Arthur A. DeSmet

The effect of overlying calcification on lumbar bone densitometry.

SummaryWe studied bone mineral density (BMD) of the spine using dual photon absorptiometry, as well as standard anterior-posterior and lateral lumbar spine X-ray film in 113 ambulatory elderly male volunteers with a mean age of 72 years (range 66–91 years). Each subject had three measurements taken for lumbar vertebrae 1 through 4: BMD, length of aortic calcification (AC), and degenerative facet sclerosis graded 0–3. A separate statistical model was fit to BMD for each vertebra using analysis of covariance. AC did not contribute significantly to BMD. BMD was increased by 0.28–0.03 g/cm2 (L1–L4) with a sclerosis score of 2, and by 0.47–0.25 g/cm2 with a sclerosis score of 3,P<0.001. The association between increased BMD and overlying facet sclerosis may be related to the bone density within the sclerosis itself or to an association between degenerative joint disease and a generalized increase in subchondral bone.

Arthroscopic Treatment of the Painful “Internal” Snapping Hip Results of a New Endoscopic Technique and Imaging Protocol

Background Traditional surgical treatment for a painful snapping iliopsoas tendon has been an open lengthening of the tendon. Hypothesis An endoscopic release will alleviate painful snapping of the tendon. Study Design Case series; Level of evidence, 4. Methods Six patients with painful snapping hips who had no pain relief after magnetic resonance arthrography, which included injection of bupivacaine into the hip joint, subsequently had an ultrasound evaluation of their iliopsoas tendons and an anesthetic injection into the psoas bursa. In all 6 patients, the injection relieved their hip pain, and in 4, real-time imaging demonstrated snapping of the tendon. All hips were evaluated with the 100-point Harris hip scoring system before and at 1.5, 3, 6, and 12 months after surgery. Results Preoperative hip scores averaged 58 points. After surgery, all patients had hip flexor weakness, used crutches for 5 weeks, and had 6-week scores that averaged 62 points. The patients continued to improve, and at 6 and 12 months, their scores averaged 90 and 96 points, respectively, and none had recurrence of their snapping or pain. Conclusion Ultrasound-guided anesthetic injection of the psoas bursa is useful to confirm snapping of the iliopsoas tendon as the cause of a patients hip pain. Endoscopic release of the tendon is a safe outpatient procedure that provides effective relief of the snapping and pain.

Diagnosis of partial and complete rotator cuff tears using combined gradient echo and spin echo imaging

Most magnetic resonance (MR) studies evaluating the rotator cuff for tears have used T2-weighted imaging in the coronal oblique and sagittal oblique planes, T2*-weighted gradient echo imaging, however, has advantages over spin echo imaging, including contiguous slices without cross-talk, high contrast around the cuff, and intrinsically shorter imaging times which can be used to increase the number of signals averaged and thus improve the signal-to-noise ratio. We reviewed the shoulder MR scans of 87 consecutive patients who underwent both a MR scan and a shoulder arthroscopy during which the size of tears, if present, was graded. The reviewers were blinded as to the history and arthroscopic results. The MR scans included oblique coronal T2*-weighted gradient echo and oblique sagittal T2-weighted spin echo images. MR cuff grades were correlated with arthroscopic findings. For complete tears, the sensitivity of MR was 0.91 and the specificity 0.95. For partial tears, the sensitivity was 0.74 and the specificity 0.87. This accuracy is similar to two-plane T2-weighted imaging as previously reported in the literature. There was a statistically significant correlation (p < 0.0005) between the cuff grade as determined by MR and the arthroscopic findings.

MRI of selected sports injuries: Muscle tears, groin pain, and osteochondritis dissecans

This article discusses three selected areas of sports medicine in which MRI is useful. The first is muscle injuries and includes the MRI findings in muscle tears, contusions, and myositis ossificans. The second section discusses the usefulness of MRI in imaging the athlete with groin pain, which is a difficult clinical problem for the orthopedist. The ability of MRI to differentiate between such causes of groin pain as osteitis pubis, bursitis, and stress fractures is shown. The final section covers plain radiographic and MRI findings in osteochondritis dissecans. Also discussed is the MRI staging of osteochondritis dissecans, which is important in treatment decisions and surgical planning.

Hip Pain Referral Patterns in Patients with Labral Tears: Analysis Based on Intra-articular Anesthetic Injections, Hip Arthroscopy, and a New Pain “Circle” Diagram

Background: Fluoroscopically guided intra-articular (FGIA) anesthetic hip joint injections have been used to determine whether the hip joint is the source of a patients hip pain. However, there have been no reports documenting the efficacy of their use for defining the pain referral patterns (PRPs) of patients with labral tears. The aim of this study was to determine the PRPs of patients with labral tears and evaluate a new pain “circle” diagram (PCD) developed for this analysis. Methods: Fifty-two patients were evaluated at our institution who had: 1) a preoperative FGIA anesthetic hip joint injection; 2) completed our PCD and a visual analog pain scale pre- and postinjection; 3) significant (≥ 80%) pain reduction after their FGIA injection; and 4) a labral tear and minimal (≤ grade II) degenerative joint disease, as documented by hip arthroscopy. The PCD had circles in which patients put an “X” in to indicate pain in the following locations: anterior superior spine, lateral peritrochanteric area, central groin, symphysis pubis, proximal inner thigh, anterior thigh, posterior iliac crest, sacroiliac joint, sciatic notch, and ischial tuberosity. Results: Based on the percentage of patients with significant (≥ 80%) pain reduction after administration of FGIA, 2 areas demonstrated substantially more and consistent presence of pain, which improved after injection. These were the central groin (P < 0.001) and the lateral peritrochanteric area (P = 0.02). Conclusion: The most common locations of pain were the central groin and the lateral peritrochanteric area. The least common were the ischial tuberosity and the anterior thigh, which are 2 areas often associated with osteoarthritis of the hip. The use of the PCD combined with an FGIA anesthetic injection may help physicians reconcile the expectations of those patients with labral tears who believe that hip arthroscopy will treat their multiple areas of “hip” pain.

Atraumatic vertebral deformities in elderly males

SummaryLittle information is available on the prevalence of vertebral wedge deformities in elderly males; therefore, 116 ambulatory male volunteers age 65 and over were studied with lumbar and thoracic radiographs. Each patient was questioned concerning a history of high-energy spinal trauma. Those having 25% or greater anterior vertebral wedging were identified. Eleven percent of the males had at least one 25% atraumatic wedge deformity, and 2% had two or more such vertebra. These results are discussed in relation to the few published studies on this topic.

Plain film evaluation of bone grafting for nonunited scaphoid fractures

Forty-six men and four women were included in the study. Their mean age was 30 years with a range from 21–43 years.ObjectiveTo determine how the appearance of fracture line bridging and graft incorporation changed on sequential plain films obtained during the healing of successful grafts for scaphoid nonunion.PatientsWe identified 50 patients who had healed Russe bone grafts for nonunited scaphoid fractures. These patients had 214 sets of wrist radiographs obtained 1–36 months after surgery. Each set of radiographs was reviewed in random order by two observers who were blinded as to the patients name and the time interval since surgery. Closure of the fracture line and the presence of a linear lucency in each of six zones surrounding the graft were assessed using a three-point grading scale.Results and ConclusionsWith increasing time after surgery, there was progressive fracture line closing and disappearance of linear lucencies at the interfaces between the scaphoid and the graft. However, 20% of the patients had a well-defined lucency in at least one of the six zones around the graft on their last film. Even 1 year after surgery, the fracture line showed no bridging on the radial side in 22% of patients and on the ulnar side in 11%. We conclude that after grafting, most scaphoid nonunions show progressive fracture line closure and graft incorporation. However, the fracture line may not completely close and lucencies may persist in several zones around the graft for more than 1 year. These radiographic appearances should be recognized as part of the normal spectrum of healing.

Bilateral Fractures of the Humeral Head Related to Myoclonic Jerks and Use of a Tray Table for Positioning

he term myoclonus refers to brief, “lightninglike” muscle jerks.’ Myoclonic jerks may be focal, segmental, or generalized. Symptomatic T myoclonus may occur as part of metabolic encephalopathies and dementias. Advanced dementia is often associated with immobility and disuse, which may lead to osteoporosis? We are reporting the case of an elderly patient with progressive dementia and generalized myoclonus who sustained bilateral fractures of the humeral head when he was positioned with a rigid tray table. We are unaware of any similar cases previously described.