements between the traditional true-size films and the 3 other methods were small: for MA -0.20 to 0.07 degrees, and for TFA -0.02 to 0.18 degrees. Also, the limits of agreement between the traditional true-size films and the three other methods were small. INTERPRETATION: The agreement of the alignment measurements across the 4 different media was good. Orthopedic angles can be measured as accurately from analog films as from digital screens, regardless of film or monitor size.

Pain relief, motion, and function after rotator cuff repair or reconstruction may not persist after 16 years.

BACKGROUND: Short- to medium-term rotator cuff repair reportedly relieves pain in 82% to 97% of patients and provides normal or almost normal shoulder function in 82% to 92%. However, it is unknown whether pain relief and function persist long term. QUESTIONS/PURPOSES: We asked whether, after rotator cuff repair or reconstruction, pain relief, ROM, shoulder strength, and function remained over the long term. PATIENTS AND METHODS: We retrospectively reviewed 75 patients who underwent rotator cuff repair between 1980 and 1989. There were 55 men and 20 women. Their mean age at surgery was 52 years. The minimum followup was 16 years (mean, 20 years; range 16-25 years). RESULTS: Twenty-eight of the 75 patients (37%) had persistent relief of pain lasting for 20 years. In the remaining 47 patients, alleviation of pain lasted, on average, 14 years (range, 0-24 years). Mean flexion and abduction strength increased postoperatively but during long-term followup decreased to less than preoperative levels. External rotation also decreased. At the last followup, the Constant-Murley score averaged 66 (range, 10-98) in men and 60 (range, 29-89) in women. In the Simple Shoulder Test questionnaire, the mean number of yes answers was eight of 12. Of the 75 patients, 32 (43%) reported impairment in activities of daily living owing to an index shoulder complaint. Severe degenerative changes of the glenohumeral joint were evident in 14 patients (19%). CONCLUSIONS: The early high functional scores after primary rotator cuff repair or reconstruction of the types we performed in the 1980s did not persist. The function achieved postoperatively was lost, as ROM and strength decreased to less than preoperative values. However, alleviation of pain was long-standing in most patients. Based on our data, we should warn patients to expect less than permanent relief with those repairs. We cannot say whether the same will apply to currently performed types of repairs. LEVEL OF EVIDENCE: Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

Reproducibility of dual-energy x-ray absorptiometry total and regional body composition measurements using different scanning positions and definitions of regions.

Repeated dual-energy x-ray absorptiometry (DEXA) measurements are often performed both in clinical work and in research studies. The aims of the present study were to investigate the repeatability of DEXA total body measurements, to clarify the effect of the scanning positioning of the subject, and to compare the reliability of DEXA measurements of the extremities between automatically and manually defined regions of interest (ROIs). Three DEXA measurements of the total body composition, that is, fat tissue mass, lean tissue mass (LM), and bone mineral content, were performed on 30 male volunteers (mean age, 45.2 years) in addition to measurements of bone mineral density. Using a narrow fan-beam Lunar Prodigy densitometer (GE Lunar, Madison, WI), 3 DEXA scans (2 supine and 1 prone) of the total body were performed. For regional measurements of the right arm and leg, ROIs were set automatically and manually in the supine-supine and supine-prone positions. Repeatability of total body DEXA measurements was excellent for bone mineral content (r = 0.99), LM (r = 0.99), fat tissue mass (r = 1.00), and bone mineral density (r = 0.98) in supine scanning. Change of position from supine to prone slightly decreased the reproducibility of total body measurements. Reproducibility of regional measurements was inferior to total body results; especially in the upper extremity, the repeated automatic LM measurements in supine-supine positions produced r values as low as 0.74 but increased to 0.93 after manual adjustment of the ROIs. To obtain maximal reliability of the composition measurements, we recommend manual checking of machine-made ROIs and, if needed, manual adjustment to avoid measurement errors.

Dextrocardia and coronal alignment of thoracic curve: a population study.

The objective of this study was to evaluate the coronal alignment of the thoracic spine in persons with dextrocardia. Generally, the thoracic spine is slightly curved to the right. It has been suggested that the curve could be triggered by pulsation forces from the descending aorta. Since no population study has focused on the alignment of the thoracic spine in persons with situs inversus, dextrocardia, and right-sided descending aorta, we compared the radiographs of the thoracic spine in persons with dextrocardia to those having normal levocardia. Among 57,440 persons in a health survey, 11 cases of dextrocardia were identified through standard radiological screening. The miniature chest radiographs of eight persons were eligible for the present study. The study was carried out as a nested case-control study. Four individually matched (age, gender, and municipality) controls with levocardia were chosen for each case. Coronal alignment of the thoracic spine was analyzed without knowledge of whether the person had levo- or dextrocardia. A mild convexity to the left was found in all persons with dextrocardia and right-sided descending aorta (mean Cobb angle 6.6 degrees to the left, SD 2.9). Of the 32 normal levocardia persons, 29 displayed a convexity to the right, and the remaining three had a straight spine (mean Cobb angle 5.2 degrees to the right, SD 2.3). The difference (mean 11.8 degrees , SD 3.5) differed significantly from unity (P = 0.00003). In conclusion, it seems that a slight left convexity of the thoracic spine is frequent in dextrocardia. We assume that the effect of the repetitive pulsatile pressure of the descending thoracic aorta, and the mass effect of the heart may cause the direction of the convexity to develop opposite to the side of the aortic arch.

Liver echogenicity: relation to systemic blood pressure and other components of the metabolic syndrome.

We studied the impact of liver echogenicity among other potential predictors of systemic blood pressure (BP) and the metabolic syndrome. 38 persons (32 males, six females, aged 29 to 66) had their liver echogenicities scored, BPs measured and standard serum laboratory tests studied. There was a significant correlation between both systolic (r=0.438, p=0.006) and diastolic (r=0.498, p=0.001) BP and liver echogenicity. Liver echogenicity was the strongest predictor for systolic BP and the second strongest (after body mass index, BMI) for diastolic BP. Body height may modify the relation between liver echogenicity and systolic BP. Liver echogenicity also correlated significantly with BMI (r=0.527, p=0.001), serum triglycerides (r=0.472, p=0.003) and, to a lesser degree, with serum total cholesterol (r=0.305, p=0.066). Incidentally found increased liver echogenicity should alert the US performer and the clinician reading the report on the possibility of elevated BP or other features of the metabolic syndrome.

Liver echogenicity: measurement or visual grading?

OBJECTIVE: Two methods to assess liver echogenicity were compared. METHODS: Liver/kidney echogenicity ratio was measured in 41 persons with the ultrasound software and visually graded by two radiologists and a radiographer. These echogenicity ratios and grades were related to risk factors for fatty liver and to liver enzyme levels. RESULTS: These determinants explained 55% of the radiologists' mean grades, 14% of the radiographer's and 31% of the measured echogenicity ratios. CONCLUSION: Radiologists' visual gradings correlated best with the indirect determinants of early liver pathology. Computerized measurements may be inferior to visual grading due to the lack of holistic tissue diagnostics.

Total knee arthroplasty in patients with diastrophic dysplasia.

BACKGROUND: Diastrophic dysplasia results in severe disproportionate short stature, generalized joint deformities, and early osteoarthritis. The knee joint often has an abnormal valgus position and is unstable, and degeneration of all joint compartments occurs, even during growth. The purpose of our study was to evaluate the clinical and radiographic results of total knee arthroplasty in a series of patients with diastrophic dysplasia. METHODS: Between February 1992 and March 2000, twenty-one primary total knee arthroplasties were performed on fourteen consecutive patients with severe osteoarthritis due to diastrophic dysplasia. The patients were followed prospectively with clinical examinations, determination of the Hungerford knee scores, and radiographs. Preoperatively, ten knees had chronic dislocation of the patella. The mean duration of follow-up was 3.4 years. RESULTS: The mean Hungerford knee pain and total scores improved from 5.8 points and 46 points preoperatively to 50 points and 83 points, respectively, at the final follow-up examination (p < 0.001 for both comparisons). Two knees required a distal femoral corrective osteotomy because of metaphyseal angulation. None of the total knee arthroplasties had to be revised during the follow-up period. Six complications were recorded. CONCLUSIONS: Total knee arthroplasty substantially improved the function of patients with diastrophic dysplasia. Additional peripatellar procedures were commonly needed, and complications were frequent.