Operative treatments for osteochondral lesions of the talus in adults: A systematic review and meta-analysis

PURPOSE

This systematic review aimed to identify the available evidence regarding the comparative effectiveness and safety of various operative treatments in adult patients with osteochondral lesions of the talus (OLT).

MATERIALS AND METHODS

The PubMed, Embase, ISI Web of Knowledge, and the Cochrane Controlled Trial Register of Controlled Trials were searched from their inception date to September 2019. Two reviewers selected the randomized controlled trials (RCTs) and non-RCTs assessing the comparative effectiveness and safety of various operative treatments for OLT. The meta-analysis was performed using Revman 5.3.

RESULTS

Eight studies (1 RCT and 7 non-RCTs) with 375 patients were included in this review. The difference in the American Orthopaedic Foot and Ankle Society (AOFAS) score between the cartilage repair and replacement was not significant. The cartilage regeneration with or without cartilage repair had significant superiority in improving the AOFAS score compared with the cartilage repair. The difference in the magnetic resonance observation of cartilage repair tissue score between the cartilage repair and replacement and between cartilage repair and cartilage repair plus regeneration was significant.

CONCLUSIONS

Cartilage regeneration and cartilage repair plus regeneration had significant superiority in improving the ankle function and radiological evaluation of OLT, although the trials included did not have high-level evidence. Moreover, which treatment between the 2 was safer could not be addressed in this review as most of the trials did not report the safety outcome. Further studies are needed to define the best surgical option for treating OLT.

Pediatric Pain Syndromes and Noninflammatory Musculoskeletal Pain

Chronic musculoskeletal pain (CMP) is one of the main reasons for referral to a pediatric rheumatologist and is the third most common cause of chronic pain in children and adolescents. Causes of CMP include amplified musculoskeletal pain, benign limb pain of childhood, hypermobility, overuse syndromes, and back pain. CMP can negatively affect physical, social, academic, and psychological function so it is essential that clinicians know how to diagnose and treat these conditions. This article provides an overview of the epidemiology and impact of CMP, the steps in a comprehensive pain assessment, and the management of the most common CMPs.

Purulent Chondritis of the Laryngeal Framework Cartilages

This manuscript reports on our experience with purulent chondritis of the laryngeal cartilages (PCLC), an entity that has not yet been described. Three patients had a diagnosis of PCLC. The probable causes were relapsing polychondritis, a previous prolonged intubation, and an idiopathic cause. The patients suffered from hoarseness and inspiratory stridor for 1 to 3 months before diagnosis. None complained of pain in the neck. Laryngoscopy showed supraglottic edema. A computed tomography scan revealed abscess formation between the intact inner and outer perichondria of the thyroid cartilage. The treatment included rigid endoscopy, external incision and drainage, and prolonged medical therapy. The culture results were Staphylococcus aureus in the first 2 cases and Aspergillus fumigatus in the third. The second patient (in whom the cricoid cartilage was also affected) required emergency tracheotomy. The other 2 patients did not require airway intervention. The rarity of PCLC and the relatively mild symptoms require a high index of suspicion for its diagnosis.

Co-segregation of Freiberg's infraction with a familial translocation t(5;7)(p13.3;p22.2) ascertained by a child with cri du chat syndrome and brachydactyly type A1B

The identification of chromosomal breakpoints in association with human abnormal phenotypes can enable elucidation of gene function. We report on epiphyseal aseptic necrosis of the lesser head of the second metatarsal bone, known as Freiberg's infraction (FI), in two female carriers of the apparently balanced t(5;7)(p13.3;p22.2) ascertained by a 16-year-old girl with cri-du-chat syndrome and unusual skeletal features in association with an unbalanced translocation der(5) t(5;7)(p13.3;p22.2). Mapping of the chromosome breakpoints using fluorescent in situ hybridization (FISH) narrowed them to the coding sequence of ADAMTS12 on chromosome 5p13.3 and SDK1 on 7p22.2. In addition, several skeletal abnormalities classified as brachydactyly type A1B (BDA1B) were present in the proband and in both carriers of t(5;7)(p13.3;p22.2), suggesting a potential role of ADAMTS12 in the development of the BDA1B observed in this family.

[Second Köhler disease]

Les auteurs rapportent 17 cas de la deuxième maladie de Köhler. Il s'agit de jeunes femmes (13 cas), qui ont consulté pour des douleurs métatarso-phalangiennes unilatérales de type mécanique. La maladie touche la deuxième tête métatarsienne dans 14 cas. Le diagnostic est posé grâce à la radiologie: le stade III est retrouvé dans 11 cas. Nous avons opté pour l'intervention de Gauthier: Ostéotomie de dorsiflexion de la tête métatarsienne par résection cunéiforme à base dorsale de la zone nécrotique. Les suites opératoires sont bonnes et l’évolution est favorable pour nos patients, avec un recul moyen de 3 ans.

A simple surgical technique for treatment of Freiberg's disease

BACKGROUND

Of all the osteochondrosis, Freiberg's disease is reported to be the fourth most common, exceeded by Köhler's disease, Panner's disease, and Sever's disease. This disease usually occurs in the 2nd metatarsal head and relatively in the 3rd and 4th metatarsal heads.

OBJECTIVE

The purpose of this study was to evaluate the outcome of debridement, synovectomy, dorsal closing wedge osteotomy and pin fixation for Freiberg's disease treatment.

METHODS

Ten female patients, mean age 18.3 years; (ranged 14-24 years) were treated by the above mentioned technique. The main presenting symptom was pain on walking or sport; affected their daily life and activities and was not improved by non-surgical treatment. The second metatarsal head was affected in all patients. Halve of patients had a history of trauma. According to Smillie's classification, four patients were type V and six patients were type IV. Mean follow-up period was 19.2 months (range 6-36 months).

RESULTS

Were assessed by the Lesser Metatarsophalangeal-Interphalangeal (LMPI)Scale by Kitaoka et al. At the final follow up, scoring was changed from (44-76) with an average 57 to (66-100) with an average 80. There was no case of infection, avascular necrosis, arthritis or pseudoarthrosis.

CONCLUSION

We founded that dorsiflexion osteotomy of the metatarsal head is presented as a logical procedure that is simple, reliable, not destructive, and capable of good results regardless of the stage of the disease.

Prevalence of osteochondritis among preparatory and primary school children in an Egyptian governorate

Epiphyseal osteochondritis is a localized disorder in childhood. Vascular insufficiency is thought to be the most significant etiologic factor. This study had been carried on Primary and Preparatory school children in Zagazig City and surrounding villages in Sharkia Governorate, Egypt. Total number of studied children were 16,060, 7,380 males, 8,680 females. The mean age was 11.41 ± 1.99. Our results showed that the prevalence of osteochondritis was 21:10,000. Distribution of Sever's and Osgood-Shlatter diseases were significantly high compared with other osteochondritis. Regarding the sex distribution, osteochondritis was frequent in males. Our results showed that there was history of trauma especially in Sever's and Osgood-Schlatter diseases.

Ultrasonographic evaluation of degenerative changes in the distal radioulnar joint: correlation of findings with gross anatomy and MR arthrography in cadavers

OBJECTIVE

To determine the accuracy of ultrasonography (US) in the evaluation of degenerative changes in the distal radioulnar joint (DRUJ).

METHODS AND MATERIALS

Ten cadaveric specimens were obtained. US evaluation of cartilage degeneration and thickness was performed by two independent and blinded readers (R1 and R2). Gross anatomy and MR arthrography evaluated by two readers in consensus served as the reference standard. The joint surface not accessible to US was measured.

RESULTS

US interreader agreement was non-existent for cartilage thickness measurements and moderate for cartilage degeneration grading (weighted kappa = 0.41). Comparing US and MR imaging evaluation, there was no correlation between US R1 and MR imaging (Pearson correlation coefficient [PCC] = 0.352) and a moderate correlation between US R2 and MR imaging (PCC = 0.570) concerning cartilage thickness measurements. Concerning cartilage degeneration grading, there was a moderate to strong (R1 Spearman correlation coefficient [SCC] = 0.729)/R2 SCC = 0.767) correlation concerning cartilage degeneration grading. Comparing US and gross anatomic evaluation, there was no correlation for US R1 (PCC = 0.220) and a strong correlation for US R2 (PCC = 0.922) concerning cartilage thickness measurements, and a strong to moderate correlation (R1 SCC = 0.808/R2 SCC = 0.597) concerning cartilage degeneration grading. The mean sector of the articular surface of the ulna head not accessible to US was 13°.

CONCLUSION

In conclusion the DRUJ is accessible to US except in the central 13° sector of the joint surface. US was approved to be sufficient in demonstrating advanced stages of cartilage degeneration. Thus, US of the DRUJ is recommended in patients suffering from ulnar-sided wrist pain.

[Features of a cerebral hemodynamics at military men with initial exhibitings of cerebral circulation insufficiency of the pre-existing initial manifestations]

During the epidemiological survey of the military men of the Republic of Karelia with the pre-existing initial manifestations of cerebral circulation insufficiency were established it's main etiological reasons (somatoform autonomic dysfunction--35.2%, cervical osteochondrosis--34.3%) and risk factors (hereditary tainted cardiovascular event, north climate, stress, social habits, peculiarities of military service). Clinical characteristic of labile cerebrastenic syndrome and its peculiarities in compliance with etiological reasons of disease in the presence of autonomic disorders of suprasegmentary character and absence of significant nidal marks in neurological status was given. Complex program for expert diagnosis of the pre-existing initial manifestations of cerebral circulation insufficiency and methods of its propaganda (school, questionary, jotting) were developed and introduced into the practice of neurologist.

Osteochondral transfer using a transmalleolar approach for arthroscopic management of talus posteromedial lesions

Characterizing osteochondral lesions of the talus has enabled the strategies of surgical management to be better specified. The main technical problem is one of access for arthroscopy instruments to posteromedial lesions. A range of techniques and approaches has been described in ankle arthroscopy in general, and a transmalleolar approach provides reliable and efficient access in these cases. It is frequently used for transchondral drilling, but also enables satisfactory implant positioning in autologous osteochondral mosaicplasty procedures. We report our technique and results on five cases with a minimum 1.2 years' follow-up.

Osteochondral lesions of the humeral trochlea in the young athlete

OBJECTIVE

The purpose of this study was to characterize the variety of osteochondral abnormalities of the humeral trochlea in the pediatric athlete.

MATERIALS AND METHODS

Patients with trochlear abnormalities were identified through keyword search of radiology dictations from 1999 to 2007. The patient's medical record, imaging studies, and surgical reports were reviewed. The osteochondral lesions were categorized based on the imaging appearance. Surgical results were reviewed in conjunction with the imaging findings.

RESULTS

Eighteen patients were identified. Trochlear lesions were stratified into two imaging groups: Osteochondral injury/osteochondritis dissecans (OCD) vs. avascular necrosis (AVN). The osteochondral injury group was stratified into medial and lateral trochlear abnormalities. The medial lesions (n = 3) were small (<6 mm) and were located on the posterior articular surface of the medial trochlea. The lateral lesions (n = 10) were larger (10-14 mm), circumscribed, and were located on the posterior inferior aspect of the lateral trochlea. Trochlear AVN (n = 5) affected development of the lateral trochlea (type A) or both the medial and lateral aspects of the trochlea (type B). AVN occurred exclusively in athletes with history of remote distal humeral fracture. Seven of the 18 patients underwent elbow arthroscopy. Surgical findings and treatment regimens are summarized.

CONCLUSION

Trochlear lesions should be considered in throwing athletes presenting with medial elbow pain and flexion contracture/extension block. Medial trochlear osteochondral injuries may result from posteromedial olecranon abutment. Lateral OCD lesions occur in a characteristic vascular watershed zone resulting from the unique blood supply of the trochlea. Trochlear AVN may be unmasked years following treated distal humeral fracture when the athletic demands upon the adolescent elbow increase, revealing the altered growth and biomechanics.

Micro-computed tomography of early lesions of osteochondrosis in the tarsus of foals

INTRODUCTION

Osteochondrosis (OC) is an important developmental orthopedic disease of human and equine patients. The disease is defined as a focal disturbance in enchondral ossification. In horses, the disturbance can occur secondary to failure of the blood supply to growth cartilage. Diagnosis of the early, subclinical stages that can clarify the etiology is currently confined to cross-sectional histological examination. The potential for micro-computed tomography (micro-CT) with angiography to detect early lesions of OC has not yet been investigated.

MATERIALS AND METHODS

Nine Standardbred foals bred from parents with OC of the tarso-crural joint were sacrificed at weekly intervals from birth to 7 weeks of age. Permanent barium angiograms were created within one hind limb post mortem, and samples collected from two predilection sites for OC within the tarso-crural joint of the perfused hind limb. The resulting 18 sample blocks were scanned with a custom-built micro-CT equipment set-up, and analyzed as 2D slices and 3D volume rendered models before sectioning for conventional histological examination.

RESULTS

Histological examination identified eight early lesions in seven locations within six joints from the nine foals. Micro-CT with angiography was able to detect seven lesions in the same sites as histological examination. Lesions consisted of non-perfused foci within growth cartilage. No perfused vessels exited from subchondral bone deep to any lesion. Six of the seven lesions were associated with focal defects in the subchondral bone plate. Evidence of ongoing ossification was seen in three out of the seven lesions and included one separate center of ossification.

CONCLUSION

Micro-CT was a useful technique for examination of early lesions of OC. The results of micro-CT were compatible with failure of cartilage canal vessels at the point where they cross the ossification front. Resultant areas of ischemic chondronecrosis were associated with focal delay in enchondral ossification as visualized in 3D volume rendered models. Micro-CT combined with histology clarified the role of different forms of ossification in the secondary repair responses to lesions.

[Lumbosacral pain syndrome in sportsmen and ballet-dancer (diagnostic algorithm)]

There is presented an experience of the examination of 517 cases including sportsmen and ballet dancers, 15-45 olds, suffering from low back pain syndrome. 265 patients were diagnosed with osteochondrosis, 105 cases--with spondylolis, 92--with facet syndrome, and 55 cases--with pelvic ligaments ligamentopathia. Based upon the analysis of the results of examination diagnostic algorithm and differential diagnostics of these diseases were developed. The use of the proposed algorithm in patients with dissimilar variants of low back pain syndrome showed its informational content. It permits to make a right diagnosis and apply an adequate therapeutic approach.

Posterosuperior osteochondritis of the calcaneus

Osteochondritis of the posterosuperior area of the talocalcaneal surface is a relatively uncommon injury, and only 1 case has been described in the literature. We present a 37-year-old man who complained of pain in the tarsal canal area during walking and when standing up. The magnetic resonance imaging study showed an osteochondral signal in the posterosuperior medial area of the calcaneus on the talocalcaneal surface. The persistence of pain and lack of improvement with conservative treatment made arthroscopic debridement of the injury necessary. The arthroscopic procedure was performed through 2 medial portals, made under fluoroscopy, marked with needles, and dissected with mosquito clamps, and the affected surface could be fully visualized, showing a chondral lesion. Debridement of the osteonecrotic area was performed, and the Steadman technique was used on the injured bone surface. The patient was pain-free, and limited activity (i.e., standing up and walking without symptoms) was allowed. After 24 months, the patient remains asymptomatic with weight-bearing working activities and when standing. Arthroscopic curettage and scission of the injury have been shown to yield good or excellent outcomes in 75% to 80% of patients with regard to the talar surface.

Identification of infrared absorption spectral characteristics of synovial fluid of horses with osteochondrosis of the tarsocrural joint

OBJECTIVE

To determine the feasibility of the use of Fourier-transform infrared (FTIR) spectroscopy within the midinfrared range to differentiate synovial fluid samples of joints with osteochondrosis from those of control samples.

ANIMALS

33 horses with osteochondrosis of the tarsocrural joint and 31 horses free of tarsocrural joint disease.

PROCEDURES

FTIR spectroscopy of synovial fluid was used. Sixty-four synovial fluid samples from the tarsocrural joint were collected. Of these, 33 samples were from horses with radiographic evidence of osteochondrosis of the tarsocrural joint and 31 from control joints. Disease-associated features within infrared spectra of synovial fluid were statistically selected for spectral classification, and the variables identified were used in a classification model. Linear discriminant analysis and leave-one-out cross-validation were used to develop a classifier to identify joints with osteochondrosis.

RESULTS

12 significant subregions were identified that met the selection criteria. The stepwise discriminant procedure resulted in the final selection of 6 optimal regions that most contributed to the discriminatory power of the classification algorithm. Infrared spectra derived from synovial fluid of joints with osteochondrosis were differentiated from the control samples with accuracy of 77% (81% specificity and 73% sensitivity).

CONCLUSIONS AND CLINICAL RELEVANCE

The disease-associated characteristics of infrared spectra of synovial fluid from joints with osteochondrosis may be exploited via appropriate feature selection and classification algorithms to differentiate joints with osteochondrosis from those of control joints. Further study with larger sample size including age-, breed-, and sex-matched control horses would further validate the clinical value of infrared spectroscopy for the diagnosis of osteochondrosis in horses.

Overuse injuries in adolescents

The incidence of overuse injuries in young athletes is on the rise and accounts for a significant number of visits to the primary care office. There are distinctive intrinsic and extrinsic factors that place young athletes at risk for overuse injuries. These injuries vary in severity from being a temporary inconvenience to having potential lifelong morbidity. An understanding of the young athlete and their unique injuries is important for enabling early recognition and treatment. Prevention strategies are also discussed.

Osteochondral fragments involving the dorsomedial aspect of the proximal interphalangeal joint in young horses: 6 cases (1997–2006)

OBJECTIVE

To determine clinical and diagnostic imaging findings in young horses with osteochondral fragments involving the dorsomedial aspect of the proximal interphalangeal (PIP) joint.

DESIGN

Retrospective case series.

ANIMALS

6 horses.

PROCEDURES

Medical records were reviewed. Follow-up information was obtained through telephone conversations with owners or trainers or by examining race records.

RESULTS

Horses were between 1 and 4 years old. Three had bilateral osteochondral fragments in the forelimbs (n = 2 horses) or hind limbs (1). Radiographically, all but 1 fragment seemed to originate from the dorsomedial aspect of the distal end of the first phalanx. Fragment size ranged from 6 x 9 mm to 11 x 21 mm. Three horses had lameness referable to the region of the affected joint; the other 3 horses did not have clinical signs referable to affected PIP joints. Two horses were euthanized shortly after diagnosis at the owners' request because of concerns that the horses would be unsuited for their intended athletic use. Two of the 3 horses in which fragments were incidental findings were able to race successfully, although 1 received intra-articular corticosteroid treatments; the third was retired because of unrelated orthopedic problems.

CONCLUSIONS AND CLINICAL RELEVANCE

Results suggested that osteochondral fragments involving the dorsomedial aspect of the PIP joint may be an incidental finding in young horses. Given the absence of clinical signs in 5 of 9 affected joints and the fact that 3 of 6 horses were affected bilaterally, a developmental origin of the fragments was suspected.

Multiple osteochondroses of bilateral knee joints: a case report

Knee injuries in young athletes include not only the typical adult bone injuries, ligament and cartilage, but also the growth plate lesions. Osteochondroses are idiopathic, self-limited disturbance of enchondral ossification in which a rapid growth spurt is present. The patella could be affected by two different kinds of osteochondroses: Kohler syndrome and Sinding-Larsen-Johansson. Here we are reporting the first case of simultaneous location of osteochondroses of the two ossification centers of both patella. A 9-year-old boy, competitive skater, presented a history of anterior knee pain involving both knees. Standard X-rays, axial patellar view, MRI and arthro-MR were performed. In order to follow the natural history of the pathology and the evolution of the healing, examinations at 2 years were repeated. We proposed the young skater a medical and a physiotherapeutic treatment based on unloading, isometric exercises, NSAID. As the symptoms improve a gradual return to competitive sports activity was allowed. The case mentioned above can be considered an atypical case because the patient suffered for a bilateral knee osteochondroses, involving simultaneously the primary ossification centre (Kohler syndrome) and the secondary ossification centre (Larsen syndrome) of the patella.

Osgood Schlatter syndrome

PURPOSE OF REVIEW

Osgood Schlatter syndrome presents in growing children (boys, 12-15 years; girls, 8-12 years) with local pain, swelling and tenderness over the tibial tuberosity. Symptoms are exacerbated with sporting activities that involve jumping (basketball, volleyball, running) and/or on direct contact (e.g. kneeling). With increased participation of adolescent children in sports, we critically looked at the current literature to provide the best diagnostic and treatment guidelines.

RECENT FINDINGS

Osgood Schlatter syndrome is a traction apophysitis of the tibial tubercle due to repetitive strain on the secondary ossification center of the tibial tuberosity. Radiographic changes include irregularity of apophysis with separation from the tibial tuberosity in early stages and fragmentation in the later stages. About 90% of patients respond well to nonoperative treatment that includes rest, icing, activity modification and rehabilitation exercises. In rare cases surgical excision of the ossicle and/or free cartilaginous material may give good results in skeletally mature patients, who remain symptomatic despite conservative measures.

SUMMARY

Osgood Schlatter syndrome runs a self-limiting course, and usually complete recovery is expected with closure of the tibial growth plate. Overall prognosis for Osgood Schlatter syndrome is good, except for some discomfort in kneeling and activity restriction in a few cases.

[Clinical and diagnostic peculiarities of multilevel degeneration of lumbar disks]

The authors present the results obtained in the study of medical records, complaints and neurological symptoms of 148 patients with lumbar disk degeneration at 3 and more levels. The following peculiarities have been singled out: illness duration 5 years and longer was found in 65.6% of patients and in 74.3% the duration of last exacerbation was from 3 months to 1 year. Only 17.6% of patients reported acute pain, 82.4% had mild stable pain that became worse during gait and in the horizontal state and in 83.8% the pain irradiated to one leg. Inconsistency was found between complaints on leg weakness (25.6%) and the reduction of pain sensitivity (22.3%) and symptoms found during the clinical examination: movement disturbances were observed in 45.3% of patients and sensitivity disturbances--in 96.7%. Biradicular symptoms were found in 37.8%; polyradicular--in 62.2% of patients.

[The efficacy of paravertebral blockades in the complex treatment of patients with the combination of neurological symptoms of cervical-thoracic osteochondrosis and ischemic disease]

Sixty-seven patients with clinical symptoms of cervical-thoracic osteochondrosis and ischemic disease have been studied. In the main group included 43 patients, paravertebral blockades (PVB) were applied and in the control group (24 patients) - antianginal and metabolic therapy was used. Treatment efficacy was assessed by the dynamics of pain syndrome parameters as measured with the visual analogue scale and by changes of heart rhythm variability, ischemic disturbances and arrhythmia measured by Holter monitoring. The higher therapeutic efficacy of PVB in the complex treatment of these patients comparing to traditional treatment of ischemic disease was found.

(Modic-)Signalveränderungen vertebraler Endplatten und ihr Bezug zu einer minimalinvasiven Injektionstherapie lumbaler Bandscheibenvorfälle

PURPOSE

To study the influence of (Modic) signal alterations (SA) of the cartilage endplate (CEP) of vertebrae L3-S1 on the outcome of an in-patient minimally invasive treatment (MIT) using epidural injections on patients with lumbar disc herniation (LDH).

MATERIALS AND METHODS

The MR images of 59 consecutive patients with LDH within segments L3/L4 - L5/S1 undergoing in-patient minimally invasive treatment with epidural injections were evaluated in a clinical study. The (Modic) signal alterations of the CEP were recorded using T1- and T2-weighted sagittal images. On the basis of the T2-weighted sagittal images, the extension and distribution of the SA were measured by dividing each CEP into 9 areas. The outcome of the MIT was recorded using the Oswestry Disability Index (ODI) before and after therapy and in a 3-month follow-up. Within a subgroup of patients (n = 35), the distribution and extension of the signal alterations were correlated with the development of the ODI.

RESULTS

Segments with LDH showed significantly more (p < 0.001) SA of the CEP than segments without LDH. Although the extension of the SA was not dependent on sex, it did increase significantly with age (p = 0.017). The outcome after MIT did not depend on the sex and age of the patients nor on the type of LDH. The SA extension tended to have a negative correlation with the outcome after MIT after 3 months (p = 0.071). A significant negative correlation could be established between the SA extension in the central section of the upper endplate and the outcome after 3 months (p = 0.019).

CONCLUSION

1. Lumbar disc herniation is clearly associated with the prevalence of (Modic) signal alterations. 2. Extensive signal alterations tend to correlate with a negative outcome of an MIT using epidural injections. 3. Such SA in the central portion of the upper CEP correlate significantly with a negative treatment result. 4. The central portion of the upper CEP being extensively affected by (Modic) SA is a negative predictor for the success of a minimally invasive pain therapy.

Prevalence of bowlegs among child and adolescent soccer players

OBJECTIVE

Little is known about the interactions of sports-related demands and human body, in particular on musculoskeletal features, during growth. Focusing on the relationship between soccer and lower limb alignment, we examined the hypothesis that varus knee deviation is more prevalent among high-performance pediatric and adolescent soccer players.

DESIGN

Cross-sectional study with focused sampling.

SETTING

First league sports clubs.

PARTICIPANTS

106 male child/adolescent soccer players aged 10 to 21 years and 68 age-matched tennis players.

INTERVENTIONS

All athletes completed a demographic questionnaire and underwent physical examinations, which included height, weight, generalized laxity, knee, ankle, foot and spine axis, hip range of motion, tibial torsion, Q angle, foot navicular height, and progression angle.

MAIN OUTCOME MEASUREMENT

Varus/valgus axis was determined by the intercondylar intermalleolar distance while standing. Soccer and tennis players were compared on knee axis and other outcome variables by analysis of covariance, adjusting for age and by t-tests within age groups.

RESULTS

A significantly higher prevalence of knee varus was found among the soccer players compared to that among the tennis players. The difference in intracondylar distance was statistically significant after the age of 13 years (P < 0.001). In addition, compared to tennis players, soccer players had higher foot arches, decreased hip external rotation and increased external tibial torsion.

CONCLUSIONS

Varus knee axis deviation was more common among children and adolescent soccer players than among tennis players. The prevalence was more pronounced among players aged 13 years or older. Further research is needed to explore the rationale of this phenomenon.

Sports-related injuries of the elbow: an approach to MRI interpretation

MRI is a valuable tool for evaluating the athlete with elbow pain, particularly in those with nonlocalizable pain. MRI also is helpful in sorting out the cause of pain in athletes who may have acute trauma superimposed on tendinopathy or other chronic injuries from repetitive microtrauma. Even in athletes in whom the cause of pain confidently can be diagnosed clinically, MRI can document the injury severity, which can be helpful for estimating recovery time or in preoperative planning. By contributing to an accurate early diagnosis, MRI also can help minimize the time that athletes are away from their sports. The authors describe their approach to the MRI interpretation of elbow injuries in athletes, including osteochondral lesions, epicondylitis, and tears of the medial collateral ligament.

COMPARISON OF THE ULTRASONOGRAPHIC APPEARANCE OF OSTEOCHONDROSIS LESIONS IN THE CANINE SHOULDER WITH RADIOGRAPHY, ARTHROGRAPHY, AND ARTHROSCOPY

Osteochondrosis lesions in 29 shoulder joints (from 20 dogs) were evaluated with ultrasound (US) and the results were compared with survey radiography, arthrography, and arthroscopy. US was performed with a 7-12 MHz linear matrix transducer which was placed in cranio-caudal direction just distally to the acromion while the joint was adducted and maximally endorotated to visualize the caudal aspect of the humeral head. With US, the subchondral defect was completely visible in 21 joints and partially visible in 8 joints. The length of the subchondral defect measured on US was comparable with the length measured on survey radiographs. In two joints, the cartilage flap was mineralized and thus already visible on survey radiographs. The mineralized flap was visible on US as a straight hyperechoic line above the subchondral defect. In the other joints, survey radiographs could not assess the status of the articular cartilage. In 17 joints, the presence of a cartilage flap or cartilage fissuring was suspected based on the presence of a second hyperechoic line at the base of the subchondral defect, and this suspicion was confirmed by arthroscopic examination in 16 joints and also by arthrographic examination in 15 joints. One joint that was suspected of having a cartilage flap on US was normal on arthroscopy and arthrography. When US revealed only focal thickening of the anechoic cartilage layer (5 joints), the joints appeared normal on arthroscopic and arthrographic examination. Of the four joints where the subchondral defect was irregular and covered by heteroechogeneous material on US, arthroseopy revealed the presence of a lesion resembling chondromalacia in two joints, the presence of a small cartilage flap in one joint and the presence of scar tissue underneath the flap at the level of the subchondral defect in one joint. In conclusion, US is a helpful imaging modality in the identification of osteochondritic lesions in the canine shoulder joint. US also appears to be a satisfactory imaging tool for identifying lesions such as joint mice, joint effusion, and distinct new bone formation.

Osteochondrosis dissecans of the shoulder glenoid fossa diagnosed in four throwing athletes

The aim of this study was to report 4 observations of osteochondrosis dissecans (OCD) of the shoulder glenoid fossa diagnosed in throwing athletes. A retrospective review of medical and radiological records of throwing athletes, performed for the period 1992 to 2002, revealed 215 studies of the shoulder. The patients were elite throwing athletes suffering for recurrent shoulder pain. Four cases (1.86%) of OCD of the glenoid fossa were identified; conventional radiographs of the shoulder were taken for all patients followed by MR examination. All cases received a definitive surgical diagnosis.

Microcomputed tomography and histology of a fragmented medial coronoid process in a 20-week-old golden retriever

A 20-week-old male golden retriever, which was not lame and showed no clinical signs of a fragmented medial coronoid process (FCP), was euthanased for another study and perfused intravenously with formaldehyde. Gross dissection revealed no abnormalities within the right elbow joint. The medial coronoid process was excised, embedded in methylmethacrylate, scanned in a microcomputed tomography (microCT) scanner and sectioned for histology. The microCT scans revealed a dense trabecular bone structure, much denser than in other dogs of similar age, which was considered to be responsible for the sclerosis visible at the base of the coronoid process in radiographs. Three-dimensional reconstructions indicated that there was a small step within the subchondral bone, extending from the apex towards the radial notch. Histology revealed a necrotic lesion between locally thickened articular cartilage and the subchondral bone, characteristic of osteochondrosis.

Musculoskeletal infections in children

Serious musculoskeletal infections in children include osteomyelitis, septic arthritis, pyomyositis, and necrotizing fasciitis. The epidemiology, pathophysiology, and microbiology of each of these infections are reviewed. Specific diagnostic studies and management strategies are discussed. Prompt recognition and treatment is emphasized to prevent potential long-term sequelae.

MRI scores of ankle joints in children with haemophilia--comparison with clinical data

Fifty-six ankle joints in 38 haemophilic boys were investigated by magnetic resonance imaging (MRI) and the findings were classified according to both the Denver- and the European scoring schemes. The different MRI scores were compared with each other and with clinical data on number of joint bleeds and the orthopaedic joint score. MRI changes that were more advanced than a small effusion were found in 33 (59%) of the ankles and osteochondral changes were observed in 20 (36%). The total number of bleeds in individual ankles ranged from 0 to 80 (mean: 11). The orthopaedic joint score was 0 for 49 ankles and ranged from one to four for seven ankles. There was a significant and strong correlation between the assessment results obtained with the two MRI scoring methods (correlation coefficients ranged from 0.80 to 0.95, P < 0.001), and both types of MRI scores were weakly but significantly correlated with the clinical data on the number of joint bleeds and the orthopaedic joint score (correlation coefficients: 0.32-0.39, P < 0.01 or P < 0.05). MRI is useful for evaluating early joint changes in patients with haemophilia. The European scoring method differentiates the arthropathic changes further than the Denver scale does, but the two different scoring methods have similar correlation to the number of joint bleeds and the orthopaedic joint score.

[Mid-term results of autologous chondrocyte transplantation in knee and ankle. A one- to six-year follow-up study]

BACKGROUND

The reimplantation of autologous chondrocytes is a new technique in reconstruction of cartilage defects; initial results achieved with this technique have been promising. In an arthroscopic procedure, scales of cartilage are obtained from intact cartilage. The chondrocytes are then multiplied in special laboratories. A few weeks later, in a second procedure, the cartilage defect is filled with the cell suspension and closed with a flap of periosteum.

METHOD

At our department, autologous chondrocyte transplantation (ACT) has been used in 10 patients since 1996, in 6 cases in the knee joint, and in 4 cases in the ankle joint. The mean age of the patients was 30 years. The mean size of the defect was 4 cm(2). In 4 patients, a parallel surgical procedure was required at the time of removal.

RESULTS

The mean duration of follow-up was 21/2 years. Six patients had good to excellent results, 3 patients had moderate results, and one patient a poor result. The modified Cincinnati rating scale was improved from 2.4 to 7.1 points, and the Lysholm score from 59.2 to 86.6 points. The AOFAS score for ankle joints had improved from 33 to 76.

CONCLUSION

We were able to show that ACT achieves improvement in the knee as well as ankle joint in the majority of patients. ACT appears to be a promising therapeutic concept for both joints.

[Chronic thoracic vertebral syndrome by roundabout diagnosis]

Back pain, especially in the lumbar region is a frequent symptom in ambulatory medicine. The differential diagnosis is wide and ranges from rather harmless muscular distortions to systematic disease, such as chronic infections or cancer. Our case shows, that sometimes the diagnosis is not quite simple to determine. A atypically picture may lead to unnecessary further evaluations and in some case even invasive diagnostic tests. However, the benefit should overweight the harm and costs. Not every back pain needs to be examined in every case and with every diagnostic possibility. Recent guidelines recommend a conservative approach to patients with back pain if they are younger than 50 years of age and if cancer or chronic infection is not suspected from their clinical evaluation and past medical history. For patients older than 50 years of age and suspicion for systematic disease, a radiograph of the spine and a routine laboratory measurement, including markers of inflammation (e.g. C-reactive protein), alkaline phosphatase, PSA (prostate-specific antigen) and immune-electrophoresis is mandatory. More detailed diagnostic steps, e.g. CT or MRT, should be performed if symptoms persist for longer than 6 weeks. In addition, if symptoms do not resolve with analgesia and physiotherapy more invasive therapeutically options may be considered.

Compatible scales for progressive and additive MRI assessments of haemophilic arthropathy

The international MRI expert subgroup of the International Prophylaxis Study Group (IPSG) has developed a consensus for magnetic resonance imaging (MRI) scales for assessment of haemophilic arthropathy. A MRI scoring scheme including a 10 step progressive scale and a 20 step additive scale with identical definitions of mutual steps is presented. Using the progressive scale, effusion/haemarthrosis can correspond to progressive scores of 1, 2, or 3, and synovial hypertrophy and/or haemosiderin deposition to 4, 5, or 6. The progressive score can be 7 or 8 if there are subchondral cysts and/or surface erosions, and it is 9 or 10 if there is loss of cartilage. Using the additive scale, synovial hypertrophy contributes 1-3 points to the additive score and haemosiderin deposition contributes 1 point. For osteochondral changes, 16 statements are evaluated as to whether they are true or false, and each true statement contributes 1 point to the additive score. The use of these two compatible scales for progressive and additive MRI assessments can facilitate international comparison of data and enhance the accumulation of experience on MRI scoring of haemophilic arthropathy.

Sports-Related Osteochondral Injuries: Clinical Presentation, Diagnosis, and Treatment

These lesions present with a variety of symptoms and historical findings.A careful joint-specific examination and appropriate imaging studies can help direct the physician in the treatment of the patient who has a chondral,osteochondral, or osteochondritis dissecans lesion. Categorizing the patient based on the size of the lesion, physiologic age, and desired activity level can aid in determining which patients might succeed with nonoperative versus operative management.

Isolated medial cuneiform tuberculosis: a case report

Skeletal involvement in extrapulmonary tuberculosis is extremely rare, and foot involvement accounts for less than 10% of osteoarticular tuberculosis. Tuberculosis osteomyelitis of the foot can also mimic a wide range of pathology. As a result, this condition is often misdiagnosed, or the true nature of the lesion is identified late in the diagnostic process. This article reports a case of tuberculosis in the medial cuneiform of a 3-year-old girl. Initially misdiagnosed as osteochondrosis, the patient returned 2 years later with a draining sinus on the medial aspect of the left midfoot. New radiographs showed a cystic lesion in the substance of the medial cuneiform. A diagnosis of tuberculosis was established after biopsy and histopathological examination of operative specimen. Antituberculosis treatment was implemented and continued for 16 months. At that time, clinical signs of infection had ceased.

Prospective study on diagnostic strategies in osteochondral lesions of the talus. Is MRI superior to helical CT?

Our aim in this prospective study was to determine the best diagnostic method for discriminating between patients with and without osteochondral lesions of the talus, with special relevance to the value of MRI compared with the new technique of multidetector helical CT. We compared the diagnostic value of history, physical examination and standard radiography, a 4 cm heel-rise view, helical CT, MRI, and diagnostic arthroscopy for simultaneous detection or exclusion of osteochondral lesions of the talus. A consecutive series of 103 patients (104 ankles) with chronic ankle pain was included in this study. Of these, 29 with 35 osteochondral lesions were identified. Twenty-seven lesions were located in the talus. Our findings showed that helical CT, MRI and diagnostic arthroscopy were significantly better than history, physical examination and standard radiography for detecting or excluding an osteochondral lesion. Also, MRI and diagnostic arthroscopy performed better than a mortise view with a 4 cm heel-rise. We did not find a statistically significant difference between helical CT and MRI. Diagnostic arthroscopy did not perform better than helical CT and MRI for detecting or excluding an osteochondral lesion.

Calcaneal apophysitis (Sever disease)

Calcaneal apophysitis is a painful inflammation of the calcaneal apophysis believed to be caused by repetitive microtrauma from the pull of the Achilles tendon on the unossified apophysis. It frequently occurs before or during the peak growth spurt and often shortly after a child begins a new sport or season. Coaches and parents should be aware of the clinical symptoms of Sever disease so that early protective and proactive measures and appropriate treatment can be instituted.

Juvenile and adolescent elbow injuries in sports

Elbow injuries in skeletally immature athletes continue to increase as juvenile and adolescent athletes participate in organized athletics at earlier ages and with greater intensity. Specialization in specific sports at younger ages has led to an increase in injuries related to repetitive microtrauma. As a result, the spectrum of injuries commonly seen in skeletally immature athletes has increased at a time when long-term outcomes and less invasive interventions with biologic principles are gaining greater attention. Optimal treatment of these injuries requires a knowledge of the complex developmental and radiographic anatomy, the pathophysiology and natural history, and the indications and expected outcomes for conservative and operative management.