Interobserver and Intraobserver Reliability of Classification Systems for Radiographic Complications After Radial Head Arthroplasty.

PURPOSE: Although several classifications are used to assess radiographs following radial head arthroplasty (RHA), including the Popovic classification for radiolucency, the Chanlalit classification for stress shielding (SS), the Brooker classification for heterotopic ossification (HO), and the Broberg-Morrey classification for radiocapitellar arthritis, little is known about the reliability of these classification systems. The purpose of this study was to determine the interobserver and intraobserver reliability of these classifications. METHODS: Six orthopedic surgeons at various levels of training reviewed elbow radiographs of 20 patients who underwent RHA and classified them according to the Popovic, Chanlalit, Brooker, and Broberg-Morrey classifications for radiolucency, SS, HO, and RHA, respectively. Four weeks after initial review, radiographic reviews were repeated. Reliability was measured using the Fleiss kappa and the intraclass correlation coefficient. Agreement was interpreted as none (<0), slight (0.01-0.2), fair (0.21-0.4), moderate (0.41-0.6), substantial (0.61-0.8), and almost perfect (0.81-1) based on agreement among attending surgeons. RESULTS: Among fellowship-trained attending surgeons, interobserver reliability was slight for SS (Chanlalit) and the categorical interpretation of radiolucency (Popovic), fair for radiocapitellar arthritis (Broberg-Morrey) and HO (Brooker), and substantial for the ordinal interpretation of radiolucency (Popovic). Residents had a higher interobserver reliability than attending physicians when using the Brooker classification. Mean intraobserver reliability was fair for SS (Chanlalit) and the categorical interpretation of radiolucency (Popovic), moderate for HO (Brooker) and radiocapitellar arthritis (Broberg-Morrey), and almost perfect for the ordinal interpretation of radiolucency (Popovic). Trainees had higher intraobserver reliability than attending surgeons using the SS (Chanlalit) classification. CONCLUSIONS: The number of Popovic zones is reliable for communication between physicians, but caution should be taken with the Brooker, Chanlalit, Broberg-Morrey, and categorical interpretation of the Popovic classifications. All the classifications had better intraobserver than interobserver reliability. CLINICAL RELEVANCE: Reliability of classification systems for radiographic complications after RHA is less than substantial except the number of zones of radiolucency; therefore, caution is required when drawing conclusions based on these classifications.

Is Cementless Total Knee Arthroplasty Safe in Women Over 75 Y of Age?

BACKGROUND: Cementless total knee arthroplasty (TKA) is the subject of renewed interest. Previous concerns about survivorship have been addressed and there is an appeal in terms of biological fixation and surgical efficiency. However, even surgeon advocates have concerns about the risk of marked subsidence when using this technology in older patients at risk for osteoporosis. METHODS: This was a retrospective analysis of 1,000 consecutive fully cementless mobile bearing TKAs performed at a single institution on women over 75 years of age who had postoperative and 1-year x-rays. The primary outcome was the incidence of subsidence. RESULTS: There were three asymptomatic cases with definite subsidence and change in alignment. In a fourth symptomatic case, the femoral component subsided into varus and the tibia into valgus, thus maintaining alignment which facilitated nonoperative treatment in a 92-year-old. Overall, at 1 year, there were two- liner revisions for infection without recurrence. Five patients had further surgery, of which three were washouts and two were for periprosthetic fractures sustained postoperatively within 1 year. Seven patients had further anesthesia, of which five were manipulations and two were nonrecurrent closed reductions for spinouts. CONCLUSION: Cementless TKA did not have a high risk of subsidence in this at-risk population. In the hands of experienced surgeons, these procedures can be used safely irrespective of bone quality.

Comparison of canal fill and radiolucent line formation between two fully coated, hydroxyapatite tapered stems: a 2-year follow-up after total hip arthroplasty.

INTRODUCTION: Comparison between fully hydroxyapatite (HA)-coated stems with differing geometry are lacking in the total hip arthroplasty (THA) literature. This study aimed to compare femoral canal fill, radiolucency formation, and 2-year implant survivorship between two commonly used, HA-coated stems. METHODS: All primary THAs performed with two fully HA-coated stems (Polar stem, Smith&Nephew, Memphis, TN and Corail stem, DePuy-Synthes, Warsaw, IN) with a minimum 2-year radiographic follow-up were identified. Radiographic measures of proximal femoral morphology based on the Dorr classification and femoral canal fill were analyzed. Radiolucent lines were identified by Gruen zone. Perioperative characteristics and 2-year survivorship were compared between stem types. RESULTS: A total of 233 patients were identified with 132 (56.7%) receiving the Polar stem (P) and 101 (43.3%) receiving the Corail stem (C). No differences were observed with respect to proximal femoral morphology. Femoral stem canal fill at the middle third of the stem was greater for P stem patients than for C stem patients (P stem; 0.80 ± 0.08 vs. C stem; 0.77 ± 0.08, p = 0.002), while femoral stem canal fill at the distal third of the stem and presence of subsidence were comparable between groups. A total of six and nine radiolucencies were observed in P stem and C stem patients, respectively. Revision rate at 2-year (P stem; 1.5% vs C stem; 0.0%, p = 0.51) and latest follow-up (P stem; 1.5% vs C stem; 1.0%, p = 0.72) did not differ between groups. CONCLUSION: Greater canal fill at the middle third of the stem was observed for the P stem compared to the C stem, however, both stems demonstrated robust and comparable freedom from revision at 2-year and latest follow-up, with low incidences of radiolucent line formation. Mid-term clinical and radiographic outcomes for these commonly used, fully HA-coated stems remain equally promising in THA despite variations in canal fill.

Early pathological changes of peri-coronal tissue in the distal area of erupted or partially impacted lower third molars.

AIM: This study was performed to histologically evaluate peri-coronal tissues of partially impacted and erupted third molars that did not exhibit pathologic peri-coronal radiolucency. MATERIALS AND METHODS: Healthy patients with erupted or partially erupted (with part or all of the dental crown present in the oral cavity) mandibular third molars (classified as IA and IIA according to the Pell and Gregory classification) and vertically positioned (according to the Winter classification or erupted third molars) associated with peri coronal radiolucency of equal to or less than 2.5 mm. Associated with third molar surgery, tissue sampling from the distal area was performed, which was subjected to an anatomopathological examination to determine the histological nature. RESULTS: One hundred teeth (100 patients) were selected, and 100 specimens were analyzed. 53% of the sample were included in the non-pathological group and 47% showed pathological changes (fibrotic tissue (n 15), periodontal cyst-like (n 9), squamous epithelial metaplasia (4 cases), islands of odontogenic epithelial residues organized micro-cyst with keratocystic/ameloblastic appearance (4 cases), granulation tissue (n 8), giant cell tumour (n 4) and lobular capillary hemangioma (n 4)). Pathological changes did not have differences in incidence between the gender (p value = 0.85) and did not show any correlation with age, (p value = 0,96). CONCLUSIONS: These findings suggest that radiographic appearance may not be a reliable indicator of the absence of disease within a dental follicle. Therefore, clinicians should pay attention to or follow up on even peri-coronal radiolucency of less than 2.5 mm.

Effect of orthodontic treatment on the periapical radiolucency of endodontically treated teeth: a CBCT analysis.

BACKGROUND: This study aimed to evaluate periapical radiolucency of endodontically treated teeth before and after orthodontic treatment using cone-beam computed tomography (CBCT). METHODS: Patients who underwent orthodontic treatment at Wonkwang University Daejeon Dental Hospital between January 2009 and June 2022 were included based on the following criteria: root canal treatment, and availability of CBCT images taken before and after orthodontic treatment with an interval of > 1 year between both scans. Patients with primary teeth or orthodontic tooth extractions were excluded. The size of the periapical radiolucency (SPR) of the endodontically treated tooth was evaluated using CBCT. Pre-orthodontic treatment CBCT images and the latest post-orthodontic treatment CBCT images were analyzed. The selected teeth were further categorized based on the orthodontic duration, CBCT interval, the patient sex and age, the tooth type and position (maxilla or mandible), and quality of root canal obturation. Statistical analyses were performed to evaluate changes in SPR using the paired t-test and multiple regression analysis. RESULTS: In total, 115 teeth (37 anterior teeth, 22 premolars and 56 molars) from 61 patients (age, 14-54 years) were included, with 39 teeth from male patients and 76 teeth from female patients. The age was ranged between 14 and 54 years old, and mean age was 25.87 years old. The mean CBCT interval and orthodontic treatment period were 43.32 months and 36.84 months, respectively. Seventy-five teeth showed good obturation quality, 80 were not used as anchors during orthodontic treatment, and 71 were maxillary. The SPR size increased after orthodontic treatment for 56 teeth and decreased for 59 cases. The average change in SPR was -0.102 mm and the difference was not significant. Significant decrease of SPR were observed between female patients (p = 0.036) and maxillary teeth (p = 0.040). CONCLUSION: Orthodontic treatment had no significant impact on the changes in the SPR in endodontically treated teeth in most categories. However, there was a significant difference among females and the maxillary teeth. In both categories, the size of radiolucency decreased significantly.

An Observational Study on Cystic Alterations in Normal Dental Follicles Associated with Impacted Lower Third Molar for Early Intervention.

AIM: To evaluate the cystic changes in the radiographically normal dental follicle associated with impacted mandibular third molar. MATERIALS AND METHODS: This study was conducted on 80 patients. Samples were selected using a convenient sampling technique from the patients who had impacted mandibular third molars in Pell and Gregory's positions B and C, with follicular space less than 2.5 mm in diameter. After surgical removal of an impacted tooth, the dental follicle was sent for histopathologic evaluation. RESULTS: Pathologic alterations were found in 19% of cases out of 80 samples. Odontogenic keratocystic and dentigerous cystic changes were found in 7% of cases. A statistically significant cystic alteration was found in female patients and distoangular impacted teeth. CONCLUSION: This study shows a significant cystic alteration in the radiologically normal dental follicles. Clinical and radiographic features alone may not be a reliable indicator of the absence of pathology. Early intervention of impacted teeth will help to reduce morbidity due to the development of pathology. CLINICAL SIGNIFICANCE: This study will help educate patients on the risks of retaining impacted teeth, based on scientific facts, in order to minimize the risks and to assess the correlation of pathologic alterations with the depth of impaction and angular position of the impacted tooth.

Radiolucent line assessment in cemented stemmed total knee (RISK) arthroplasty: validation of a modernized classification system.

BACKGROUND: This study aims to implement and assess the inter- and intra-reliability of a modernized radiolucency assessment system; the Radiolucency In cemented Stemmed Knee (RISK) arthroplasty classification. Furthermore, we assessed the distribution of regions affected by radiolucency in patients undergoing stemmed cemented total knee arthroplasty. METHODS: Stemmed total knee arthroplasty cases over 7-year period at a single institution were retrospectively identified and reviewed. The RISK classification system identifies five zones in the femur and five zones in the tibia in both the anteroposterior (AP) and lateral planes. Post-operative and follow-up radiographs were scored for radiolucency by four blinded reviewers at two distinct time points four weeks apart. Reliability was assessed using the kappa statistic. A heat map was generated to demonstrate the reported regions of radiolucency. RESULTS: 29 cases (63 radiographs) of stemmed total knee arthroplasty were examined radiographically using the RISK classification system. Intra-reliability (0.83) and Inter-reliability (0.80) scores were both consistent with a strong level of agreement using the kappa scoring system. Radiolucency was more commonly associated with the tibial component (76.6%) compared to the femoral component (23.3%), and the tibial anterior-posterior (AP) region 1 (medial plateau) was the most affected (14.9%). CONCLUSION: The RISK classification system is a reliable assessment tool for evaluating radiolucency around stemmed total knee arthroplasty using defined zones on both AP and lateral radiographs. Zones of radiolucency identified in this study may be relevant to implant survival and corresponded well with zones of fixation, which may help inform future research.

Short-term clinical and radiographic outcomes of a hybrid all-polyethylene glenoid based on preoperative glenoid morphology.

BACKGROUND: The primary purpose of this study was to compare 2-year anatomic total shoulder arthroplasty (TSA) functional and radiographic outcomes between Walch type A and B glenoids treated with an all-polyethylene glenoid designed for hybrid fixation with peripheral cement and central osseous integration. The secondary purpose was to evaluate outcomes based on central peg technique. The hypotheses were that there would be no difference in short-term radiographic or functional outcome scores based on preoperative glenoid morphology or central peg technique. METHODS: We performed a multicenter retrospective review of patients who underwent TSA with the same hybrid all-polyethylene glenoid and had minimum 2-year follow-up. Patient-reported outcomes and radiographic outcomes were analyzed based on preoperative Walch morphology and central peg technique. Radiographic analysis included preoperative glenoid morphology; preoperative and postoperative glenoid version, glenoid inclination, and posterior humeral head subluxation; and postoperative glenoid radiolucencies according to the Wirth and Lazarus classifications. RESULTS: A total of 266 patients with a mean age of 64.9 ± 8.2 years were evaluated at a mean of 28 months postoperatively. Postoperatively, there were significant improvements in all functional outcome measures (P < .001), range-of-motion measures (forward elevation, external rotation at 0°, external rotation at 90°, internal rotation by spinal level, and internal rotation at 90°; P < .001), and strength measures (Constant, external rotation, and modified belly press; P < .001). There were no clinically meaningful differences in functional outcomes or statistically significant differences in radiographic appearance between Walch type A and B glenoids. Subgroup analysis revealed that glenoids with a cemented central peg had the worst radiographic outcomes based on Lazarus scoring. CONCLUSION: Patients undergoing TSA with a hybrid in-line pegged glenoid have excellent clinical outcomes at short-term follow-up regardless of preoperative glenoid morphology. Different central peg techniques do not appear to play a significant role in the risk of glenoid component lucencies at 2 years postoperatively.

Improved mechanical fixation of an all-polyethylene glenoid reduces postoperative radiolucent lines.

BACKGROUND: The rationale for advances in implant design is to improve performance in comparison to their predecessors. The purpose of this study was to compare a newer, self-pressurizing peripheral peg glenoid to a traditional polyethylene pegged glenoid through biomechanical evaluation and a retrospective radiographic and clinical review. METHODS: Three testing conditions (uncemented, partially cemented, and fully cemented) were chosen to assess the 2 component designs in a foam block model. The number of hammer hits to seat the component, amount of time to seat the component, and resistance-to-seat were collected. The implants were then cyclically loaded following ASTM F2028-17 testing standard. Clinically, postoperative radiographs of patients with a self-pressurized glenoid component (n = 225 patients) and traditional glenoid component (n = 206 patients) were evaluated for radiolucent lines and glenoid seating at various timepoints. Clinical outcomes (American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form, Simple Shoulder Test, and visual analog scale pain scores) and complications were recorded. The presence of radiolucent lines at the bone-cement interface was evaluated using the Modified Franklin Grade and the Lazarus grade. RESULTS: The self-pressurizing glenoid design required significantly more hammer hits than traditional glenoid designs in all groups tested (P < .029). Moreover, the self-pressurizing design had significantly more resistance-to-seat than traditional components in both the uncemented and partially cemented group (P < .002). No difference in resistance-to-seat was found between designs in the fully cemented group. The uncemented and partially cemented groups did not survive the full 50,000 cycles; however the self-pressurizing design had significantly less motion than the traditional design (P < .001). No differences between component designs were found in the fully cemented group at 50,000 cycles. The self-pressurizing glenoid component had 0.005% radiographic radiolucent lines, and the traditional glenoid component had 45% radiographic radiolucent lines, with 38% of the radiolucencies in the traditional glenoid component group being defined as grade E. There were no progressive radiolucencies, differences in clinical outcomes, or complications at 2 years postoperatively. CONCLUSION: In the fully cemented condition, the 2 component designs had comparable performance; however, the differences in designs could be better observed in the uncemented group. The self-pressurizing all-polyethylene design studied has superior biomechanical stability. Clinically, the improved stability of the glenoid component correlated with a reduction of radiolucent lines and will likely lead to a reduction in glenoid component loosening.

Evaluation of clinical and radiographic outcomes after total shoulder arthroplasty with inset Trabecular Metal-backed glenoid.

BACKGROUND: Trabecular Metal (TM)-backed glenoid implants were introduced for their theoretical ability to increase osseointegration while minimizing wear and the risk of loosening in total shoulder arthroplasty (TSA). Initial follow-up studies of TM-backed glenoids demonstrated high rates of metallic debris formation around the implant site, raising concerns about longevity. More recent data suggest that metallic debris formation may be less prevalent than previously reported and that the implants may have positive long-term outcomes regardless of debris. The goal of our study was to assess the clinical and radiographic outcomes at mid-term follow-up of TSA using a TM-backed glenoid implant placed with full backside support using an inset technique. We hypothesized that our clinical and radiographic outcomes would be good using this technique. METHODS: We retrospectively reviewed the charts of 39 patients who underwent 41 TSA procedures with a Zimmer Biomet TM-backed glenoid component performed by a single surgeon between January 2010 and March 2016. After exclusions for death unrelated to surgery and loss to follow-up, 35 patients (37 shoulders) with minimum 2-year clinical follow-up were included in the study. The glenoids were all placed in an inset fashion with full backside support. Clinical, patient-reported, and radiographic outcomes were analyzed. RESULTS: The average follow-up period was 7.2 years (range, 2-11 years). At final follow-up, average shoulder elevation was 153° ± 22° and average external rotation was 53° ± 12°. The average American Shoulder and Elbow Surgeons score was 86.8 ± 19.0, and the average visual analog scale score was 1.3 ± 2.4. Metallic debris was found in 9 shoulders (27%), and radiolucency was observed around the glenoid components in 13 shoulders (39%) on the final postoperative radiographs. Metallic debris and radiolucency findings were low in severity, with average grades of 0.32 (standard deviation, 0.54) and 0.39 (standard deviation, 0.50), respectively. There were no reoperations. CONCLUSION: This study of 37 shoulders undergoing TSA with a TM-backed glenoid demonstrated 100% implant survivorship at an average follow-up of 7 years. Clinical outcomes were excellent despite the occurrence of some metallic debris formation. The findings suggest that a TM-backed glenoid component implanted in an inset fashion to achieve full backside support can provide good clinical and patient-reported outcomes in TSA patients at mid-term follow-up and suggest that continued consideration of the role of TM-backed glenoids and the optimal technique for implantation may be warranted.