Abida Z. Ginai

The active straight leg raising test and mobility of the pelvic joints.

Abstract Objective signs to assess impairment in patients who are disabled by peripartum pelvic girdle pain hardly exist. The purpose of this study was to develop a clinical test to quantify and qualify disability in these patients. The study examined the relationship between impaired active straight leg raising (ASLR) and mobility of pelvic joints in patients with peripartum pelvic girdle pain, focusing on (1) the reduction of impairment of ASLR when the patient was wearing a pelvic belt, and (2) motions between the pubic bones measured by X-ray examination when the patient was standing on one leg, alternating left and right. Twenty-one non-pregnant patients with peripartum pelvic girdle pain in whom pain and impairment of ASLR were mainly located on one side were selected. ASLR was performed in the supine position, first without a pelvic belt and then with a belt. The influence of the belt on the ability to actively raise the leg was assessed by the patient. Mobility of the pelvic joints was radiographically visualized by means of the Chamberlain method. Assessment was blinded. Ability to perform ASLR was improved by a pelvic belt in 20 of the 21 patients (binomial two-tailed P = 0.0000). When the patient was standing on one leg, alternating the symptomatic side and the reference side, a significant difference between the two sides was observed with respect to the size of the radiographically visualized steps between the pubic bones (binomial two-tailed P = 0.01). The step at the symptomatic side was on average larger when the leg at that side was hanging down than when the patient was standing on the leg at that side. Impairment of ASLR correlates strongly with mobility of the pelvic joints in patients with peripartum pelvic girdle pain. The ASLR test could be a suitable instrument to quantify and qualify disability in diseases related to mobility of the pelvic joints. Further studies are needed to assess the relationship with clinical parameters, sensitivity, specificity and responsiveness in various categories of patients. In contrast with the opinion of Chamberlain, that a radiographically visualized step between the pubic bones is caused by cranial shift of the pubic bone at the side of the standing leg, it is concluded that the step is caused by caudal shift of the pubic bone at the side of the leg hanging down. The caudal shift is caused by an anterior rotation of the hip bone about a horizontal axis near the sacroiliac joint.

The Development of Cam-Type Deformity in Adolescent and Young Male Soccer Players

Background: Cam impingement is a well-recognized cause of hip pain and might cause osteoarthritis of the hip. Clinically, cam impingement is mostly observed in young, active male patients, but only a few studies have focused on the manifestation of cam-type deformities during skeletal development. Purpose: To determine the age of onset and prevalence of cam-type deformities in young male soccer players versus controls. Study Design: Cross-sectional study; Level of evidence, 3. Methods: In this study, 89 elite preprofessional soccer players and 92 controls aged 12 to 19 years were included. In the soccer players, range of motion and impingement tests were performed. Both an anteroposterior (AP) pelvic radiograph and a frog-leg lateral radiograph of the hip were obtained according to a standardized protocol. Controls with both an AP pelvic and a frog-leg lateral radiograph and no hip disorders were obtained from radiology databases. The α angle was automatically determined in all radiographs, using a threshold value of 60° to define a cam-type deformity. Further, all radiographs were scored using a 3-point scoring system. The anterosuperior head-neck junction was classified as (1) normal, (2) flattened, or (3) having a prominence. Differences in prevalence were tested using logistic regression. Differences in range of motion were calculated using generalized estimating equations. Results: An α angle >60° was already found at the age of 12 years in some soccer players and controls. A cam-type deformity defined by α angle tended to be more prevalent in soccer players (26%) than in controls (17%; P = .31). In 13% of soccer players, a prominence was visible on radiographs and was first seen at the age of 13 years. The anterosuperior flattening (56% vs 18%, P = .0001) and prominence (13% vs 0%, P < .03) were more prevalent in soccer players than in controls. Conclusion: Cam-type deformities were recognizable and present from the age of 13 years and were more prevalent in soccer players than in their nonathletic peers. Cam-type deformity develops during adolescence and is likely to be influenced by high-impact sports practice.

A Cam Deformity Is Gradually Acquired During Skeletal Maturation in Adolescent and Young Male Soccer Players A Prospective Study With Minimum 2-Year Follow-up

Background: A cam deformity is a major risk factor for hip osteoarthritis, and its formation is thought to be influenced by high-impact sporting activities during growth. Purpose: To (1) prospectively study whether a cam deformity can evolve over time in adolescents and whether its formation only occurs during skeletal maturation and (2) examine whether clinical or radiographic features can predict the formation of a cam deformity. Study Design: Cohort study (prognosis); Level of evidence, 2. Methods: Preprofessional soccer players (N = 63; mean age, 14.43 years; range, 12-19 years) participated both at baseline and follow-up (mean follow-up, 2.4 ± 0.06 years). At both time points, standardized anteroposterior and frog-leg lateral radiographs were obtained. For each hip, the α angle was measured, and the anterosuperior head-neck junction was classified by a 3-point visual system as normal, flattened, or having a prominence. Differences between baseline and follow-up values for the α angle and the prevalence of each visual hip classification were calculated. Additionally, the amount of internal hip rotation, growth plate extension into the neck, and neck shaft angle were determined. Results: Overall, there was a significant increase in the prevalence of a cam deformity during follow-up. In boys aged 12 and 13 years at baseline, the prevalence of a flattened head-neck junction increased significantly during follow-up (13.6% to 50.0%; P = .002). In all hips with an open growth plate at baseline, the prevalence of a prominence increased from 2.1% to 17.7% (P = .002). After closure of the proximal femoral growth plate, there was no significant increase in the prevalence or increase in severity of a cam deformity. The α angle increased significantly from 59.4° at baseline to 61.3° at follow-up (P = .018). The amount of growth plate extension was significantly associated with the α angle and hip classification (P = .001). A small neck shaft angle and limited internal rotation were associated with cam deformities and could also significantly predict the formation of cam deformities (α angle >60°) at follow-up. Conclusion: In youth soccer players, cam deformities gradually develop during skeletal maturation and are probably stable from the time of growth plate closure. The formation of a cam deformity might be prevented by adjusting athletic activities during a small period of skeletal growth, which will have a major effect on the prevalence of hip osteoarthritis.

Effect of Glucosamine Sulfate on Hip Osteoarthritis: A Randomized Trial

Context Although many patients use glucosamine to treat osteoarthritis, available studies have reported inconsistent effects of glucosamine on symptoms and joint changes. In addition, previous studies have more often included patients with knee than with hip osteoarthritis. Contribution The investigators randomly assigned 222 patients with hip osteoarthritis to glucosamine, 1500 mg/d, or placebo. After 2 years of treatment, no clinically significant effect on pain, function, or joint space narrowing was found. Caution Twenty of the patients in the trial had joint replacement during the study. The Editors The effectiveness of glucosamine sulfate for treating osteoarthritis is controversial. A 2005 systematic review of 20 trials found evidence to be inconclusive (1). In the 15 trials comparing glucosamine with placebo, the overall effect on pain favored glucosamine, but 8 of the trials found no effect on pain. More recent trials (24) have also yielded inconclusive results. In the Netherlands and other countries, glucosamine is sold as an over-the-counter dietary supplement and is used by many patients, often on the advice of their physicians. Given the prevalent use of glucosamine, definitive evidence about its effectiveness is needed. Some studies suggest that glucosamine may provide greater benefit to patients with less severe radiographic osteoarthritis than to patients with more severe disease (5, 6). Most previous trials have studied only patients with knee osteoarthritis, with the exception of 3 early trials that included patients with other affected joints (79). Trials specifically testing glucosamine in patients with hip osteoarthritis have not been available. Although osteoarthritis of the knee is more common than hip osteoarthritis, hip osteoarthritis is common enough to warrant assessment of glucosamine for this condition. To date, only 2 trials have published data on the effects of glucosamine sulfate on joint structure (10, 11). Some expressed concern about the radiography protocol used in these trials (1214), and further study is needed to clarify these findings. To explore some of the uncertainties regarding the effectiveness of glucosamine sulfate, we conducted a 2-year, blinded, randomized, placebo-controlled trial to evaluate the effect of glucosamine sulfate on the symptomatic and radiographic progression of hip osteoarthritis in patients recruited from primary care settings. Methods Study Design In this trial, all outcome assessors, patients, data analysts, and researchers were blinded to group assignment. The Medical Ethics Committee of the Erasmus Medical Center, Rotterdam, the Netherlands, approved the study design, and patients provided written informed consent. We reported the detailed study protocol in 2005 (15) and summarize it here. Setting and Participants General practitioners in the Rotterdam area recruited study patients. Patients were eligible for inclusion if they met the American College of Rheumatology clinical criteria for hip osteoarthritis (16) during a screening examination at the research center. Patients who had undergone or were awaiting hip replacement surgery were not eligible. We excluded patients who had a Kellgren and Lawrence score of 4 (17), renal disease, liver disease, diabetes mellitus, or a disabling comorbid condition that would make visits to the research center impossible, as well as patients already receiving glucosamine and those unable to fill out Dutch questionnaires. We encouraged patients who violated study protocol and those who had total hip arthroplasty during the study to complete data collection to limit the loss to follow-up. Randomization and Intervention Eligible patients were randomly assigned to receive either 1500 mg of oral glucosamine sulfate (administered once daily as two 750-mg tablets) or placebo for 2 years. The glucosamine used in this study was provided by Numico Research BV (Wageningen, the Netherlands) but was manufactured by Nutricia Manufacturing USA (Greenville, South Carolina). It contained 2000 mg of D-glucosamine sulfate 2-potassium chloride, which results in a net content of 1500 mg of glucosamine sulfate per 2 pills. The placebo pills were identical in appearance, smell, and taste. We used a computer-generated, blinded randomization list provided by an independent researcher to randomly assign patients to glucosamine sulfate or placebo. This list, which was randomized per block of 6 numbers, stratified patients by radiologic findings (Kellgren and Lawrence score <2 vs. 2) and by local versus generalized osteoarthritis; patients received a number in chronological order (15). Assignment of patients to the right stratum of the random assignment list was done by the main researcher, who was blinded to therapy. To evaluate blinding, patients had to indicate in the last questionnaire to which treatment they thought they were randomly assigned. Outcomes and Follow-up Primary outcome measures were WOMAC 3.1 (5-point Likert format) pain and function over 24 months and joint space narrowing after 24 months (18, 19). Secondary outcome measures were WOMAC pain, function, and stiffness after 3, 12, and 24 months; overall WOMAC stiffness; a visual analogue scale (VAS) to measure pain in the past week; and pain medication use. The WOMAC subscales are presented as normalized scores (0 to 100, where 0 equals no symptoms). We recorded the use of pain medication; classified patients as never, occasional, or daily users; and then determined whether people increased, decreased, or did not change their use of pain medication from baseline. In the case of patients with bilateral hip symptoms, we asked patients to indicate their most affected hip for our analyses of joint space narrowing. For patients who were undecided, we used the hip with the highest Kellgren and Lawrence score or the smallest internal rotation during a physical examination. We used QBone Planner 5.4 (Medis, Leiden, the Netherlands) to measure joint space width on calibrated digital radiographs of the hip joints. We read radiographs from both time points (baseline and 24 months) side by side. One researcher measured joint space width manually on predefined lateral, superior, axial, and medial sites (20). In addition to these 4 points, we visually identified and measured the minimal joint space width on both the baseline and 24-month radiograph. We used the smallest of these 6 measurements as the actual minimum joint space width for analyses. A second observer also measured the joint space width in a random subset of 28 study patients, and we found high interobserver agreement (intraclass correlation coefficient of minimal joint space width, 0.98). We collected data for the primary and secondary outcome measures at different time points throughout the study. At baseline and after 24 months, patients came to the Erasmus Medical Center for radiography and to complete study questionnaires. Weight-bearing, anteroposterior digital radiography of the pelvis was performed according to a highly standardized protocol to allow reliable measurement of joint space narrowing (15). At baseline and then every 3 months through month 24, we asked patients to complete the WOMAC instrument, a VAS for pain in the past week (score range, 0 to 100; 0 equals no pain), and a checklist for specific adverse events and to answer questions regarding pain medication and adherence. We mailed the intermediate questionnaires to the patients for completion at home. A researcher visited patients every 6 months to deliver a new supply of study medication and evaluate adherence by using the Brief Medication Questionnaire (BMQ) (21) and a pill count. The BMQ monitors the amount of days per week that patients have taken their study medication. For overall effect, we considered patients to be adherent if they ingested more than 80% of the total study medication. Statistical Analysis We used the data from all nine 3-month questionnaires (at baseline and 3, 6, 9, 12, 15, 18, 21, and 24 months). We also report outcomes for measurements at 3, 12, and 24 months and a mean effect of the therapy over 24 months incorporating all scores. We performed the analyses by using SPSS 11.0.1 (SPSS, Chicago, Illinois) and SAS 8.2 (SAS Institute, Cary, North Carolina). We used linear mixed models to analyze the data, assuming that data were missing at random. We chose an unstructured covariance structure to model the covariance of repeated measures by patients, because this yielded the lowest Akaike information criterion. Fixed effects were time, time by therapy, and the covariates we adjusted for. For patients who had total hip arthroplasty during the trial, we included observed data before surgery in the analysis and assumed data after surgery to be missing. For patients who were lost to follow-up, we included all observed data in the analysis. We adjusted the WOMAC and VAS pain analyses for body mass index, sex, and agefactors that may have influenced symptoms (22, 23). We also adjusted analyses for pain medication use and Kellgren and Lawrence score. The analyses for joint space narrowing were adjusted for Kellgren and Lawrence score (24), age, and sex (25). We used ordinal regression analysis to assess the effect of glucosamine sulfate on pain medication use by using data from all patients who completed the study and did not have total hip arthroplasty. We performed additional analyses to assess the effect of adherence on the outcome. To explore the validity of the missing-at-random data assumption for patients who underwent total hip arthroplasty during the study, we did sensitivity analyses on the WOMAC pain data. In 5 scenarios, the missing data for patients who underwent total hip arthroplasty were imputed with extreme scores: mean of the 5 best scores for the glucosamine sulfate recipients and that of the 5 worst scores for the placebo recipients (traditional best case); mean of the best scores for placebo recipients and

Percutaneous treatment of displaced intra-articular calcaneal fractures

BackgroundThe outcome after displaced intra-articular calcaneal fractures is influenced by the condition of the surrounding soft tissues. To avoid secondary soft tissue complications after surgical treatment, several less-invasive procedures for reduction and fixation have been introduced. The percutaneous technique according to Forgon and Zadravecz is suitable for all types of displaced intra-articular calcaneal fractures and was therefore introduced in our clinic. The aim of this study was to evaluate the long-term outcome of percutaneous treatment according to Forgon and Zadravecz in patients with displaced intra-articular calcaneal fractures.MethodsA cohort of patients with displaced intra-articular calcaneal fractures treated with percutaneous surgery was retrospectively defined. Clinical outcome was evaluated by standardized physical examination, radiographs, three published outcome scores, and a visual analogue scale of patient satisfaction.ResultsFifty patients with 61 calcaneal fractures were included. After a mean follow-up period of 35 months, the mean values of the Maryland foot score, the Creighton-Nebraska score, and the American Orthopaedic Foot and Ankle Society score were 79, 76, and 83 points out of 100, respectively. The average visual analogue scale was 7.2 points out of 10. The average range of motion of the ankle joint was 90% of normal and subtalar joint movements were almost 70% compared with the healthy side or normal values. Superficial wound complications occurred in seven cases (11%) and deep infections in two (3%). A secondary arthrodesis of the subtalar joint was performed in five patients and was scheduled in four patients (15%).ConclusionsCompared with the outcome of historic controls from randomized trials and meta-analyses, this study indicates favorable results for the percutaneous technique compared with the open technique. Despite similar rates of postoperative infection and secondary arthrodesis, the total outcome scores and preserved subtalar motion are overall good to excellent.

Stress Radiography of the Talocrural and Subtalar Joints

The object of this investigation was to determine a possible subtalar component in a group of 33 patients with chronic ankle instability. A group of 10 subjects without ankle/foot symptoms acted as controls. A standardized radiographic assessment of talar and simultaneous subtalar tilt was made. A hinge device to stress the joints and a specific subtalar stress view (Brodén view) were used under fluoroscopic control. Radiographs were made with the feet: (1) in neutral position, (2) after inversion with moderate force until the point of fair restraint (step 1), and (3) after inverting with more force as far as the conditions would allow (step 2). An increase of talar tilt between step 1 and step 2 was only found in feet that were symptomatic. This suggests that this increase is only possible when lateral ligaments are damaged. Further research is necessary to determine whether this finding can serve as a parameter to discriminate between physiological and abnormal talar tilt. A wide range of subtalar motion was found in both symptomatic and asymptomatic feet. With the present method, practically all subtalar joints showed some loss of congruity and medial shift of the calcaneus in relation to the talus. This could not be correlated with ankle instability at the talocrural joint. The consequence of the use of different subtalar stress methods has so far received little attention and is discussed.

Magnetic resonance imaging for diagnosing lumbar spinal pathology in adult patients with low back pain or sciatica: a diagnostic systematic review

PurposeIn about 5% of all cases LBP is associated with serious underlying pathology requiring diagnostic confirmation and directed treatment. Magnetic resonance imaging (MRI) is often used for this diagnostic purpose yet its role remains controversial. Consequently, this review aimed to summarize the available evidence on the diagnostic accuracy of MRI for identifying lumbar spinal pathology in adult low back pain (LPB) or sciatica patients.MethodsMEDLINE, EMBASE and CINAHL were searched (until December 2009) for observational studies assessing the diagnostic accuracy of MRI compared to a reference test for the identification of lumbar spinal pathology. Two reviewers independently selected studies for inclusion, extracted data and assessed methodological quality. Pooled summary estimates of sensitivity and specificity with 95% confidence intervals were calculated for homogenous subsets of studies.ResultsEight studies were included in this review. Strata were defined for separate pathologies i.e. lumbar disc herniation (HNP) and spinal stenosis. Five studies comparing MRI to findings at the surgery for identifying HNP were included in a meta-analysis. Pooled analysis resulted in a summary estimate of sensitivity of 75% (95% CI 65–83%) and specificity of 77% (95% CI 61–88%). For spinal stenosis pooling was not possible.ConclusionsThe results suggest that a considerable proportion of patients may be classified incorrectly by MRI for HNP and spinal stenosis. However, the evidence for the diagnostic accuracy of MRI found by this review is not conclusive, since the results could be distorted due to the limited number of studies and large heterogeneity.

Effects of ligament sectioning on the kinematics of the distal tibiofibular syndesmosis: A radiostereometric study of 10 cadaveric specimens based on presumed trauma mechanisms with suggestions for treatment

Background Syndesmotic injuries of the ankle without fractures can result from external rotation, abduction and dorsiflexion injuries. Kinematic studies of these trauma mechanisms have not been performed. We attempted to describe the kinematics of the tibiofibular joint in cadaveric specimens using radiostereometry after sequential ligament sectioning, and resulting from different trauma mechanisms and axial loading, in order to put forward treatment guidelines for the different types of syndesmotic injuries. Methods We assessed the kinematics of the distal tibiofibular joint in fresh–frozen cadaveric specimens using radiostereometry in the intact situation, and after alternating and sequential sectioning of the distal tibiofibular and anterior deltoid ligaments. To assess which of the known trauma mechanisms would create the largest displacements at the syndesmosis, the ankle was brought into the following positions under an axial load that was comparable to body weight (750 N): neutral, dorsiflexion, external rotation, abduction, and a combination of external rotation and abduction. Results In the neutral position, the largest displacements of the fibula consisted of external rotation and posterior translation. Loading of the ankle with 750 N did not apparently increase or decrease the displacements of the fibula, but gave a larger variety of displacements. In every position, sectioning of a ligament resulted in some fibular displacement. Sectioning of the anterior tibiofibular ligament (ATiFL) invariably resulted in external rotation of the fibula. Additional sectioning of the anterior part of the deltoid ligament (AD) gave a larger variety of displacements. In general, sectioning of the posterior tibiofibular ligament (PTiFL) gave the smallest displacements. Combined sectioning of the ATiFL and the PTiFL resulted in a larger variety of displacements in the neutral position. Sectioning of the AD together with the ATiFL and PTiFL resulted in tibiofibular displacements in the neutral situation exceeding the maximum values found in the intact situation, the most important being fibular external rotation. Interpretation Sectioning of the ATiFL results in mechanical instability of the syndesmosis. Of all trauma mechanisms, external rotation of the ankle resulted in the largest and most consistent displacements of the fibula relative to the tibia found at the syndesmosis. Based on our findings and the current literature, we recommend that patients with isolated PTiFL or AD injuries should be treated functionally when no other injuries are present. Patients with acute complete ATiFL ruptures, or combined ATiFL and AD ruptures should be treated with immobilization in a plaster. Patients with combined ruptures of the ATiFL, AD and PTiFL need to be treated with a syndesmotic screw.

Responsiveness of outcome measurements in rehabilitation of patients with posterior pelvic pain since pregnancy.

Study Design. A cohort study was conducted. Objective. To develop a test battery for evaluating the course of posterior pelvic pain since pregnancy. Summary of Background Data. Properly validated scales to evaluate the course of posterior pelvic pain since pregnancy are scarce. Moreover, the use of many tests would be too strenuous for the patient and has an unfavorable cost–benefit ratio. Methods. The ability of 48 effect measures to detect clinically relevant changes over time (responsiveness) was tested in patients with posterior pelvic pain since pregnancy. In this test, 35 measures were evaluated in a group of 44 patients, and 16 measures in a group of 56 patients (three measures were evaluated in both groups). All the tests were performed at baseline and after 8 weeks treatment. A global impression of improvement (improved or not improved) scored by the patient was used as the standard for assessing the course of the disease. Responsiveness was examined by calculating the standardized response mean of the improved patients and by using a two-tailed Mann–Whitney nonparametric test to compare the patients who had improved and those who had not improved. Results. Of the 48 effect measures, 26 measures of five categories (activities of daily living, pain, hip muscle strength, spine mobility, and spine muscle strength) showed good correlation with the patient’s global impression of improvement. The measures in the “mobility of the pelvic joints” category were insufficient for assessing clinical change in posterior pelvic pain since pregnancy. The measures in the “fatigue” and “pain provocation tests” categories correlated only moderately with clinical change. Conclusions. It seems possible to gain appropriate information about the course of posterior pelvic pain since pregnancy with a small test battery. The usefulness of the Québec Back Pain Disability Scale, the hip adduction strength assessment, and the active straight-leg-raise test was proved by the current study. The value of 23 other instruments was substantiated, but further studies are needed to confirm their usefulness. The correlation of 22 evaluated measures with the patient’s global improvement was too weak for them to be recommended as measures of clinical changes over time in posterior pelvic pain since pregnancy. It is recommended that clinicians and investigators compile a small test battery by selecting the best representatives of the five measurement categories that have good correlation with the patient’s global impression of improvement.

The whole leg radiograph: standing versus supine for determining axial alignment.

The whole leg radiograph (WLR), the standard technique for determining axial alignment, is usually taken in a standing position, although some prefer the supine position. To determine the difference between these two positions, we performed a standing and a supine WLR in 20 patients with a varus alignment. We found an average of 2 degrees more varus deviation in the standing position than in the supine position.