Musculo-Skeletal Clinic Institute, Orthopaedic Surgery Department, Hospital Clinic, University of Barcelona, Villarroel, 170, 08036 Barcelona, Spain. email@example.com
The aim of this study was (1) to determine the variability in detecting radiological signs of knee osteoarthritis (OA) between an orthopaedics specialist, a fourth-year resident in the speciality and a recently qualified doctor and (2) to determine which of the existing criteria show the greatest variability when used by the three participants to detect the degree of evolution of the pathology. This observational study included radiographs of 95 patients with knee pain. Osteophytes, narrowing of joint space (excluding inter-osteophyte bridges) subchondral sclerosis, subchondral cysts, collapse of the central joint cortical bone and lateral deformity, according to the criteria of Kellgren and Lawrence, modified by Kallman et al. were evaluated. Anteroposterior radiographs were used. Knees that had undergone previous surgery were excluded. Cohen's kappa index was used to calculate the degree of agreement between observers. The concordance analysis showed a low level of agreement among the three observers of the radiological variables with a maximum of 50% in some parameters. The authors discuss the possible causes of this low level of agreement. The low degree of agreement of 50% among the three observers is in line with previous reports and suggests that better training of observers is necessary and that the use of any classification is problematic.
Comparison of MRI-based assessment systems for osteoarthritic knees: the irregularity index system and WORMS.
Kei O Matsuki, Takahisa Sasho, Koichi Nakagawa, Nobuyasu Ochiai, Satoshi Yamaguchi, Masahiko Saito, Naoshi Ikegawa, Ryuichiro Akagi, Atsuya Watanabe, Yuichi Wada, Keisuke Matsuki, Kazuhisa Takahashi
Department of Orthopaedic Surgery, Graduate School of Medicine, Chiba University, 1-8-1 Inohana, Chuo-ku, Chiba, 260-8670, Japan.
PURPOSE Several MRI-based evaluation systems for osteoarthritis (OA) of the knee have been developed. Among them the whole-organ magnetic resonance imaging score (WORMS), which evaluates the status of the entire knee joint, appears to be representative. We developed an irregularity index system to measure irregularities of the contours of the femoral condyle on MRI. Only the contour of the condyle was assessed by the irregularity index, whereas several items comprising the knee joint were taken into account by WORMS. This study compared the irregularity index and WORMS in terms of their correlations with clinical scores. METHODS Thirty-one medial-type OA knees were studied. Kellgren-Lawrence grading was used for X-ray grading: 8 were grade II, 11 were grade III, and 12 were grade IV. Japanese Orthopaedic Association scores and Japanese knee osteoarthritis measure scores were used for clinical assessments. We determined the correlations between MRI-based assessment scores and clinical scores. RESULTS Both the irregularity index and WORMS exhibited positive correlations with these clinical scores. The irregularity index was associated with bone cysts of the medial compartment and menisci in the articular features of WORMS. CONCLUSIONS These MRI-based methods are useful for evaluating OA severity. However, the irregularity index may have advantages over WORMS because of its semi-automatic features.
Different thresholds for detecting osteophytes and joint space narrowing exist between the site investigators and the centralized reader in a multicenter knee osteoarthritis study-data from the Osteoarthritis Initiative.
Ali Guermazi, David J Hunter, Ling Li, Olivier Benichou, Felix Eckstein, C Kent Kwoh, Michael Nevitt, Daichi Hayashi
Quantitative Imaging Center, Department of Radiology, Boston University School of Medicine, 820 Harrison Avenue, FGH Building 3rd Floor, Boston, MA, 02118, USA, firstname.lastname@example.org.
OBJECTIVE: To evaluate how the reading of knee radiographs by site investigators differs from that by an expert musculoskeletal radiologist who trained and validated them in a multicenter knee osteoarthritis (OA) study. MATERIALS AND METHODS: A subset of participants from the Osteoarthritis Initiative progression cohort was studied. Osteophytes and joint space narrowing (JSN) were evaluated using Kellgren-Lawrence (KL) and Osteoarthritis Research Society International (OARSI) grading. Radiographs were read by site investigators, who received training and validation of their competence by an expert musculoskeletal radiologist. Radiographs were re-read by this radiologist, who acted as a central reader. For KL and OARSI grading of osteophytes, discrepancies between two readings were adjudicated by another expert reader. RESULTS: Radiographs from 96 subjects (49 women) and 192 knees (138 KL grade ≥ 2) were included. The site reading showed moderate agreement for KL grading overall (kappa = 0.52) and for KL ≥ 2 (i.e., radiographic diagnosis of "definite OA"; kappa = 0.41). For OARSI grading, the site reading showed substantial agreement for lateral and medial JSN (kappa = 0.65 and 0.71), but only fair agreement for osteophytes (kappa = 0.37). For KL grading, the adjudicator's reading showed substantial agreement with the centralized reading (kappa = 0.62), but only slight agreement with the site reading (kappa = 0.10). CONCLUSION: Site investigators over-graded osteophytes compared to the central reader and the adjudicator. Different thresholds for scoring of JSN exist even between experts. Our results suggest that research studies using radiographic grading of OA should use a centralized reader for all grading.
The effect of a manual therapy knee protocol on osteoarthritic knee pain: a randomised controlled trial.
Macquarie Injury Management Group, Department of Health and Chiropractic, Macquarie University, NSW 2109, Australia. email@example.com
BACKGROUND Knee osteoarthritis is a highly prevalent condition with a significant socioeconomic burden to society. It is known to effect sufferers through pain, loss of function and changes in health related quality of life. Management typically involves pharmacologic and/or exercise based therapy approaches to reduce pain. Previous studies have shown multimodal treatment approaches incorporating manual therapy to be efficacious. The aim of this study is to determine if a manual therapy technique knee protocol can alter the self reported pain experienced by a group of chronic knee osteoarthritis sufferers in a randomised controlled trial. METHODS 43 participants with a chronic, non-progressive history of osteoarthritic knee pain, aged between 47 and 70 years were randomly allocated following a screening procedure to an intervention group (n=26; 18 men and 8 women, mean age 56.5 years) or a control group (n=17; 11 men and 6 women, mean age 54.6 years). Participants were matched for present knee pain intensity measured on a visual analogue scale. The intervention consisted of the Macquarie Injury Management Group Knee Protocol whilst the control involved a non-forceful manual contact to the knee followed by interferential therapy set at zero. Participants received three treatments per week for two consecutive weeks with a follow up immediately after the final treatment. Post-treatment Participants completed 11 questions including present knee pain intensity and feedback regarding their response to treatment utilizing a visual analogue scale. Results were analysed using descriptive statistics. RESULTS Prior to the intervention, there was no significant differences in age or present knee pain intensity. Following treatment, the intervention group reported a significant decrease in the present pain severity (mean 1.9) when compared to the control group (mean 3.1). Response to treatment questions indicated that compared to the control group, the intervention group felt the intervention had helped them (intervention mean 7.0; control mean 3.4), felt it decreased their knee symptoms such as crepitus (intervention mean 6.0; control mean 3.4) and improved their knee mobility (intervention mean 6.4; control mean 3.4) and their ability to perform general activities (intervention mean 6.5; control mean 3.8). Importantly the MIMG Knee Protocol intervention group reported no adverse reactions during treatment. CONCLUSIONS A short-term manual therapy knee protocol significantly reduced pain suffered by participants with osteoarthritic knee pain and resulted in improvements in self-reported knee function immediately after the end of the 2 week treatment period.
Good reliability, questionable validity of 25 different classification criteria of knee osteoarthritis: a systematic appraisal.
Department of General Practice, Erasmus Medical Center, P.O. Box 2040, 3000 CA Rotterdam, The Netherlands. firstname.lastname@example.org
OBJECTIVES Despite extensive epidemiological and clinical research, there is no consensus on classification criteria to define knee osteoarthritis (OA). No gold standard is available and many different definitions are used. For future research and interpretation of epidemiological studies, we aimed to evaluate reliability and validity of commonly used classification criteria. STUDY DESIGN AND SETTING Systematic searches were performed in Medline/Pubmed and Embase for articles evaluating reliability, construct validity, and content validity of knee OA classification criteria. RESULTS In 18 articles, 25 classification criteria were found that could be summarized in three categories (radiological clinical and radiological combined classification criteria, and clinical classification criteria). No classification criteria based on magnetic resonance imaging could be included. In general, intra- and interrater reliabilities were good. Construct validity was low when radiological criteria were compared with clinical classification criteria. Associations between classification criteria and symptoms and risk factors like pain and obesity were moderate. CONCLUSION More research is needed to investigate the impact of different classification criteria in epidemiological research and to reach consensus about which criteria should be used to define knee OA. Meanwhile, to create uniformity in epidemiological research we recommend separate lesion scoring, overall scoring, and pain registration to define knee OA.
Osteophytosis, subchondral bone sclerosis, joint effusion and soft tissue thickening in canine experimental stifle osteoarthritis: comparison between 1.5 T magnetic resonance imaging and computed radiography.
Marc-André D'Anjou, Maxim Moreau, Eric Troncy, Johanne Martel-Pelletier, François Abram, Jean-Pierre Raynauld, Jean-Pierre Pelletier
Companion Animal Research Group, Département de Sciences Cliniques, Faculté de Médecine Vétérinaire, Université de Montréal, Saint-Hyacinthe, Québec, Canada. email@example.com
OBJECTIVE: To compare use of 1.5 T magnetic resonance imaging (MRI) and computed radiography (CR) for morphologic and temporal evaluation of osteophytosis, subchondral sclerosis, joint effusion, and synovial thickening in experimentally induced canine stifle osteoarthritis (OA). STUDY DESIGN: Prospective study. ANIMALS: Dogs (n=8). METHODS: CR (mediolateral and caudocranial projections) and MRI (dorsal 3D T1-weighted gradient echo, sagittal 3D SPGR and T2-weighted fast spin echo with fat saturation) were performed at baseline (n=8) and at week 4 (n=5), week 8 (n=8), and week 26 (n=5) after cranial cruciate ligament transection. Osteophytosis, subchondral bone sclerosis, and joint effusion were scored on CR and MRI, and synovial thickening on MRI. RESULTS: MRI was more sensitive than CR for detection of osteophytosis and could better discriminate joint effusion from soft tissue thickening, although scores for these variables strongly correlated between modalities (rho=0.94 [osteophytosis] and 0.80 [effusion]; P<.001). Scores for subchondral bone sclerosis also correlated (rho=0.54, P<.004), although this variable may have been over interpreted on CR. Joint effusion and synovial thickening peaked at week 8, before partially regressing at week 26. Conversely, osteophytosis and sclerosis progressed semi-linearly over 26 weeks. CONCLUSION: MRI is more sensitive than radiography in assessing onset and progression of osteophytosis in canine experimental stifle OA and provides enhanced discrimination between joint effusion and synovial thickening. CLINICAL RELEVANCE: MRI is as a more powerful imaging modality that should be increasingly used in animals to assess the joint related effects of disease-modifying OA drugs.
Tina L Racunica, Andrew J Teichtahl, Yuanyuan Wang, Anita E Wluka, Dallas R English, Graham G Giles, Richard O'Sullivan, Flavia M Cicuttini
Monash University, Alfred Hospital, Melbourne, Victoria, Australia.
OBJECTIVE It is unclear whether physical activity that is beneficial for the cardiovascular system is detrimental to knee structures. We examined the association between intensity, frequency, and duration of physical activity and knee structures in a community-based population. METHODS A total of 297 healthy adults ages 50-79 years with no history of knee injury or disease were recruited from an existing study on healthy aging. Each subject underwent knee magnetic resonance imaging (MRI) to measure tibial cartilage volume, tibiofemoral cartilage defects, and bone marrow lesions. Physical activity and anthropometric data were obtained via questionnaire during 1990-1994 and 2003-2004. RESULTS Tibial cartilage volume increased with frequency (P = 0.01) and duration (P = 0.001) of vigorous activity (activity leading to diaphoresis or dyspnea) reported 10 years previously, as well as recent vigorous activity in the 7 days prior to MRI (P = 0.05). Recent weight-bearing vigorous activity increased with tibial cartilage volume (P = 0.02) and was inversely associated with cartilage defects (P = 0.02). A reduced risk of bone marrow lesions was associated with regular walking (P = 0.04). CONCLUSION Vigorous physical activity appears to have a beneficial effect on knee articular cartilage in healthy, community-based adults with no history of knee injury or disease. Regular walking reduces the risk of bone marrow lesions in the knee. This study provides further support for a beneficial effect of physical activity for diseases associated with aging and suggests that exercise that is good for the heart is also good for the knees.
Separation of healthy and early osteoarthritis by automatic quantification of cartilage homogeneity.
Image Group, University of Copenhagen, Denmark.
OBJECTIVE Cartilage loss as determined either by magnetic resonance imaging (MRI) or by joint space narrowing in X-rays is the result of cartilage erosion. However, metabolic processes within the cartilage that later result in cartilage loss may be a more accurate assessment method for early changes. Early biological processes of cartilage destruction are among other things, a combination of proteoglycan turnover, as a result of altered charge distributions, and local alterations in water content (edema). As water distribution is detectable by MRI, the aim of this study was to investigate cartilage homogeneity visualized by MRI related to water distribution, as a potential very early marker for early detection of knee osteoarthritis (OA). DESIGN One hundred and fourteen right and left knees from 71 subjects aged 22-79 years were scanned using a Turbo 3D T(1) sequence on a 0.18T MRI Esaote scanner. The medial compartment of the tibial cartilage sheet was segmented using a fully automatic voxel classification scheme based on supervised learning. From the segmented cartilage sheet, homogeneity was quantified by measuring entropy from the distribution of signal intensities inside the compartment. For each knee an X-ray was acquired and the knees were categorized by the Kellgren and Lawrence (KL) index and the joint space width (JSW) was measured. The P-values for separating the groups by each of JSW, cartilage volume, cartilage mean intensity, and cartilage homogeneity were calculated using the unpaired t-test. RESULTS The P-value for separating the group diagnosed as KL 0 from the group being KL 1 based on JSW, volume and mean signal intensity the values were P=0.9, P=0.4 and P=0.0009, respectively. In contrast, the P-value for homogeneity was P=0.0004. The precision of the measures assessed, as a test-retest root mean square coefficient of variation (RMS-CV%) was 3.9% for JSW, 7.4% for volume, 3.9% for mean signal intensity and 3.0% for homogeneity quantification. CONCLUSION These data demonstrate that the distribution of components of the articular matrix precedes erosion, as measured by cartilage homogeneity related to water concentration. We show that homogeneity was able to separate early OA from healthy individuals in contrast to traditional volume and JSW quantifications. These data suggest that cartilage homogeneity quantification may be able to quantify early biochemical changes in articular cartilage prior to cartilage loss and thereby provide better identification of patients for OA trials who may respond better to medicinal intervention of some treatments. In addition, this study supports the feasibility of using low-field MRI in clinical studies.
Automatic morphometric cartilage quantification in the medial tibial plateau from MRI for osteoarthritis grading.
Image Group, IT University of Copenhagen, Denmark.firstname.lastname@example.org
OBJECTIVE To evaluate whether a novel, fully automatic, morphometric cartilage quantification framework is suitable for assessing level of knee osteoarthritis (OA) in clinical trials. METHOD The population was designed with a normal population and groups with varying degree of OA of both sexes and at ages from 21 to 78. Posterior-anterior X-rays were acquired in semi-flexed, load-bearing position. The radiographic signs of OA were evaluated based on the Kellgren and Lawrence score (KL) and the joint space width (JSW) was measured. Turbo 3D T1 magnetic resonance imaging (MRI) scans were acquired with resolution 0.7x0.7x0.8mm(3) from a 0.18T scanner. The morphometric cartilage quantification from MRI resulted in volume, surface area, thickness and surface curvature for the medial tibial cartilage compartment. These quantifications were evaluated against JSW with respect to precision and ability to separate healthy subjects from OA subjects. RESULTS The automatic, morphometric cartilage quantifications allowed fairly precise measurements with scan-rescan coefficient of variations (CVs) in the range from 3.4% to 6.3%. All quantifications, including JSW, allowed separation of the groups of healthy and OA subjects. However, for separation of the healthy from the borderline cases (KL 0 vs KL 1), only the Cartilage Curvature quantification allowed statistically significant separation (P<0.01). CONCLUSION The novel morphometric framework shows promise for use in clinical trials. The ability of the Cartilage Curvature quantification to detect the early stages of OA and the effectiveness of the focal thickness Q10 measure are particularly noteworthy. Furthermore, these results may indirectly support that low-field MRI may be a low-cost option for clinical trials.
Irregularity of medial femoral condyle on MR imaging serves as a possible indicator of objective severity of medial-type osteoarthritic knee-a pilot study.
Department of Orthopaedic Surgery, Chiba University, Graduate School of Medicine, Chiba, Japan.
Irregularly described contour of the femur and the tibia on magnetic resonance (MR) imaging is commonly seen in osteoarthritic (OA) knees. The aim of this study is to examine the relationship between irregularity of contour of medial femoral condyle (tentatively named I-index) and severity of OA. Twenty-six medial-type OA knees with a mean age of 63.8 were studied. All patients had undergone MR imaging to measure the I-index using image analysis software, and its relationship to Lysholm score was examined. The I-index negatively correlated with Lysholm score (r =-0.55, p < 0.01). The I-index for each Kellgren and Lawrence grade was significantly different. We have concluded that the I-index is a potent indicator to objectively describe the severity of OA especially for the advanced stage OA.
Comparison of proprioceptive functions between computerized proprioception facilitation exercise and closed kinetic chain exercise in patients with knee osteoarthritis.
Department of Orthopaedics, En Chu Kong Hospital, Taipei, Taiwan, Republic of China.
AIM The aim of this study was to compare proprioceptive function between computerized proprioception facilitation exercise (CPFE) and closed kinetic chain exercise (CKCE) for knee osteoarthritis. DESIGN Randomized-controlled. SETTING Kinesiology laboratory. PATIENTS Eighty-one patients with bilateral knee osteoarthritis were randomly assigned to CPFE, CKCE, and control groups. INTERVENTION Both exercise groups underwent an 8-week program of three sessions per week. The control group received no training. The CPFE program included a 20-min computer game to be played by the trained foot of the subject. CKCE included 10 sets of 10 repetitions of repeated knee extension and flexion with resistance of 10-25% of body weight. MAIN OUTCOME MEASURES Absolute reposition error, functional score, walking speed, and knee muscle strength were assessed with an electrogoniometer, the physical function subscale of Western Ontario and McMaster Osteoarthritis Index, a CASIO stopwatch, and a Cybex 6000 dynamometer before and after the 8-week period. RESULTS The results of this study showed that both CPFE and CKCE were effective in improving joint position sense, functional score, walking speed, and muscle strength. Furthermore, CKCE showed greater effect in increasing knee extensor torque in patients with knee osteoarthritis. CONCLUSION Clinical effects of CPFE were the same as those of CKCE except for knee extensor torque. The increase in knee extensor torque in CPFE patients was not as great as that seen in CKCE patients.
Other papers by authors:
Health-related quality of life and costs in patients with osteoarthritis on waiting list for total knee replacement.
Department of Rheumatology, Biomedical Research Institute August Pi i Sunyer (IDIBAPS), Hospital Clínic, Villarroel 170, 08036 Barcelona, Spain.
OBJECTIVES: To determine:(1) health-related quality of life (HRQL) in patients with severe osteoarthritis (OA) on a waiting list (WL) for total knee replacement (TKR) and to compare it with general Spanish reference population values (RPVs);(2) the influence of sociodemographic and clinical variables on HRQL dimensions and (3) the use and cost of resources related to knee OA. METHODS: Cross-sectional study. HRQL was measured by Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) and Medical Outcomes Study 36 Item Short Form Health Survey (SF-36) questionnaires. Sociodemographic and disease characteristics, body mass index, pharmacological treatment and the cost and use of economic resources related to knee OA during the 6-months previous to baseline were recorded. Relationships were analyzed using linear regression models. RESULTS: One hundred consecutive outpatients (71 female, mean age 71+/-6.89 years, mean disease duration 11.84+/-10.52 years) were included. Patients showed worse HRQL measured by SF-36 than the reference population, mainly in physical function, physical role and bodily pain dimensions (P<0.05). A low number of visits to physicians were recorded (mean 0.62+/-1.04). Total mean direct medical costs were 200.24 euro (95%CI 167.08-233.40) and total mean direct non-medical costs were 1234.87 euro (95%CI 812.74-1657.00). CONCLUSIONS: The HRQL of patients on a WL is worse than that of the reference population. The main costs of these patients were on non-medical resources, mainly due to functional limitations and loss of autonomy. The results suggest little compliance with knee OA management guidelines.
Health-related quality of life in patients with osteoarthritis after total knee replacement: factors influencing outcomes at 36 months of follow-up.
M Núñez, E Núñez, J Luis Del Val, R Ortega, J M Segur, M Victoria Hernández, L Lozano, S Sastre, F Maculé
Rheumatology Department, Biomedical Research Institute August Pi i Sunyer (IDIBAPS), Hospital Clínic, Villarroel 170, 08036 Barcelona, Spain.
OBJECTIVES:(1) To evaluate health-related quality of life (HRQL) in patients with severe osteoarthritis (OA) undergoing total knee replacement (TKR) and (2) to identify the influence of sociodemographic, clinical, intra-operative and postoperative variables on HRQL at 36 months after TKR. DESIGN: Prospective study with a 36-month follow-up. Preoperative interviews were carried out with 90 in-patients. The disease-specific Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) questionnaire was used to measure the health status. Sociodemographic, clinical, intra-operative degree of difficulty, in-patient and postoperative data were collected. Associations were analyzed using linear regression models. RESULTS: Of the 90 potentially eligible patients, 67 (54 females, mean age 74.83, standard deviation [SD] 5.57) completed follow-up assessment. There were significant differences between preoperative and postoperative WOMAC pain, stiffness and function scores (P<0.001, P=0.005 and P<0.001, respectively). Variables retained in each of the models explained between 15% and 23%(R(2) adjusted) of the variability of each WOMAC dimension. Higher preoperative WOMAC scores were associated with greater postoperative improvement (P<0.001). Chronic musculoskeletal pain unrelated to knee OA was associated with higher WOMAC pain, stiffness and function dimension scores (P=0.004, P=0.029 and P=0.005, respectively). Severe (Class III) obesity (body mass index [BMI] 35-39.9) was associated with more pain (P=0.049). CONCLUSIONS: In patients with severe OA, HRQL significantly improved at 36 months after TKR, especially in the pain dimension. Lower preoperative WOMAC scores, chronic pain unrelated to knee OA, and severe obesity negatively influenced postoperative WOMAC scores. This disease-specific questionnaire may help to identify patients at increased risk of negative outcomes after surgery.
Dept of Orthopaedic Surgery, Hospital Clinic, University of Barcelona, Spain.
One of the possibilities in the reconstruction of severe bone loss in revision total knee arthroplasty is impaction bone grafting with support of a mesh. We report the use of a fascia lata allograft as a biological mesh for keeping involved impacted bone graft in one case of uncontained tibial bone defects.
Department of Orthopaedic Surgery, Musculo-Skeletal Clinic Institute, Hospital Clínic, Barcelona, Spain.
In order to determine the behaviour of bone allografts in the advancement of the tibial tuberosity, we studied retrospectively 134 knees belonging to 119 recipients of frozen bone allograft for the treatment of a symptomatic patellofemoral osteoarthrosis. All patients had a 1.2-1.5 cm tibial tuberosity advancement with a release of the lateral patellar retinacula and no other additional surgery. Total incorporation of grafts took place in 116 cases (86.6%); graft resorption appeared in 16 patients (11.9%)(total resorption 3, and partial resorption 13). No disease transmission has been detected. To avoid donor site morbidity associated with harvesting iliac crest, the use of frozen bone allograft is a good alternative in the advancement of the tibial tuberosity.
Secondary patellar resurfacing in the treatment of patellofemoral pain after total knee arthroplasty.
Department of Orthopaedic and Trauma Surgery, Unit of Knee, Hospital Clínic of Barcelona, University of Barcelona, C/Villarroel 170, 08036, Barcelona, Spain, email@example.com.
PURPOSE: This paper reports a prospective review of patients who, between 2004 and 2007, underwent secondary patellar resurfacing (SPR) due to anterior knee pain after a primary total knee arthroplasty (TKA). The aim was to evaluate the clinical outcomes obtained with the SPR and to compare them with radiological findings. METHODS: A total of twenty-seven consecutive patients met the inclusion criteria. There were twenty-three (85%) women and four (15%) men with a median age of 70 years. The patients were evaluated before and after the surgery with the same functional scores and radiological parameters. Bone scintigraphy was also used in the assessment, and a CT-scan was performed in order to evaluate the femoral component rotation. The median time between TKA and SPR was 18 months. RESULTS: With a median follow-up of 23 months, seventeen patients (63%) reported a clear subjective improvement after SPR, and patellofemoral scores (primary outcome measure), KSS and WOMAC (secondary outcome measures) showed a statistically significant improvement following the procedure. There were no significant changes after SPR in the Insall-Salvati ratio, the lateral patellar displacement or the lateral patellar tilt. The mean time between TKA and SPR had no statistically significant effect on outcome. The bone scintigraphy revealed increased patellar uptake in seven cases, but this was not related to subsequent improvement after SPR. Rotational computed tomography showed a median internal rotation of the femoral component of 1º. The complications observed were a patellar component loosening and an acute post-infection. CONCLUSION: No clinical or radiological parameter was found to be related to the final outcome after SPR. There was a discrepancy between functional scale scores and the patient's subjective satisfaction. LEVEL OF EVIDENCE: Prospective case series with no comparison group, Level IV.
Intramedullary versus Extramedullary Tibial Cutting Guide in Severely Obese Patients Undergoing Total Knee Replacement: A Randomized Study of 70 Patients with Body Mass Index >35 kg/m(2).
Knee Section, Orthopaedic Surgery Department, ICEMEQ, Hospital Clínic, University of Barcelona, Villarroel 170, 08009, Barcelona, Spain, firstname.lastname@example.org.
BACKGROUND: Patients with obesity have an increased risk of osteoarthritis of the knee, which can lead to the need for total knee replacement (TKR). TKR may be more complex in obese patients and the correct orientation of the implant is more difficult. We selected patients with body mass index (BMI)>35 kg/m(2) undergoing TKR and studied the utility of an intramedullary tibial cutting guide in facilitating the correct orientation of the tibial implant. METHODS: Seventy patients with BMI >35 kg/m(2) were selected for a prospective, randomized study. Patients were divided into two groups: In group 1 (n = 31), the tibial component was implanted using the aid of a intramedullary tibial guide. In group 2 (n = 39), the tibial component was implanted using the aid of an extramedullary tibial cutting guide. RESULTS: The two groups were comparable with respect to age, BMI, and degree of preoperative deformity. Mean age was 69.35 in group 1 and 70.06 in group 2. Group 1 had a mean BMI of 39.84 kg/m(2) and group 2 of 40.05 kg/m(2). Postoperative orientation of the femur and tibia and the mechanical axis were within the normal range in both groups. A statistically significant difference between the two groups was observed in tourniquet time, which was longer in group 2 than in group 1 (p = 0.038). CONCLUSION: Two types of guide were compared in correctly orienting the tibial component of the TKR in patients with a BMI >35 kg/m(2). The lesser tourniquet time in the group in which the intramedullary guide was used suggest its usefulness because the positioning and orientation of the tibial cut was carried out more rapidly and anatomical references were not needed for correct orientation, as it is guided by the anatomical axis of the tibia. The use of the intramedullary guide reduces surgical time in these patients.
Relationship Between Knee Anthropometry and Surgical Time in Total Knee Arthroplasty in Severely and Morbidly Obese Patients: A New Prognostic Index of Surgical Difficulty.
Knee Section, Orthopaedic Surgery Department, ICEMEQ, Hospital Clínic, University of Barcelona, Villarroel 170, 08009, Barcelona, Spain, email@example.com.
BACKGROUND: Total knee arthroplasty (TKA) in patients with severe and morbid obesity is one of the current challenges in prosthetic knee surgery. The body mass index (BMI) is used to identify patients who may present difficulties during surgery and postoperative complications. We carried out a prospective study with an initial hypothesis that BMI is not associated with tourniquet time in obese patients undergoing TKA and that some anthropometric parameters may be useful in predicting tourniquet time in severely and morbidly obese patients. METHODS: One hundred consecutive patients diagnosed with knee osteoarthritis with BMI >/=35 kg/m(2) scheduled for TKA were prospectively studied. Suprapatellar, infrapatellar, and supra/infrapatellar anthropometric indexes were calculated before surgery. The tourniquet time was determined. RESULTS: The mean BMI was 39.81 kg/m(2)(SD +/- 3.75). A total of 58% of patients were classified as class III obesity (BMI 35-39.99) and 42% as class IV (BMI >/= 40) Mean tourniquet time was 41.67 min (SD +/- 9.26). There was no association between the BMI and tourniquet time. The suprapatellar index was negatively associated with tourniquet time (p < 0.038). DISCUSSION: The BMI is not the only parameter that should be considered in order to identify severely and morbidly obese patients who may have more surgical difficulties during TKA. Preoperative determination of the suprapatellar index helped us to classify these patients according to the morphology of the knee and predicted a longer tourniquet time and, therefore, greater surgical difficulty, in patients with a suprapatellar ratio below 1.6 in this study.
The effect of an educational program to improve health-related quality of life in patients with osteoarthritis on waiting list for total knee replacement: a randomized study.
Orthopaedic Surgery Department, Hospital Clinic, Rheumatology, Villarroel 170, Barcelona, Spain.
OBJECTIVE: To evaluate the effect of therapeutic education and functional readaptation (TEFR) on health-related quality of life (HRQL) in patients diagnosed with osteoarthritis on a waiting list for total knee replacement (TKR). METHODS: Randomized controlled trial of 9 months duration was conducted. One hundred consecutive outpatients (71 females, mean age 71 years (range 50-86), mean disease duration 11.84+/-10.52 months) were included. Patients were randomized in two groups. The intervention group received TEFR added to conventional (pharmacological) treatment (n=51). The control group received conventional (pharmacological) treatment only (n=49). The main outcome variable was self-reported HRQL measured by the Spanish version of Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC). Secondary outcomes were general HRQL measured by Short Form Health Survey general questionnaire (SF-36), number of visits to general physicians and their cost. Assessments were done at baseline and at 9 months. MAIN RESULTS: Eighty patients completed the study. Significant improvement in the WOMAC function was found at 9 months in the TERF group with respect to the control group (P=0.035). Consumption of analgesics increased significantly in the TERF group compared with controls (P=0.036). Significant improvements in pain (P=0.027) measured by WOMAC and in bodily pain (P=0.043) and physical function (P=0.031), measured by SF-36, were observed in the intervention group with respect to baseline. CONCLUSIONS: The function dimension measured by WOMAC of patients who received both pharmacological treatment and TERF improved with respect to the control group receiving only pharmacological treatment. This suggests that a program of TEFR during the period on the waiting list for TKR may reduce the negative impact of this situation.
Ann Transplant. 2001 ;6 (1):32-5 11803603
Department of Orthopaedic Surgery, Hip Unit, Bone Bank Unit, Musculo-Skeletal Clinic Institute, Hospital Clinic, University of Barcelona, Spain.
The implant of a proximal femoral structural allograft is one of the possibilities to restore circumferential defects of multiply revised total hip arthroplasties. A review of 7 patients who underwent proximal femoral reconstruction with an allograft-prosthesis composite to restore bone loss in revision hip replacements is presented. The average follow-up period was 50.2 months. Two patients developed an infection and in one case an instability of the prosthesis appeared. Incorporation in the remaining 5 cases was/achieved in an average period of 8.2 months. Neither fractures nor high rate of resorption appeared in our series. The majority of patients have improved in the functional assessment. Despite the rate of complications, structural femoral allografts can be used with success in this difficult challenge of reconstructing major segmental bone loss of the proximal femur in revision hip surgery.
Servicio de Cirugía Ortopédica y Traumatología, Hospital Clinic, Barcelona, Spain.
A case of isolated posterior dislocation of the head of the radius is presented. It is a rare entity and, to our knowledge, only 3 adult cases have been published. The mechanism responsible is a fall on the hand with the elbow semiflexed and pronated. A simple reduction is made after an early diagnosis. After a short period in a cast, complete recovery can be expected.
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Rheumatology (Oxford). 2012 Jul 27;: 22843774
Annamaria Iagnocco, Carlo Perricone, Chiara Scirocco, Fulvia Ceccarelli, Mariagrazia Modesti, Angelica Gattamelata, Caterina Vavala, Iolanda Maria Rutigliano, Anca Musetescu, Guido Valesini
Rheumatology Unit, Dipartimento di Medicina Interna e Specialità Mediche, Sapienza Università di Roma, Rome, Italy and Rheumatology Department, Emergency Clinical County Hospital Craiova, University of Medicine and Pharmacy Craiova, Craiova, Romania.
Objective. To assess the interobserver reliability between sonographers with different levels of experience in detecting inflammatory and structural damage abnormalities in patients with knee OA.Methods. After achieving consensus on definitions and scanning protocols, three ultrasonographers with different levels of experience in musculoskeletal US examined the knees of nine patients with OA. US examinations were conducted with independent blinded evaluations of inflammatory (joint effusion, synovial hypertrophy, power Doppler signal, Baker's cysts) and structural (osteophytes, cortical bone irregularities, femoral hyaline cartilage abnormalities, protrusion of the medial meniscus) lesions. All abnormalities were scored by applying a dichotomous scale (0-1). In addition, at each knee joint site global scores for joint inflammation, cortical bone abnormalities and cartilage damage were calculated by summing the single-lesion scores. Reliability was assessed using kappa (κ) coefficients.Results. Seventeen knees were examined. Inflammatory abnormalities were observed with moderate to very good agreement (κ = 0.55-0.88) between the observers. From fair to very good agreement (κ = 0.31-0.82) was registered between sonographers for structural damage lesions. The overall κ was 0.716 for junior and 0.571 for beginner sonographers comparing their findings with those of senior sonographers.Conclusion. This represents the first ultrasonographic study focusing on the analysis of interobserver reliability between sonographers with different levels of experience in demonstrating inflammatory and structural abnormalities in knee OA. Globally, even considering some variable results that were mainly obtained by the evaluation of single components of bone involvement, US offered a reliable assessment of a wide set of abnormalities in knee OA.
Acta Orthop. 2012 Apr ;83 (2):185-9 22329668
Radiographic evaluation of osteoarthritis of the hip: an inter-observer study of 61 hips treated for late-detected developmental hip dislocation.
Department of Orthopaedics, Oslo University Hospital, Norway. firstname.lastname@example.org
BACKGROUND AND PURPOSE Different methods have been used to classify osteoarthritis (OA) of the hip. We evaluated the reliability of different classifications in order to find which grading system is most appropriate for use in clinical practice. PATIENTS AND METHODS 49 patients (61 affected hips) with late-detected developmental dislocation of the hip (DDH) were studied. The mean age at follow-up was 45 (32-49) years. 3 classifications of OA were compared. The gradings by Kellgren and Lawrence (1957)(K&L) and Croft et al.(1990) are global visual assessments based on osteophytes, cysts, subchondral sclerosis, and narrowing of the joint space. The third classification is based on narrowing in the upper, weight-bearing part of the joint and defines as OA a minimum joint space width (JSW) of less than 2.0 mm at the narrowest part. 2 experienced observers, one radiologist and one orthopedic surgeon, assessed and measured the radiographs. RESULTS Minimum JSW (< 2.0 mm in 9 hips) gave the best inter-observer agreement (kappa value = 0.87). Using the K&L grading, inter-observer agreement was moderate (kappa = 0.55), but kappa increased when the number of categories was reduced from 5 to 3 (no OA, mild OA, and severe OA). The Croft classification gave similar agreement as the K&L grading. The intra-observer agreement was better than inter-observer agreement, irrespective of the grading system. There was a good accordance between the minimum JSW and the 2 other methods. INTERPRETATION Joint space narrowing using a minimum JSW of < 2.0 mm as criterion for OA was the simplest and most reproducible classification in long-term follow-up of patients with DDH. A classification based on global visual assessment can be used in addition if only hips with severe OA are included.
Impact of different descriptions of the Kellgren and Lawrence classification criteria on the diagnosis of knee osteoarthritis.
Department of General Practice, Erasmus MC, University Medical Center, Rotterdam, The Netherlands. email@example.com
OBJECTIVES Although the Kellgren and Lawrence (K&L) criteria for defining radiological osteoarthritis are widely used in epidemiological and clinical studies, the authors previously documented the existence of five different versions of these criteria. This study identifies the impact of the use of alternative versions of the K&L criteria and evaluates which description has the highest association with knee complaints. METHODS Two readers scored most radiographs of the knees of participants of the Rotterdam Study with the original K&L description (90%). In addition, each alternative description was used in a random part (20%) of the radiographs. The authors calculated reproducibility of all descriptions, and compared sensitivity and specificity of the alternative descriptions for three cut-off points with the original description as reference standard (K&L≥1, K&L≥2 and K&L≥3). The authors calculated κ statistics to compare agreement between the original and alternative descriptions, and evaluated the association with knee complaints. RESULTS The dataset comprises radiographs of knees of 3071 people. For cut-off K&L≥1 all four alternatives classified more people as having osteoarthritis than the original description; κ was low, and sensitivity and specificity were moderate to good. For cut-offs K&L≥2 and K&L≥3 there was little difference in the number of cases and κ, sensitivity and specificity were good to perfect. The original description and alternative 3 showed the strongest association with knee complaints. CONCLUSIONS The different descriptions of the K&L criteria have impact on the classification of osteoarthritis in the lowest grade (K&L≥1). All descriptions have strengths and weaknesses. It depends on the purpose which is the best description.
Diabet Med. 2011 Mar 12;: 21395675
E García Morales, J L Lázaro-Martínez, F J Aragón-Sánchez, A Cecilia-Matilla, J V Beneit-Montesinos, M A González Jurado
Diabetic Foot Unit, University Podiatric Clinic, College of Podiatry, Complutense University of Madrid, Madrid Diabetic Foot Unit, La Paloma Hospital, Las Palmas de Gran Canarias, Spain.
Aims Probing to bone was defined and validated by Grayson in 1995. Despite the proven validity of this test, one of the limitations of previous studies and one of the most important characteristics from any diagnosis test is its reproducibility. The objectives of our study were (i) to analyse the inter-observer reproducibility or diagnostic variability of the probing-to-bone test, depending on the training of the professional involved, and (ii) to assess whether the probing-to-bone test can be extrapolated to any professional specialty that deals with these patients. Methods This was a cross-sectional study, involving 75 patients with diabetic foot ulcer and clinical suspicion of osteomyelitis. A registration sheet was completed for all patients involved in the research study, gathering data relative to the results of the probing-to-bone test performed by three observers. Observer 1 was a healthcare professional without experience in the treatment of the diabetic foot; observer 2 was a medium-experienced professional whose experience ranges from 6 to 12 months in the treatment of the diabetic foot; observer 3 was a very experienced professional with several years of experience in the treatment of the diabetic foot. Data were gathered confidentially by a fourth researcher. Results The results showed a kappa index of 0.593 (95% CI 0.407-0.778) between observer 1 and observer 2, 0.397 (95% CI 0.188-0.604) between observer 1 and observer 3 and 0.53 (95% CI 0.335-0.725) between observer 2 and observer 3. Conclusions The probing-to-bone test demonstrated moderate to fair concordance with an experienced examiner, although the degree of concordance is not significant between groups.
Observer Variability and the Performance between Faculties and Residents: US Criteria for Benign and Malignant Thyroid Nodules.
Sung Hun Kim, Chang Suk Park, So Lyung Jung, Bong Joo Kang, Jee Young Kim, Jae Jung Choi, Ye Il Kim, Jin Kyung Oh, Jung Suk Oh, Hanna Kim, Seung Hee Jeong, Hyeon Woo Yim
Department of Radiology, College of Medicine, The Catholic University of Korea, Seoul 137-701, Korea.
OBJECTIVE: To evaluate the interobserver variability and performance in the interpretation of ultrasonographic (US) findings of thyroid nodules. MATERIALS AND METHODS: 72 malignant nodules and 61 benign nodules were enrolled as part of this study. Five faculty radiologists and four residents independently performed a retrospective analysis of the US images. The observers received one training session after the first interpretation and then performed a secondary interpretation. Agreement was analyzed by Cohen's kappa statistic. Degree of performance was analyzed using receiver operating characteristic (ROC) curves. RESULTS: Agreement between the faculties was fair-to-good for all criteria; however, between residents, agreement was poor-to-fair. The area under the ROC curves was 0.72, 0.62, and 0.60 for the faculties, senior residents, and junior residents, respectively. There was a significant difference in performance between the faculties and the residents (p < 0.05). There was a significant increase in the agreement for some criteria in the faculties and the senior residents after the training session, but no significant increase in the junior residents. CONCLUSION: Independent reporting of thyroid US performed by residents is undesirable. A continuous and specialized resident training is essential to enhance the degree of agreement and performance.
Erasmus MC, Department of General Practice, Rotterdam, The Netherlands. firstname.lastname@example.org
OBJECTIVE Correct application of the Kellgren and Lawrence (K&L) classification system is difficult due to inexact wording of the descriptors. We summarised different descriptions and searched for evidence on the impact of such variations on classification of knee osteoarthritis (OA) in epidemiological studies. METHODS We searched Medline/Pubmed (1966 to August 2006) for studies of epidemiological cohorts that professed use of the original K&L scale (grades 0-4, with 0 being normal and 4 severe OA), and recorded their descriptions of the five grades. The descriptions were compared with each other and with the original description. RESULTS We identified five different descriptions. In grade 2, often used as a cut-off to classify OA, one description replaced "definite osteophytes and possible narrowing of joint space"(K&L) by "definite osteophyte, unimpaired joint space". Another description for grade 2 was "minimal osteophytes, possible narrowing, cysts, and sclerosis". In some cohort studies, descriptions changed during follow-up. None of the included articles studied the impact of the use of different descriptions. CONCLUSION Major OA cohort studies disagree between each other and even among themselves on the definition and grading of disease according to the original K&L system. The impact of this disagreement warrants further study, but consensus urgently needs to be reached on a single valid and feasible classification system.
Department of Pediatrics and Clinical Epidemiology Unit, Indira Gandhi Government Medical College, Nagpur, India. email@example.com
BACKGROUND Pneumonia diagnosed using chest radiographs is often used as a study end point in trials and epidemiological studies. We studied whether training of the end-users in 172 standardized chest radiographic features will decrease variability in the interpretation. METHODS Inter-observer variation of 3 observers in recognizing standardized radiographic features for pneumonia was studied in 172 chest radiographs of children with clinical severe pneumonia.(as per WHO definition). The observers were then trained using a software with a repository of normal and abnormal films showing a spectrum of radiological changes in pneumonia. The interobserver variation in recognizing the same standardized radiographic features was recorded after this training. For each radiographic feature, Cohen's kappa statistics to assess the between-observer agreement and Fleiss's multiple rater kappa statistics to assess agreement among all three clinicians was used. RESULTS The 'uniterpretable' films reduced from 16.6%(95% CI 0%-34.1%) before training to 8.1%(95% CI 0%-17.7%) after training. The 'adequate' films increased from 54.2%(95% CI 12.5%-95.9%) before training to 70%(95% CI 46.5%-93.4%) after training. For all features, agreement between observers 1 with 2 and 1 with 3, the Cohen's kappa improved from poor to moderate agreement. The Fleiss's kappa values before training were 0.1 to 0.2 and after training ranged from 0.37 to 0.52 indicating moderate to good agreement after training. CONCLUSIONS Training of the doctors using standardized features with the help of a software improves agreement substantially in identifying radiological pneumonia.
Z Orthop Unfall. ;145 (4):430-5 17912660
[Is there a correlation between the clinical, radiological and intrasurgical findings of osteoarthritis of the knee? A Prospective study on 103 patients]
AIM: The aim of this study was to compare the different diagnostic features (symptoms, physical examination, radiographic features and intraoperative findings) of osteoarthritis of the knee before total joint replacement and consequently relate them with each other. METHOD: Patients with primary osteoarthritis of the knee, who where accepted for total joint replacement in our clinic, were integrated in our study. The medical conditions were recorded by using the Womac score, the knee subscore (KS) of the Knee Society Clinical Rating System and a visual analogue scale (VAS). A physical examination was also performed. The radiological evaluation was performed by using standardised radiographs. Joint space narrowing, subchondral sclerosis, osteophytes, knee alignment and the Kellgren score were recorded. During surgery an orthopaedic specialist documented the progression of cartilage lesions using the classification of chondromalacia described by Outerbridge. The analysis of correlation was performed by using the Spearman correlation (SpK) coefficient. RESULTS: 103 patients were integrated in the study (mean age: 68 years, 70 women). No significant correlation could be found between the Womac score or VAS and the results of the radiological examination (SpK [Womac - Kellgren score]:- 0.04; SpK [VAS - Kellgren score]: 0.08). There was a significant correlation between the KS and the results of the radiological examination as well as the progression of the cartilage lesions, caused by the results of the physical examination documented in the KS (SpK [KS - Kellgren score]:- 0.39). The radiographic features, with the exception of subchondral sclerosis, showed a significant correlation with the degree of chondromalacia (SpK [Kellgren score - chondromalacia]: 0.43). The amount of osteophytes correlated the most with the cartilage lesions: SpK: 0.43. CONCLUSION: The knee subscore appears to be an efficient method for staging the clinical progression of osteoarthritis of the knee for clinical practice as well as for clinical trials. The Womac score especially serves to record the level of pain. We were able to confirm that the presence of osteophytes is the most significant radiographic feature of osteoarthritis of the knee. The Kellgren score turned out to be a reliable method for monitoring the radiographic progression of osteoarthritis of the knee.
Knee Images Digital Analysis (KIDA): a novel method to quantify individual radiographic features of knee osteoarthritis in detail.
A C A Marijnissen, K L Vincken, P A J M Vos, D B F Saris, M A Viergever, J W J Bijlsma, L W Bartels, F P J G Lafeber
Rheumatology and Clinical Immunology, UMC Utrecht, The Netherlands. firstname.lastname@example.org
OBJECTIVE Radiography is still the golden standard for imaging features of osteoarthritis (OA), such as joint space narrowing, subchondral sclerosis, and osteophyte formation. Objective assessment, however, remains difficult. The goal of the present study was to evaluate a novel digital method to analyse standard knee radiographs. METHODS Standardized radiographs of 20 healthy and 55 OA knees were taken in general practise according to the semi-flexed method by Buckland-Wright. Joint Space Width (JSW), osteophyte area, subchondral bone density, joint angle, and tibial eminence height were measured as continuous variables using newly developed Knee Images Digital Analysis (KIDA) software on a standard PC. Two observers evaluated the radiographs twice, each on two different occasions. The observers were blinded to the source of the radiographs and to their previous measurements. Statistical analysis to compare measurements within and between observers was performed according to Bland and Altman. Correlations between KIDA data and Kellgren & Lawrence (K&L) grade were calculated and data of healthy knees were compared to those of OA knees. RESULTS Intra- and inter-observer variations for measurement of JSW, subchondral bone density, osteophytes, tibial eminence, and joint angle were small. Significant correlations were found between KIDA parameters and K&L grade. Furthermore, significant differences were found between healthy and OA knees. CONCLUSION In addition to JSW measurement, objective evaluation of osteophyte formation and subchondral bone density is possible on standard radiographs. The measured differences between OA and healthy individuals suggest that KIDA allows detection of changes in time, although sensitivity to change has to be demonstrated in long-term follow-up studies.
Department of Orthopaedic Surgery, School of Health Sciences, University of Thessaly, Papakiriazi 22, Larissa 41222, Greece. email@example.com
Osteoarthritis (OA) is the most common disease of the hip joint seen in adults. The diagnosis of OA is based on a combination of radiographic findings of joint degeneration and characteristic subjective symptoms. The lack of a radiographic consensus definition has resulted in a variation of the published incidences and prevalence of OA. The chronological sequence of degeneration includes the following plain radiographic findings: joint space narrowing, development of osteophytes, subchondral sclerosis, and cyst formation. There are cases though, that plain radiographs show minor changes and the clinical suspicion of early disease can be confirmed with more sophisticated imaging methods, such as multi-detector computed tomography and MR imaging. The present article will review all the clinical information on the hip OA together with an updated radiological approach, with emphasis on the early depiction and the differential diagnosis of the disease.