An interexaminer agreement and reliability study on cadavers with musculoskeletal ultrasound of the shoulder performed by physiotherapists and radiologists compared with dissection.

STUDY DESIGN: A cross-sectional inter-examiner agreement and reliability study on fresh frozen cadaver shoulders. BACKGROUND: Musculoskeletal ultrasound (MSU) is frequently used by physical therapists and radiologists to improve specific diagnosis in rotator cuff related pathology. The evaluation of the rotator cable seems to be important as stabilizing structure when cuff tears occur. OBJECTIVES: To evaluate the inter-examiner agreement and reliability of MSU of the shoulder to detect rotator cuff-pathology and the involvement of the rotator cable in comparison to "dissection". METHODS: Physical therapists, a radiologist and an orthopedic surgeon (dissection) investigated 40 fresh frozen cadaver shoulders in order to detect shoulder pathology including rotator cable involvement. Examiners were blinded to each other's findings. RESULTS: We found a strong and significant agreement between the raters: PTs, the radiologist and the dissector in this cadaver study for all rotator cuff, the long head of the biceps pathologies and in detecting abnormalities of the rotator cable. The kappa value was substantial to (almost) perfect agreement for all diagnostic outcome categories. CONCLUSIONS: This study shows that among a limited group of physical therapists, one radiologist and a dissector a strong level of agreement with kappa values from substantial to (almost) perfect in finding subacromial pathology.

Sexual violence in medical students and specialty registrars in Flanders, Belgium: a population survey.

BACKGROUND: Sexual violence has globally been recognized as harmful to young people's health. In medical school, which is a highly competitive environment, the risk is supposedly even bigger. In this study we firstly aimed to investigate the magnitude and precipitating factors of sexual violence in medical students and specialty registrars in Flanders, Belgium. Secondly, we wanted to assess the reactive behaviours as well as the knowledge of possible types of bystander reactions as well as potential support resources for victims of sexual violence. METHODS: This study was initiated and coordinated by the Flemish medical student representation organisation (VGSO). A survey containing demographic and behaviour-specific questions based on the UNMENAMAIS and SAS-V questionnaire was sent to all undergraduate, graduate and postgraduate students of the 5 medical schools in Flanders. Participants were asked to limit their responses to internship-related events. Further questions concerning reactions to sexual violence, assailants, bystander reactions and general knowledge concerning support after sexual violence were asked. RESULTS: We received 3015 valid responses to our survey, obtaining a response rate of 29% in the potential target population. Within the total study population, 1168 of 3015 participants (38,73%) reported having been victim of at least one type of sexual violence as explored by our survey. This percentage was the highest in GP specialty registrars (53%), followed by specialty registrars (50%) and master students (39%). Assailants of sexual violence varied, most often they were medical staff members, students or patients. In most types of sexual violence, nobody reacted to this behaviour. Women (57.3%) talked about what happened afterwards more often than men (39.7%). When asked about their knowledge of possible bystander reactions and support services for sexual violence, 60% of the respondents did not know about their existence. CONCLUSIONS: Sexual violence is still a relatively frequent issue in medical students and specialty registrars. Patients form an important part of the assailants. In a third of reported sexual violence cases, nobody reacted. In addition, male victims seem to underreport. There is still much need for sensitisation on support mechanisms and centres for victims and witnesses of sexual violence.

Diagnostic ultrasound in patients with shoulder pain: An inter-examiner agreement and reliability study among Dutch physical therapists.

STUDY DESIGN: A cross-sectional inter-examiner agreement and reliability study among physical therapists in primary care. BACKGROUND: musculoskeletal ultrasound (MSU) is frequently used by physical therapists to improve specific diagnosis in patients with shoulder pain, especially for the diagnosis rotator cuff tendinopathy (RCT) including tears. OBJECTIVES: To estimate the inter-examiner agreement and reliability in physical therapists using MSU for patients with shoulder pain. METHODS: Physical therapists performed diagnostic MSU in 62 patients with shoulder pain. Both physical therapists were blinded to each other's results and patients were not informed about the test results. We calculated the overall inter-examiner agreement, specific positive and negative inter-examiner agreement, and inter-examiner reliability (Cohen's Kappa's). RESULTS: Overall agreement for detecting RC ruptures ranged from 61.7% to 85.5% and from 43.9% to 91.4% for specific positive agreement. The specific negative agreement was lower with values ranging from 44.4% to 79.1% for RC ruptures. Overall agreement for other pathology than ruptures related to SAPS, ranged from 72.6% to 93.6% and from 77.3% to 96% for specific positive agreement. The specific negative agreement was lower with values ranging from 44.4% to 79.1% for RC ruptures and 52.5%-83.3% for other pathology than ruptures related to SAPS. Reliability values varied from substantial for any thickness ruptures to moderate for partial thickness ruptures and fair for full thickness tears. Moreover, reliability was fair for cuff tendinopathy. The reliability for AC arthritis and no pathology found was fair and moderate. There was substantial agreement for the calcifying tendinopathy. CONCLUSIONS: Physical therapists using MSU agree on the diagnosis of cuff tendinopathy and on the presence of RCT in primary care, but agree less on the absence of pathology.

Rapid malignant transformation of primary synovial chondromatosis into chondrosarcoma.

Chondrosarcoma of the synovium is rare. It may arise de novo from the synovium or pre-existing synovial chondro- matosis may undergo malignant transformation into chondrosarcoma. Diagnosing a malignant transformation of the synovium remains a big challenge. It is based on the correlation of clinical findings, imaging and histology, as illustrated in this case report.

A cadaveric study of the structural anatomy of the sternoclavicular joint.

Pathologies of the sternoclavicular (SC) joint are infrequent and effective management is often hindered by a limited understanding of the anatomy. In this study, we did macroscopic evaluations of the ligaments, the intra-articular disc, and the articulating surfaces of 25 SC joints. After removal of the joint capsule, the articulating surfaces of the sternal end of clavicle and the sternum were evaluated and the intra-articular disc was macroscopically examined. The anterior SC ligament covered the intra-articular disc, which divided the joint into a clavicular and a sternal part. A thin capsule, relatively lateral and medial from the anterior SC ligament, covered the two intra-articular parts. This means that the anterior SC ligament can be used as a landmark to enter into clavicular or sternal part of the SC joint. Posteriorly, there was a thick capsule without soft-spot or clear posterior SC ligament. Only the antero-inferior surface of the sternal end of every clavicle was covered by cartilage. Of the intra-articular discs 56% were incomplete. All of these incomplete discs displayed a central hole with signs of degeneration and fraying. This was associated with increased cartilage degeneration at the clavicular side. By experimental design (past and present), it would seem reasonable to assume that the incomplete types are caused by degeneration and are not developmental.

A bare area of the glenoid misdiagnosed as a cartilage ulceration.

We report on a 17-year-old girl who developed shoulder pain after a fall on an outstretched arm. CT arthrography and MR imaging demonstrated a cartilage defect centrally located in the glenoid. This was accompanied by an eroded appearance of the underlying bone. Since symptoms persisted over several months it was initially thought this represented a cartilage injury. Subsequently arthroscopy was performed and the abnormality was identified as a bare area of the glenoid. A tear of the superior glenohumeral ligament was depicted and was repaired. The bare area is an oval area denuded of cartilage that is probably developmental and that should be differentiated from true cartilage injuries to avoid unnecessary interventions. An eroded appearance of the underlying bone may occur on imaging, a finding that has not been previously reported.

An unusual case of cat-scratch disease of the knee: case report and differential diagnosis.

We present a case of a 16-year-old boy with a painful swelling in the popliteal fossa, slight fever, articular and muscle pain of 3 weeks duration. Plain radiography and MR examination were performed in order to characterize the lesion. Additionally to the poorly defined mass, 2 satellite nodules were shown. Subsequent biopsy revealed a granulomatous process and 2 satellite lymphadenopathies highly suggestive of cat-scratch disease. This case shows that the differential diagnosis of a soft tissue mass of the knee should not only include tumoral processes or pseudotumoral lesions, but also granulomas from infectious or non-infectious origin. Knowledge of the patients contact with cats and the detection of skin scratches is usually the clue to the correct diagnosis.

MR imaging findings in patients with a surgically significant mediopatellar plica.

PURPOSE: To identify MR imaging findings seen in patients with an arthroscopically confirmed significant plica. MATERIALS AND METHODS: MR and arthroscopy reports of 450 patients were reviewed. Nine patients were identified with an arthroscopically significant plica that was resected. Nine patients from these 450 were randomly chosen as a control group. Different criteria were evaluated on the MR images of all patients including: interposition of plica, number of slices with interposition, presence of fluid (focal or generalized), and thickening of the plica. RESULTS: Interposition was found on 3 to 10 transverse imaging slices in the study group (mean, 5.9), and 1 to 4 imaging slices in the control group (mean, 3). Thickening was present in 4/9 patients of the study group and 2/9 patients in the control group. Focal fluid, out of proportion to fluid in the remainder of the joint was found in all patients of the study group and in none of the control group. CONCLUSION: Interposition of the plica on more than 5 transverse slices, and focal fluid adjacent to the plica may suggest the presence of a plica that will be considered significant at arthroscopy.

Significance of the latissimus dorsi for shoulder instability. I. Variations in its anatomy around the humerus and scapula.

In a cadaveric instability model that leaves all muscles intact initially, we studied anteroinferior glenohumeral dislocation behavior after section of the ligaments on the humeral side of the joint. In this study, the latissimus dorsi seemed to play a role when complete section did not result in a locked anteroinferior dislocation. We therefore initiated a study to test the hypothesis that the latissimus dorsi may, in certain circumstances, depending on variations in its anatomy, influence dislocation behavior. Here, in Part I, we present the results of the anatomic study of latissimus dorsi and its tendons. The anatomy of the latissimus dorsi pertaining to the scapula and humerus was studied in 100 cadaver specimens. The distance between the uppermost part of the tendon of both the latissimus dorsi and the teres major and the edge of the articular cartilage of the humeral head (tendon-cartilage distance, TCD) as well as the width and length of the tendons were measured. Furthermore, the relationship between latissimus dorsi and the inferior angle of the scapula was studied. The tendon of the latissimus dorsi inserted at a variable distance from the cartilage of the humeral head: the TCD ranged from 12.6 to 31.6 mm (mean 21.06 mm+/-5.11 mm). The latissimus dorsi can have muscular fibers arising from the inferior angle of the scapula (type 1 scapular connection, 43%). Alternatively, there may be only a few fibrous strands between the muscle and the scapula or there may be an intervening bursa (type 2 scapular connection, 57%). This variability in the morphology of the latissimus dorsi may be a factor explaining the differences observed in a study of humerus-based sequential cutting of the glenohumeral capsule. This possibility is explored in Part II of the study. The latissimus dorsi may also complete the tendinous protection of the humeral side of the capsule generally provided by the rotator cuff.

Significance of the latissimus dorsi for shoulder instability. II. Its influence on dislocation behavior in a sequential cutting protocol of the glenohumeral capsule.

In a cadaveric instability model that leaves all muscles intact initially, the latissimus dorsi seemed to play a role when complete section of the glenohumeral capsuloligamentous structures did not result in a locked anteroinferior dislocation. The present study was carried out to determine whether the latissimus dorsi does truly affect dislocation in a modified cutting protocol, and to find an anatomic explanation for this apparent behavior. This article (Part II) details the results of a sequential cutting study and relates these results with the anatomic findings of Part I. In 75 shoulders, the influence of the latissimus dorsi on dislocation behavior in the apprehension position after section of all capsuloligamentous structures was examined. After cutting all capsuloligamentous structures, either on the glenoid or on the humeral side, the tendon of either the latissimus dorsi or the subscapularis was cut. Capsular lesions on the glenoid side (20 shoulders) resulted in a locked dislocation in 16 specimens. In the other four shoulders, there was a metastable dislocation after cutting the entire capsule, which did not change after cutting either tendon. With lesions on the humeral side (55 shoulders), three possibilities arose: metastable (17 shoulders), locked anterior (9 shoulders) or locked anteroinferior (29 shoulders) dislocation. This difference in dislocation behavior was related to the variability of the tendon-cartilage distance (TCD) and the type of scapular connection of the latissimus dorsi. A locked anteroinferior dislocation was always observed when the TCD was more than 20 mm, regardless of the type of scapular connection. With a TCD < 20 mm, a metastable dislocation was the result when there was a type 1 scapular connection and a locked anterior dislocation was seen when there was a type 2 scapular connection. The tendon of the latissimus dorsi can restrain the humeral head from dropping inferiorly or can lead to a spontaneous reduction of a dislocation, depending on its anatomy. This effect can only take place in the infrequent situation of humeral avulsion of the glenohumeral ligaments. This may be an explanation for the relative paucity of these lesions in clinical instability series.

Quantitation of ligament laxity in anterior shoulder instability: an experimental cadaver model.

Three groups of cadaver specimens were studied. In group 1 (20 shoulders) glenohumeral ligaments were detached from the humerus until a permanent dislocation of the humeral head occurred in abduction plus external rotation. On the dislocated joint the ligament was reconstructed using a fascia lata lengthening plasty. After the plasty had been completed, the shoulder was reduced and instability checked in the same position. Then the capsule (including the plasty) was harvested and measured. In group 2 (20 shoulders), after the plasty had been completed in the same conditions as above, the capsule was progressively reduced by 2 mm steps until the instability disappeared. Then the capsule (including the plasty) was harvested and measured. In group 3 (12 shoulders), measurements of the head and of the capsule were done. To dislocate the shoulder the section of the three glenohumeral ligaments was required. Lengthening of the capsule in group 1 was 240-250%. In all cases shortening of the capsule led to the stabilization of the shoulder. After stabilization of the shoulder was reached a residual lengthening of 175-185% was recorded. In 3 out of 4 shoulders the amount of capsule shortening required to return to a stable shoulder was between 16 and 18 mm. This experiment did not reproduce the Bankart lesion; therefore it only concerns atraumatic instability. The main limitation of this model is the low lever force that may be used to dislocate the shoulder; consequently the elasticity of the glenohumeral ligament was not taken in account. The experimental values were likely over-estimated. Nevertheless the present results provide useful information for building an experimental model of atraumatic instability of the shoulder.

Vanishing distal clavicle after arthroscopic acromioplasty.

Arthroscopic subacromial decompression is gaining wide acceptance. There are several reports on its technique, its limitations, and its efficacy. However, papers describing complications are rare. We describe a case of osteolysis of the distal clavicle after overenthusiastic arthroscopic subacromial decompression.

Fractures of the capitellum humeri in adolescents.

Six children between 11 and 15 years old with a displaced fracture of the capitellum were treated by open reduction and fixation with one small screw. In all cases union occurred. There were no complications and all the children regained normal elbow function. There were no cases of avascular necrosis.

Clinical and radiographic evaluation of Wilson osteotomy for hallux valgus.

Thirty-two Wilson osteotomies (26 patients) were evaluated after a mean follow-up time of 20 months. According to the classification of Bonney and MacNab, there were 90% good and excellent results. There was no correlation between the patient's appraisal of the result and the clinical result based on objective, functional, and radiographic data. The occurrence of metatarsalgia or callosities did not correlate with shortening or angulation. If there was a tendency to recurrence, there was a greater loss of correction with a longer duration of follow-up. In addition, patients over 50 seemed to have a greater tendency to recurrence than younger patients.