Correlation between radiographic findings of osteoarthritis and arthroscopic findings of articular cartilage degeneration within the patellofemoral joint

Osteoarthritic Bony Alterations of Temporomandibular Joint and Relation to Low Bone Mineral Density in Postmenopausal Edentulous Females

This study aimed to evaluate the relationship between osteoarthritic bony alterations in the temporomandibular joint (TMJ) and general bone mineral density (BMD) in postmenopausal edentulous females. Cone beam computed tomography (CBCT) scans for both TMJs were acquired for 80 clinically asymptomatic patients (mean age 72 ± 8.8 y). Both lumbar spine and femoral neck measurements of BMD were performed using dual-energy X-ray absorptiometry (DXA). The most frequently observed bony alterations were flattening of the articular surface (47.5%), sclerosis (41.5%), subcortical cysts (10%), and erosions (5%). Osteophytes were not observed. No statistical differences were observed between those who had or did not have radiological signs of bony alterations according to age or DXA scores. The prevalence of radiological findings of degenerative TMJ bony alterations in clinically asymptomatic postmenopausal females did not confirm a connection with a generally low BMD.

Evaluation of Rheumatic Diseases Affecting the Temporomandibular Joint: A Cone Beam Computed Tomography Study and Literature Review

INTRODUCTION

Due to the silent manifestation of temporomandibular joint (TMJ), dentists and rheumatologists may neglect treatment for this joint.

AIMS

The aim of this study was to investigate the TMJ components in patients with various rheumatic diseases and to compare them with a control group based on cone beam computed tomography (CBCT) images.

MATERIALS AND METHODS

This study comprised an assessment of the CBCT images of 65 patients (130 temporomandibular joints) with various rheumatic diseases (mostly rheumatoid arthritis) affecting the TMJ. Moreover, 65 patients (130 temporomandibular joints) with a similar age and gender distribution were examined as the control group. Pathologies were classified into a total of 12 types for the presence of any osseous changes in the condylar head or articular fossa or for joint space narrowing. Statistical analysis of all data was performed with SPSS version 18. The conformity of continuous variables to a normal distribution was examined by the Kolmogorov-Smirnov test. The Mann-Whitney U test was used to compare the means of two independent groups. The Pearson Chi-square test, Yates correction and Fisher's exact test were used in the analysis of categorical variables.

RESULTS

The mean age of the patient and control groups was 50 ± 13 and 48 ± 16, respectively, and no statistically significant difference was found between the patient and control groups in terms of age distribution (p = 0.123). Condylar erosion, condylar flattening, subcondylar sclerosis, osteophytes, subcortical cysts, articular eminence resorption and articular eminence flattening rates were found to be statistically significantly higher in the patient group than in the control group (p < 0.05).

CONCLUSIONS

Dentomaxillofacial radiologists should examine the bony components of the TMJ in patients with rheumatic diseases, and a multidisciplinary approach involving a dental specialist and rheumatologist is required.

Interpretation of Cartilage Damage at Routine Clinical MRI: How to Match Arthroscopic Findings

This review is intended to aid in the interpretation of damage to the articular cartilage at routine clinical MRI to improve clinical management. Relevant facets of the histologic and biochemical characteristics and clinical management of cartilage are discussed, as is MRI physics. Characterization of damage to the articular cartilage with MRI demands a detailed understanding of the normal and damaged appearance of the osteochondral unit in the context of different sequence parameters. Understanding the location of the subchondral bone plate is key to determining the depth of the cartilage lesion. Defining the bone plate at MRI is challenging because of the anisotropic fibrous organization of articular cartilage, which is susceptible to the "magic angle" phenomenon and chemical shift artifacts at the interface with the fat-containing medullary cavity. These artifacts may cause overestimation of the thickness of the subchondral bone plate and, therefore, overestimation of the depth of a cartilage lesion. In areas of normal cartilage morphology, isolated hyperintense and hypointense lesions often represent degeneration of cartilage at arthroscopy. Changes in the subchondral bone marrow at MRI also increase the likelihood that cartilage damage will be visualized at arthroscopy, even when a morphologic lesion cannot be resolved, and larger subchondral lesions are associated with higher grades at arthroscopy. The clinical significance of other secondary features of cartilage damage are also reviewed, including osteophytes, intra-articular bodies, and synovitis. Online supplemental material is available for this article. Work of the U.S. Government published under an exclusive license with the RSNA.

Alignment changes after open-wedge high tibial osteotomy result in offloading in the patellofemoral joint: a SPECT/CT analysis

PURPOSE

The patellofemoral (PF) joint may be adversely affected by medial open-wedge high tibial osteotomy (OWHTO). This study aimed to evaluate the PF compartmental changes using combined single-photon emission computed tomography (SPECT) and conventional computed tomography (CT) after OWHTO to provide clinical guidance regarding the PF joint pressure and force.

METHODS

Patients with medial osteoarthritis and varus malalignment > 5° were treated using OWHTO. Patients with a minimum 2-year follow-up were included in the study. The patellar positions were evaluated based on the radiographic parameters. The changes in chondral lesions during second-look arthroscopic examination were evaluated, and the PF joint arthritis grade was recorded on patellar Merchant radiographs using Kellgren-Lawrence classification. The PF compartmental changes according to SPECT/CT analysis after OWHTO were evaluated in all patients. The scintigraphic uptake was graded on four scales. Patients were divided into improved and unimproved groups according to the PF compartmental grade using the SPECT/CT uptake grading system.

RESULTS

At a mean follow-up period of 47.0 months (range 25-74 months), the mean mechanical femorotibial angle changed significantly from varus 6.3° (range 5-12°) to valgus 2.6° (range 0-8°); p < 0.001) postoperatively. The radiological parameters presenting patellar positions, including the tibial slope, patellar convergence angle, and lateral tilt angle, did not change significantly between the preoperative values and the 2-year follow-up values. The mean patellar height significantly decreased (0.07 ± 0.14, p = 0.001 according to the Blackburn-Peel index and 0.32 ± 0.23, p < 0.001 using the modified Insall-Salvati ratio). The average tibial tubercle to trochlear groove (TT-TG) distance significantly decreased from 14.1 to 12.2 mm (p < 0.001). The Q angle also significantly decreased from 9.8^o to 7.7^o (p = 0.008). Chondral lesions of the patella and trochlear groove revealed significant deterioration; at 2 years after OWHTO, the arthritic grades of the PF joints worsened significantly, as determined by radiography (p = 0.007). Scintigraphic uptake in the PF joint was significantly lower (from 2 to 1) at 2 years postoperatively compared to that immediately after the index operation (p < 0.001). Only 4 of 56 (7.1%) patients showed increased uptake. Comparison between the improved and unimproved groups according to scintigraphic uptake changes revealed that the changes in the cartilage status on the patellar undersurface and TT-TG distance were the most significant predictive factors of increased scintigraphic uptake in the PF joint after OWHTO.

CONCLUSION

Alignment correction by OWHTO result in PF compartment offloading and should be considered when identifying the surgical indications for OWHTO.

LEVEL OF EVIDENCE

Therapeutic, Level IV.

Acetabular margin changes in feline hip joints - Implications for radiologic diagnosis and development of osteoarthritis

The development and early morphological features of feline hip osteoarthritis (OA) are largely unknown. Tears in the acetabular labrum and at the chondrolabral transition zone are suggested to be important in the pathogenesis of human hip OA, but in cats such lesions have not been described. We investigated associations between computed tomography (CT)-detected joint changes and microscopic articular cartilage lesions, the distribution of detected changes, and histologically evaluated the acetabular margin (AM) in hip joints from 20 cats. Histologic evaluation was undertaken on at least one joint from each cat. CT-detected joint changes and articular cartilage lesions were graded and the histological appearance of CT-detected osteophytes evaluated. The majority of CT-detected lesions and cartilage lesions were mild. Whole-joint CT scores and AM osteophyte CT scores showed moderate to strong correlation with cartilage scores. The odds were higher for presence of CT-detected osteophytes in craniodorsal, cranial, cranioventral, ventral and dorsal AM regions. Peripheral acetabular regions showed higher cartilage lesion grades than central regions. Tears, seen as fissures/clefts, in labral and perilabral tissues were common. CT-detected AM osteophytes morphologically presented as pointed sclerotic bone, spur-shaped bone or rounded chondro-osteophytes. The results suggest that CT is a valuable tool for diagnosing early feline hip OA. CT-detected osteophytes showed variable histologic morphologies, which may implicate different disease mechanisms and/or disease stages. Tears in the AM could represent an early event in feline hip OA and this warrants further investigation.

Common variants in LTBP3 gene contributed to the risk of hip osteoarthritis in Han Chinese population

Osteoarthritis (OA) is a common chronic joint disease affected by environmental and genetic factors. The LTBP3 gene may be involved in the occurrence and development of OA by regulating TGF-β activity and the TGF-β signaling pathway. A total of 2780 study subjects, including 884 hip OA cases and 1896 controls, were recruited. Nine tag single-nucleotide polymorphisms (SNPs) located within the LTBP3 gene region were selected for genotyping. Genetic association analyses were performed at both the genotypic and allelic levels. GTEx data were extracted to investigate the functional consequence of significant SNPs. SNP rs10896015 was significantly associated with the risk of hip OA at both the genotypic (P=0.0019) and allelic levels (P=0.0009). The A allele of this SNP was significantly associated with a decreased risk of HOA (OR [95%CI] = 0.79 [0.69–0.91]). This SNP was also significantly associated with the clinical severity of hip OA. SNP rs10896015 could affect the gene expression of 11 genes, including LTBP3, in multiple human tissues based on GTEx data. We obtained evidence for a genetic association between the LTBP3 gene and hip OA susceptibility and clinical severity based on Chinese Han populations. Our findings replicated the association signals reported by a recent genome-wide association study and deepen the basic understanding of osteoarthritis pathology.

CBCT characteristics and interpretation challenges of temporomandibular joint osteoarthritis in a hand osteoarthritis cohort

OBJECTIVES

To characterise osteoarthritis (OA) in the temporomandibular joints (TMJs) by means of cone beam CT in a hand OA population, and identify interpretation challenges.

METHODS

The TMJs of 54 individuals (mean age 71.3) recruited from the "The Oslo hand OA cohort", independently of TMJ-related symptoms, were examined with cone beam CT (ProMax MidCBCT). Images were analysed for bone change characteristics and each joint was diagnosed with either OA, no OA or as indeterminate for OA. The image analysis criteria developed for the Research Diagnostic Criteria for Temporomandibular Disorders were used. Frequencies of bone changes, joint diagnoses and severity grades (1-2) were calculated, as well as κ values for observer agreement.

RESULTS

In the OA joints, the most frequent bone changes occurred in the condyle: flattening (79%), osteophyte (72%) and subcortical sclerosis (70%). The most frequent changes in the fossa/eminence were flattening (57%), erosion (49%) and subcortical sclerosis (47%). 53 (49%) of the 108 joints were diagnosed with TMJ OA (68 % Grade 2), 29 joints (27%) with no OA, and 26 joints (24%) were indeterminate for OA. Inter- and intraobserver agreement showed mean κ values of 0.67 and 0.62, respectively.

CONCLUSIONS

TMJ changes were common in elderly with hand OA and characterised by bone productive changes. The radiologic features indicated a late stage TMJ OA. Interpretation challenges related to subtle changes were identified and are reflected by the rather low observer agreement. The diagnosis of TMJ OA should be based on evident and clear abnormalities only.

Can osteophytes be used as age at death estimators? Testing correlations in skeletonized human remains with known age-at-death

Age-at-death estimation is one of the major challenges when establishing an adult skeleton biological profile. The presence of degenerative joint changes - e.g. osteophytes - has been regarded as a good postmaturity age indicator. This study assessed if a clear relationship between age and osteophytes exists. To accomplish this goal, a total of 16 joint surfaces, from the shoulder, elbow, wrist, hip, knee, and ankle, were examined in 604 adult individuals, of both sexes from two Portuguese Identified collections. Individuals had between 20 and 98 year old at death. Statistically significant results were found between age-at-death and degrees of severity of osteophytes throughout all the articular surfaces analyzed (p>0.001). However, the strength of the correlation varies from moderate to low in the majority of the joints, for both sexes. The only strong correlation effects (r=0.567 in females and r=0.552 in males) were found associated with the left and right glenoid cavity in females and males respectively. More noticeable changes were consistently found in association with older individuals (>62 years old). Results indicate that significant relationships exist between age and the presence of osteophytes in the joint margins. However, correlation effects were low to moderate in most cases, therefore the use of osteophytes to predict age-at-death is not without significant error of interpretation.

The Clinical Significance of Osteophytes in Compartments of the Knee Joint With Normal Articular Cartilage

OBJECTIVE

The purpose of this study is to determine whether marginal osteophytes in compartments with normal cartilage would be more frequently observed in knees with cartilage lesions and osteophytes in other compartments.

MATERIALS AND METHODS

This retrospective study reviewed 500 consecutive knee MRI examinations performed within 6 months of arthroscopic knee surgery conducted for 497 patients with symptoms (289 male patients and 208 female patients; age range, 17-74 years; median age, 43 years). The highest grade of cartilage lesion detected at MRI and arthroscopy was recorded. Marginal osteophytes were graded on MRI with use of a standardized scoring system, with grade 0 denoting no osteophyte; grade 1, small osteophyte; grade 2, medium-size osteophyte; and grade 3, large osteophyte). The frequency of false-positive osteophytes, defined as osteophytes present in compartments (the patellofemoral, medial tibiofemoral, and lateral tibiofemoral compartments) with normal cartilage observed on MRI and arthroscopy, was calculated. The Goodman and Kruskal gamma statistic was used to test the association of osteophyte size between compartments. Logistic regression was used to test the association between osteophyte size and the severity of the cartilage lesions.

RESULTS

Marginal osteophytes were seen in compartments with normal cartilage on MRI and arthroscopy in 60.5% of knees (75 of 124) with cartilage lesions and osteophytes in other compartments and accounted for all false-positive grade 2 and grade 3 osteophytes. Marginal osteophytes were seen in 12.7% of knees (13 of 102) that had no cartilage lesions in any compartment on MRI or arthroscopy, and all of these were grade 1 osteophytes. The presence of larger sized osteophytes in the compartments with cartilage lesions was associated with the presence of larger sized osteophytes in the compartments with normal cartilage. More severe cartilage lesions were associated with larger osteophyte size.

CONCLUSION

Compartments with marginal osteophytes and normal cartilage are commonly seen in knees that have other compartments with osteophytes and cartilage lesions.

Idiopathic condylar resorption: The current understanding in diagnosis and treatment

Idiopathic condylar resorption (ICR) is a condition with no known cause, which manifests as progressive malocclusion, esthetic changes, and often pain. Cone-beam computed tomography and magnetic resonance imaging are the most valuable imaging methods for diagnosis and tracking, compared to the less complete and more distorted images provided by panoramic radiographs, and the higher radiation of ^99mtechnetium-methylene diphosphonate. ICR has findings that overlap with osteoarthritis, inflammatory arthritis, physiologic resorption/remodeling, congenital disorders affecting the mandible, requiring thorough image analysis, physical examination, and history-taking. Correct diagnosis and determination of whether the ICR is active or inactive are essential when orthodontic or prosthodontic treatment is anticipated as active ICR can undo those treatments. Several treatments for ICR have been reported with the goals of either halting the progression of ICR or correcting the deformities that it caused. These treatments have varying degrees of success and adverse effects, but the rarity of the condition prevents any evidence-based recommendations.

Radiographic grading of the patellofemoral joint is more accurate in skyline compared to lateral views

BACKGROUND

The patellofemoral joint is perhaps the most commonly involved compartment in knee osteoarthritis (OA). Radiographic studies are routinely ordered and are seen as the first-line investigations for patellofemoral osteoarthritis (PFOA). The Kellgren-Lawrence (K&L) grading scale is often used to quantify the severity of radiographic OA. In this study, we aim to determine the correlation of the K&L grading scale on both the skyline and lateral views with arthroscopic visualization of articular cartilage damage.

METHODS

All patients with clinical and radiographic features of PFOA who underwent knee arthroscopy by a single surgeon from 2006 to 2010 in our institution were reviewed. The study group consisted of 66 patients with PFOA. All patients had skyline and lateral radiographs of the knee taken before surgery. All patients had arthroscopic evidence of PFOA. Blinded investigators graded the radiographs according to the K&L grading scale. At arthroscopy, the patellofemoral joint was graded according to the Outerbridge classification. Correlation and statistical analysis of the radiographic and arthroscopic grade was carried out.

RESULTS

The general trend shows that the higher the radiographic K&L grading, the greater the severity of articular cartilage degeneration on arthroscopy. However, an increasing K&L grade accounts for only 39.7% and 28.4% of the variation of severity of arthroscopically-determined articular cartilage degeneration on skyline and lateral views respectively. Interestingly, on both views, better correlation with arthroscopic findings was seen in early (K&L grades 1 and 2) PFOA. Skyline views were superior to lateral views in terms of specificity, PPV, NPV and accuracy in predicting early OA.

CONCLUSIONS

Skyline radiographs are more accurate than lateral radiographs in prediction of severity of PFOA.

Age-related impairment of quality of joint motion in vibroarthrographic signal analysis

Aging is associated with degenerative changes in articular surfaces leading to quantitative and qualitative impairment of joint motion. Therefore, the aim of this study is to evaluate an age-related quality of the patellofemoral joint (PFJ) motion in the vibroarthrographic (VAG) signal analysis. Two hundred and twenty individuals were enrolled in this study and divided into five groups according to age. The VAG signals were collected during flexion/extension knee motion using an acceleration sensor and described using four parameters (VMS, P1, P2, and H). We observed that values of parameters VMS, P1, and P2 increase in accordance with the age, but H level decreases. The most significant differences were achieved between the youngest and the oldest participants' groups. Moreover, we show that parameters VMS, P1, and P2 positively correlate with age, contrary to negatively associated H parameter. Our results suggest that the impairment of joint motion is a result of age-related osteoarticular degenerative changes.

Sensitivity of standing radiographs to detect knee arthritis: a systematic review of Level I studies

PURPOSE

The purpose of this study was to perform a systematic review of the available literature to define the level of quality evidence for determining the sensitivity and specificity of different radiographic views in detecting knee osteoarthritis and to determine the impact of different grading systems on the ability to detect knee osteoarthritis.

METHODS

A systematic review of the literature was conducted to identify studies that evaluated the standing anteroposterior (AP) and 45° posteroanterior (PA) views for tibiofemoral and patellofemoral arthritis and those comparing the use of the Kellgren-Lawrence versus the joint space narrowing (JSN) radiographic grading systems using arthroscopy as the gold standard. A comprehensive search of PubMed, Scopus, CINAHL, the Cochrane Database, Clinicaltrial.gov, and EMBASE was performed using the keywords "osteoarthritis," "knee," "x-ray," "sensitivity," and "arthroscopy."

RESULTS

Six studies were included in the evaluation. The 45° flexion PA view showed a higher sensitivity than the standing AP view for detecting severe arthritis involving either the medial or lateral tibiofemoral compartment. There was no difference in the specificities for the 2 views. The direct comparison of the Kellgren-Lawrence and the JSN radiographic grading systems found no clinical difference between the 2 systems regarding the sensitivities, although the specificity was greater for the JSN system.

CONCLUSIONS

The ability to detect knee osteoarthritis continues to be difficult without using advanced imaging. However, as an inexpensive screening tool, the 45° flexion PA view is more sensitive than the standing AP view to detect severe tibiofemoral osteoarthritis. When evaluating the radiograph for severe osteoarthritis using either the Kellgren-Lawrence or JSN grading system, there is no clinical difference in the sensitivity between the 2 methods; however, the JSN may be more specific for ruling in severe osteoarthritis in the medial compartment.

LEVEL OF EVIDENCE

Level I, systematic review of Level I studies.

Joint motion quality in vibroacoustic signal analysis for patients with patellofemoral joint disorders

BACKGROUND

Chondromalacia, lateral patellar compression syndrome and osteoarthritis are common patellofemoral joint disorders leading to functional and/or structural disturbances in articular surfaces. The objective of the study was to evaluate their impact on joint motion quality via the vibroacoustic signal generated during joint movement analysis.

METHODS

Seventy-three patients (30 with chondromalacia, 21 with lateral patellar compression syndrome, and 22 with osteoarthritis) and 32 healthy controls were tested during flexion/extension knee motion for vibroacoustic signals using an acceleration sensor. Estimated parameters: variation of mean square (VMS), difference between mean of four maximum and mean of four minimum values (R4), power spectral density for frequency of 50-250 Hz (P1) and 250-450 Hz (P2) were analyzed.

RESULTS

Vibroacoustic signals recorded for particular disorders were characterized by significantly higher values of parameters in comparison to the control group. Moreover, differences were found among the various types of patellofemoral joint disturbances. Chondromalacia and osteoarthritis groups showed differences in all parameters examined. In addition, osteoarthritis patients exhibited differences in VMS, P1 and P2 values in comparison to lateral patellar compression syndrome patients. However, only the value of R4 was found to differ between knees with lateral patellar compression syndrome and those with chondromalacia.

CONCLUSION

Our results suggest that particular disorders are characterized by specific vibroacoustic patterns of waveforms as well as values of analyzed parameters.

Inferior outcomes of total knee replacement in early radiological stages of osteoarthritis

BACKGROUND

Total knee replacement (TKR) for osteoarthritis (OA) is a common and successful operation; the severity of radiographic changes plays a key role as to when it should be performed. This study investigates whether an early radiological grade of OA has an adverse effect on the outcome of TKR in patients with arthroscopically confirmed OA.

METHODS

Between January 2006 and January 2011 data was collected prospectively on all patients undergoing a primary TKR for OA. We included all patients with a Kellgren-Lawrence score of two or less on their pre-operative radiograph who had had an arthroscopy to confirm significant OA. Our primary outcomes were the Oxford Knee Score (OKS) and a satisfaction rating.

RESULTS

Over the study period 1708 primary TKRs were performed in 1381 patients. We identified 44 TKRs in 43 patients with a Kellgren-Lawrence score of two or less on their pre-operative radiograph. In this group the mean age was 63 years, 66% were female and the mean BMI was 31.7 kg/m(2). At a mean follow-up of 37 months the mean OKS was only 30 points compared to 36 in all TKRs performed over the same period (p=0.0004). Only 68% were either satisfied or very satisfied. Eight knees (18%) underwent further surgery, three (6.8%) of which were revision procedures, compared to a revision rate of 1.6% in all patients.

CONCLUSION

The outcomes of TKR in patients with early radiological changes of OA are inferior to those with significant radiological changes and should be performed with caution.

LEVEL OF EVIDENCE

Level IV case-series.

Does osteophytosis at the knee predict health-related quality of life decline? A 3-year follow-up of the ROAD study

The objective of the present longitudinal study was to clarify whether osteophytosis and joint space narrowing predict quality of life (QOL) decline using a longitudinal population-based cohort of the Research on Osteoarthritis/osteoporosis Against Disability (ROAD) study. The present study analyzed 1,525 participants who completed the radiographic examination at baseline and questionnaires regarding QOL at a 3-year follow-up (546 men and 979 women; mean age, 67.0 ± 11.0 years). This study examined the associations of osteophyte area (OPA) and minimum joint space width (mJSW) in the medial compartment of the knee at baseline with pain and physical functional disability measured by the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC). OPA and mJSW in the medial compartment of the knee were measured using a knee osteoarthritis (OA) computer-aided diagnosis system. Overall, OPA independently predicted physical functional disability after 3 years of follow-up. When analyzed in men and women separately, OPA, rather than mJSW, was an independent predictor for pain and physical functional disability after 3 years of follow-up in men. OPA, rather than mJSW, also predicted worsening of pain in men during the 3-year follow-up, whereas in women, mJSW, rather than OPA, predicted worsening of pain. In conclusion, the present longitudinal study using a large-scale population from the ROAD study found gender differences in the association of osteophytosis and joint space narrowing with pain and physical functional disability.

Triple positioning of tibial tubercle osteotomy for patellofemoral disorders

BACKGROUND AND PURPOSE

Patellofemoral disorders are often associated with patellofemoral malalignment. Tibial tubercle transfer is an effective method to correct the patellofemoral malalignment. This study evaluated the long-term results of triple positioning of tibial tubercle osteotomy for refractory patellofemoral disorders with 10-year follow-up.

PATIENTS AND METHODS

Fifty-six patients with 62 knees underwent triple positioning of tibial tubercle osteotomy for refractory patellofemoral disorders. All patients received standard rehabilitation protocol postoperatively. The average length of follow-up was 128.5±9.8 months (range 116 to 149). The evaluations included pain score, Kujala patellofemoral score, Lysholm score and radiograph of the knee.

RESULTS

The overall clinical results were excellent in 41.9%, good in 37%, fair in 12.9% and poor in 5% at 1 year; and 29% excellent, 41% good, 18.3% fair and 9.3% poor at 10 years. Satisfactory results were 78.9% and 70.9%, and unsatisfactory results 21.1% and 29.1% at 1 year and 10 years respectively. There was no correlation of clinical outcomes with age, sex, body weight and height and preoperative pain score. However, there was a positive correlation of clinical outcomes with the improvement of the congruence angle on postoperative X-rays of the knee, and a negative correlation of clinical outcome with the severity of articular cartilage damage assessed in arthroscopy. The complications included 1 non-union and 1 infection with non-union.

CONCLUSION

Triple positioning of tibial tubercle osteotomy is effective and long lasting in patients with patellofemoral disorders with 70.9% satisfactory results at 10-year follow-up.

LEVEL OF EVIDENCE

IV (refer to instructions for detailed description on the level of evidence).

Combined single photon emission computerised tomography and conventional computerised tomography (SPECT/CT) in patellofemoral disorders: a clinical review

Patellofemoral disorders are common conditions seen in a knee clinic but can present a great diagnostic challenge to the orthopaedic surgeon. Combined single photon emission computerised tomography with conventional computer tomography (SPECT/CT) provides the clinician with precise anatomical and physiological information of the patellofemoral joint. We present a clinical review that highlights the value of SPECT/CT in patients with patellofemoral disorders, where other modalities such as radiographs, MRI, and conventional CT did not provide sufficient information. SPECT/CT has proven to be helpful for establishing the diagnosis and guidance for further treatment. SPECT/CT should be recognised as a valuable diagnostic tool in orthopaedic patients.

Matrix metalloproteinases and inhibitors in cartilage tissue engineering

Inhibiting matrix metalloproteinase (MMP) activity has been considered as a potential therapeutic treatment that may modify the outcome for osteoarthritis (OA), a disease governed by abnormalities in the balance between MMPs and their inhibitors. Due to unexpected tissue fibrosis in early-phase clinical trials with some MMP inhibitors, possible divergent effects of inhibiting MMP activity on different cells are hypothesized. Therefore, we evaluated the effects of MMP inhibition on cells relevant to cartilage tissue engineering by culturing them in vitro in poly(ethylene glycol) diacrylate hydrogels to create 3D representations of cartilage tissue while allowing for local and direct administration of inhibitors. Mesenchymal stem cells demonstrated an inhibitor concentration-dependent decrease in extracellular matrix (ECM) deposition, while normal chondrocytes were mainly affected at the highest concentration of inhibitors. In contrast, the concomitant treatment of chondrocytes from patients with OA resulted in an increase in glycosaminoglycan content only in the presence of both inhibitors and anabolic growth factors. The observed upregulation of bone markers, however, indicates a delicate balance that must be addressed to therapeutically treat OA chondrocytes to stimulate more ECM production without errant bone formation. In conclusion, this study suggests that MMPs have complex interactions in both pathobiology and homeostasis.

Skyline patellofemoral radiographs can only exclude late stage degenerative changes

Accurate preoperative assessment of the patellofemoral joint is especially important in compartment specific knee arthritis. This study aims to show the actual intraoperative grade of patellofemoral cartilage damage that may be reliably detected or excluded by preoperative standard radiographic views. 100 consecutive knees awaiting arthroplasty underwent preoperative lateral and skyline radiographs and were scored using the Ahlback score. Intraoperative cartilage damage was assessed using the Collins score. The sensitivity and specificity were calculated for each grade of cartilage damage. Preoperative anterior knee pain and function were assessed and correlated to the degree of cartilage damage. The lateral radiograph shows poor sensitivity for all grades of disease (0.05-0.23). The skyline shows good sensitivity for grade 4 (large full thickness) damage (0.90) but decreases substantially for grades 1-3 (0.19-0.46). Significantly more people with skyline radiograph joint space narrowing complained of anterior knee pain than those with a normal radiograph (p<0.001). There was only a poor correlation between preoperative anterior pain and intraoperative patellofemoral cartilage damage (r=0.24). The lateral radiograph cannot exclude even large areas of full thickness cartilage damage whereas a normal skyline radiograph can reliably exclude significant (grade 4) patellofemoral disease and should be used in addition to the lateral view.

Radiographic predictability of cartilage damage in medial ankle osteoarthritis

BACKGROUND

Radiographic grading has been used to assess and select between treatment options for ankle osteoarthritis. To use radiographic grading systems in clinical practice and scientific studies one must have reliable systems that predict the fate of the cartilage.

QUESTIONS/PURPOSES

We therefore asked whether (1) radiographic grading of ankle osteoarthritis is reliable and (2) grading reflects cartilage damage observed during arthroscopy. We then (3) determined the sensitivity, specificity, and predictive values of the radiographic findings.

PATIENTS AND METHODS

We examined 74 ankles with medial osteoarthritis and 24 with normal articular cartilage based on arthroscopy. Arthroscopic findings were graded according to the modified Outerbridge grades and all radiographs were graded using the modified Kellgren-Lawrence, Takakura et al., and van Dijk et al. grading systems. The reliability of each radiographic grading system was evaluated. We correlated the radiographic grades and severity of cartilage damage for each radiographic grading system. Sensitivity, specificity, and predictive values of spurs and joint space narrowing with or without talar tilting then were determined.

RESULTS

The interobserver weighted kappa ranged from 0.58 to 0.89 and the intraobserver weighted kappa from 0.51 to 0.85. The correlation coefficients for the Kellgren-Lawrence, Takakura et al., and van Dijk et al. grades were 0.53, 0.42, and 0.42, respectively. Ankles with medial joint space narrowing (Stage 2 of Takakura et al. and van Dijk et al. grades) showed varying severity of cartilage damage. The positive predictive value of cartilage damage increased from 77% for medial joint space narrowing regardless of the presence of talar tilting to 98% for medial joint space narrowing with talar tilting.

CONCLUSIONS

Our observations suggest the inclusion of talar tilting in grading schemes enhances the assessment of cartilage damage.

LEVEL OF EVIDENCE

Level II, diagnostic study. See the Guidelines for Authors for a complete description of level of evidence.

A study of the long-term effects of anatomical open reduction of patella on patellofemoral articular cartilage in follow up arthroscopy

Anatomical open reduction is the choice treatment method in patellar fractures and the sole approach to study the cartilage surface healing is arthroscopy. This study is to evaluate the cartilage healing, long after the complete union of the fractures and the long-term effects of simple transverse patellar fractures with perfect results on patellofemoral cartilage surface. Free of charge standard diagnostic arthroscopy was done on 22 patients whose simple transverse pattelar fractures had happened at least 3 years ago with the mean age of 36.4 years. Fractures had happened at least 3 years ago and all cases had excellent union results. The data collected from cartilage surface studies were recorded. No other statistical tests were used except for X2 test to study the relation between clinical and radiological findings and arthroscopies. The elapsed time from the fracture occurrence to the arthroscopy was 39.2 months, at least 36 months. Five patients (22.6%) showed complete cartilage healing in cartilage surface arthroscopy and 10 patients (45.2%) proved to have Grade I chondral lesions. Four patients had Grade II chondral lesions and 3 patients had Grade III chondral lesions along with fibrillation. In 2 patients mirror cartilage lesions were observed in the opposite trochlea. In 3 patients with normal radiological signs, step-off was observed on cartilage surface. There was no relation between clinical signs and radiological characteristics of the patients with the healing on cartilage surface (p = 0.84). Having a diagnostic arthroscopy in an appropriate time after fusion, especially during extracting the metal instrument, is effective on evaluating patient's prognosis. Extracting metal instruments along with the simultaneous chondroplasty has low cost and complications, though leading to a decrease in the prevalence of secondary osteoarthritis and probably the eruptive swelling due to the debris released from probable fibrillations.

Research diagnostic criteria for temporomandibular disorders (RDC/TMD): development of image analysis criteria and examiner reliability for image analysis

OBJECTIVE

As part of the Multisite Research Diagnostic Criteria For Temporomandibular Disorders (RDC/TMD) Validation Project, comprehensive temporomandibular joint diagnostic criteria were developed for image analysis using panoramic radiography, magnetic resonance imaging (MRI), and computerized tomography (CT).

STUDY DESIGN

Interexaminer reliability was estimated using the kappa (kappa) statistic, and agreement between rater pairs was characterized by overall, positive, and negative percent agreement. Computerized tomography was the reference standard for assessing validity of other imaging modalities for detecting osteoarthritis (OA).

RESULTS

For the radiologic diagnosis of OA, reliability of the 3 examiners was poor for panoramic radiography (kappa = 0.16), fair for MRI (kappa = 0.46), and close to the threshold for excellent for CT (kappa = 0.71). Using MRI, reliability was excellent for diagnosing disc displacements (DD) with reduction (kappa = 0.78) and for DD without reduction (kappa = 0.94) and good for effusion (kappa = 0.64). Overall percent agreement for pairwise ratings was >or=82% for all conditions. Positive percent agreement for diagnosing OA was 19% for panoramic radiography, 59% for MRI, and 84% for CT. Using MRI, positive percent agreement for diagnoses of any DD was 95% and of effusion was 81%. Negative percent agreement was >or=88% for all conditions. Compared with CT, panoramic radiography and MRI had poor and marginal sensitivity, respectively, but excellent specificity in detecting OA.

CONCLUSION

Comprehensive image analysis criteria for the RDC/TMD Validation Project were developed, which can reliably be used for assessing OA using CT and for disc position and effusion using MRI.

Semiautomated digital analysis of knee joint space width using MR images

OBJECTIVE

The goal of this study was to (a) develop a semiautomated computer algorithm to measure knee joint space width (JSW) from magnetic resonance (MR) images using standard imaging techniques and (b) evaluate the reproducibility of the algorithm.

DESIGN

Using a standard clinical imaging protocol, bilateral knee MR images were obtained twice within a 2-week period from 17 asymptomatic research participants. Images were analyzed to determine the variability of the measurements performed by the program compared with the variability of manual measurements.

RESULTS

Measurement variability of the computer algorithm was considerably smaller than the variability of manual measurements. The average difference between two measurements of the same slice performed with the computer algorithm by the same user was 0.004 +/- 0.07 mm for the tibiofemoral joint (TF) and 0.009 +/- 0.11 mm for the patellofemoral joint (PF) compared with an average of 0.12 +/- 0.22 mm TF and 0.13 +/- 0.29 mm PF, respectively, for the manual method. Interuser variability of the computer algorithm was also considerably smaller, with an average difference of 0.004 +/- 0.1 mm TF and 0.0006 +/- 0.1 mm PF compared with 0.38 +/- 0.59 mm TF and 0.31 +/- 0.66 mm PF obtained using a manual method. The between-day reproducibility was larger but still within acceptable limits at 0.09 +/- 0.39 mm TF and 0.09 +/- 0.51 mm PF. This technique has proven consistently reproducible on a same slice base,while the reproducibility comparing different acquisitions of the same subject was larger. Longitudinal reproducibility improvement needs to be addressed through acquisition protocol improvements.

CONCLUSION

A semiautomated method for measuring knee JSW from MR images has been successfully developed.