Benton E. Heyworth

Current Concepts in the Diagnosis and Treatment of Osteochondral Lesions of the Ankle

Osteochondral lesions of the ankle are a more common source of ankle pain than previously recognized. Although the exact pathophysiology of the condition has not been clearly established, it is likely that a variety of etiological factors play a role, with trauma, typically from ankle sprains, being the most common. Technological advancements in ankle arthroscopy and radiologic imaging, most importantly magnetic resonance imaging, have improved diagnostic capabilities for detecting osteochondral lesions of the ankle. Moreover, these technologies have allowed for the development of more sophisticated classification systems that may, in due course, direct specific future treatment strategies. Nonoperative treatment yields best results when employed in select pediatric and adolescent patients with osteochondritis dissecans. However, operative treatment, which is dependent on the size and site of the lesion, as well as the presence or absence of cartilage damage, is frequently warranted in both children and adults with osteochondral lesions. Arthroscopic microdrilling, micropicking, and open procedures, such as osteochondral autograft transfer system and matrix-induced autologous chondrocyte implantation, are frequently employed. The purpose of this article is to review the history, etiology, and classification systems for osteochondral lesions of the ankle, as well as to describe current approaches to diagnosis and management.

Hylan Versus Corticosteroid Versus Placebo for Treatment of Basal Joint Arthritis: A Prospective, Randomized, Double-Blinded Clinical Trial

PURPOSE Conservative, nonsurgical therapies for basal joint osteoarthritis, such as thumb spica splinting and intra-articular corticosteroid injections, remain the mainstays for symptomatic treatment. This study compares intra-articular hylan, corticosteroid, and placebo injections with regard to pain relief, strength, symptom improvement, and metrics of manual function in a randomized, controlled, double-blinded study. METHODS Sixty patients with basal joint arthritis were randomized to receive 2 intra-articular hylan injections 1 week apart, 1 placebo injection followed by 1 corticosteroid injection 1 week later, or 2 placebo injections 1 week apart. Patients were evaluated at 2, 4, 12, and 26 weeks and assessed with Visual Analog Scale pain scores, strength measures, difference scores, Disabilities of the Arm, Shoulder, and Hand (DASH) scores, and range of motion measurements. RESULTS All groups reported pain relief at 2 weeks. The steroid and placebo groups had significantly less pain at week 4 compared with baseline, but this effect disappeared by week 12. Only hylan injections continued to provide pain relief at 12 and 26 weeks compared with baseline. There were no significant differences in pain between groups at any time. At 12 and 26 weeks, the hylan group had improved grip strength compared with baseline, whereas the steroid and placebo groups were weaker. At 4 weeks, the steroid group reported in the difference score a greater improvement in symptoms (68%) compared with the hylan (44%) and placebo (50%) groups. Whereas at 26 weeks the hylan group reported the largest improvement in symptoms (68%), this was not statistically different from the placebo (47%) and steroid (58%) groups. There were no significant differences in Disabilities of the Arm, Shoulder, and Hand scores or range of motion among the groups. There were no complications from any injection. CONCLUSIONS There were no statistically significant differences among hylan, steroid, and placebo injections for most of the outcome measures at any of the follow-up time points. However, based on the durable relief of pain, improved grip strength, and the long-term improvement in symptoms compared with preinjection values, hylan injections should be considered in the management of basal joint arthritis of the thumb. TYPE OF STUDY/LEVEL OF EVIDENCE Therapeutic I.

Internal Impingement of the Shoulder

Internal impingement of the shoulder is a pathologic condition characterized by excessive or repetitive contact of the greater tuberosity of the humeral head with the posterosuperior aspect of the glenoid when the arm is abducted and externally rotated. This arm positioning leads to rotator cuff and glenoid labrum impingement by the bony structures of the glenohumeral joint. Although some degree of contact between these structures occurs under normal conditions, to date most of the orthopaedic literature has focused on internal impingement as a disease state that affects overhead athletes and is characterized by the development of articular-sided rotator cuff tears and posterosuperior labral lesions. The precise cause of these impingement lesions remains unclear. However, it is believed that varying degrees of glenohumeral instability, posterior capsular contracture, and scapular dyskinesis may play a role in the development of symptomatic internal impingement. The purpose of this article is to review the pathomechanics, clinical complaints, physical examination findings, and imaging findings that are associated with internal impingement. The results of treatment will be reviewed, and a diagnostic and therapeutic algorithm for the management of internal impingement is presented.

CT Reveals a High Incidence of Osseous Abnormalities in Hips with Labral Tears

BackgroundAcetabular labral tears are being diagnosed with increasing frequency and there is a growing consensus that these tears rarely occur in the absence of osseous abnormalities.Questions/purposesWe therefore determined the presence of structural abnormalities in patients with acetabular labral tears using a standardized CT protocol.MethodsWe evaluated 135 consecutive patients with labral tears diagnosed by MRI with CT scans of the symptomatic hip. The CT scans were evaluated in a standardized fashion to determine acetabular and femoral pathomorphologic features. Acetabular evaluation included version measurements and anterior and lateral center-edge angles. Femoral parameters evaluated included version, alpha angle, and neck-shaft angle.ResultsOne hundred twenty-two (90%) of the 135 hips had structural abnormalities. One hundred two (76%) had an alpha angle greater than 50°, 18 (13%) had femoral version less than 5°, 22 (16%) had femoral version greater than 25º, and five (4%) had coxa valga. Fifty-eight (43%) patients had acetabular retroversion and five (4%) had a lateral center-edge angle less than 20º. Of the 58 patients with acetabular retroversion, 23 had isolated cranial retroversion, 12 had isolated central retroversion, and 23 had combined cranial and central retroversion. Sixty-seven of the 121 hips (55%) with bony abnormalities had a combination of abnormalities.ConclusionsNinety percent of patients with labral tears had structural abnormalities seen on CT scans. These structural abnormalities frequently occur in combination, and understanding these underlying morphologic features of the hip can help guide treatment.Level of EvidenceLevel IV, diagnostic study. See Guidelines for Authors for a complete description of levels of evidence.

Arthroscopic Management of Labral Tears in the Hip

Over the last decade, the diagnosis and arthroscopic management of labral tears of the hip in the young athletic population has evolved substantially due to improvements in clinical examination, diagnostic tools, surgical techniques, and flexible instrumentation in hip arthroscopy. Arthroscopic management of labral injuries in the hip has become an accepted therapeutic modality in appropriately selected patients. The treatment of labral tears and their associated disorders is crucial for hip preservation in young and active patients because several studies have demonstrated an association between labral tears and the early onset of osteoarthritis1-3. This paper will review the main causes of labral tears in the hip, including labral tears secondary to trauma, femoroacetabular impingement, instability, psoas impingement, dysplasia, and degenerative arthritis. We will discuss relevant anatomy and history, typical findings on physical examination, types of imaging studies performed, and treatment options, with a focus on the arthroscopic management of labral injuries, including labral repair. The outcomes associated with open surgical dislocation as compared with arthroscopic treatment of femoroacetabular impingement will also be reviewed. The acetabular labrum is a fibrocartilaginous structure that is located circumferentially around the acetabular perimeter and becomes attached to the transverse acetabular ligament posteriorly and anteriorly. Neuroreceptors have been identified within the labrum, and these structures may provide proprioception to the hip joint4. The articular surface of the labrum has decreased vascularity and a limited synovial covering in comparison with the portion of the labrum at the peripheral capsulolabral junction5 (Figs. 1-A and 1-B). Thus, similar to the healing potential of the menisci in the knee, which is greatest at the periphery, the healing potential of the labrum is greatest at the peripheral capsulolabral junction5-8. The labrum has an important sealing function in the hip. It plays …

Jejunal microflora in malnourished Gambian children.

Growth of bacteria greater than 10-5 organisms/ml was found in 22 children, of whom 17 gave a histroy of chronic diarrhoea. The other 8 children had either no diarrhoea or where having an acute attack lasting for a few days. In those with chronic diarrhoea, Esch. coli, bacteroides, and enterococci tended to occur more frequently, whereas streptococci occurred more frequently in those with acute diarrhoea. Bacilli, staphylococci, micrococci, klebsiellas, pseudomonads, and candidas often occurred in both groups and in large numbers in those with chronic diarrhoea. This confirms previous reports in other parts of the world that some children with malnutrition have considerable bacterial contamination of the jejunum, and that this may be of aetiological significance as a cause of much of the diarrhoea seen in malnourished children. It is possible too that this may be important in the pathogenesis of malnutrition. The presence of intestinal parasites in these malnourished children is also noted. A double-blind trial in the use of antibiotics in this condition is advocated to determine whether it is possible to break the diarrhoea-malabsorption-malnutrition cycle. At the same time the effect of simply removing the child to a more sanitary environment, together with an estimate of the natural clearance of bacteria from the upper intestine, should be evaluated.

Hip Arthroscopy in the Athletic Patient: Current Techniques and Spectrum of Disease

Over the last decade, the management of hip injuries has evolved substantially due to the advancement of techniques in arthroscopy and diagnostic tools such as magnetic resonance imaging. Arthroscopy of the hip remains a challenge due to the osseous and soft-tissue constraints of the hip. Currently, various hip lesions, including labral tears, loose bodies, femoroacetabular impingement, coxa saltans (snapping hip syndrome), ligamentum teres injuries, and capsular laxity, can be successfully treated arthroscopically. As continued improvements are made in surgical techniques and in specifically designed instrumentation for the hip, the indications for arthroscopy will continue to increase and arthroscopy of the hip will become a standard procedure performed by an increasing number of orthopaedic surgeons. After reviewing this article, the reader should: (1) have a basic understanding of the intra-articular and extra-articular hip disorders that commonly occur in athletes; (2) be able to generate a differential diagnosis for hip pain; (3) have a basic understanding of the relevant anatomy, patient history, and physical examination findings for an athlete who presents with hip pain; and (4) be able to identify normal and abnormal findings on radiographic and magnetic resonance imaging studies. The differential diagnosis of hip pain in an athletic patient is quite broad (Table I). A complete history and physical examination are necessary in order to determine the source and cause of the pain. It is still common to ascribe hip pain in an athlete to a muscle strain or a soft-tissue contusion. However, hip pain may arise from a number of soft-tissue structures in and around the hip joint, and it is important to be able to differentiate extra-articular from intra-articular abnormalities. The physician should elicit information from the patient with regard to the specific location of the discomfort, the qualitative nature of the discomfort (such as catching, clicking, instability, …

Preoperative three-dimensional CT predicts intraoperative findings in hip arthroscopy.

BackgroundCurrently, plain radiographs and MRI are the standard imaging modalities used for diagnosing femoroacetabular impingement (FAI) and preoperative planning for arthroscopic treatment of FAI. The value of three-dimensional (3D) CT for these purposes is unclear.Questions/purposesWe therefore determined the reliability of CT assessment of FAI and whether CT findings of hip disease predict arthroscopic findings.MethodsWe retrospectively assessed the preoperative CT scans of 118 patients who underwent primary hip arthroscopy. Intraoperative findings, including size of the cam lesion, presence of an acetabular labral articular disruption lesion, and one of four types of labral tear were recorded and compared with the retrospectively read CT findings.ResultsAgreement analysis between CT and intraoperative detection of FAI yielded kappa values of 0.48 for cam lesions and 0.16 for pincer lesions. Increasing values for the CT-based alpha angle correlated with increasing severity of arthroscopically assessed acetabular labral articular disruption grade. Each pattern of FAI predicted a specific labral tear type.ConclusionsOur data suggest CT has moderate value in predicting mechanically based labral tear patterns, although better parameters for assessment of pincer lesions are needed. Diagnostic assessment of patients with suspected FAI may be improved with use of 3D CT.Level of EvidenceLevel III, diagnostic study. See the Guidelines for Authors for a complete description of levels of evidence.

Treatment of posterior cruciate ligament injuries in pediatric and adolescent patients.

Background: There is sparse literature regarding the outcomes of treatment for posterior cruciate ligament (PCL) injuries in pediatric and adolescent patients. PCL injuries are rare and are often treated conservatively. The purpose of this study was to review 2 separate cohorts of patients with pediatric and adolescent PCL injuries: those treated surgically with direct repair or ligament reconstruction and those managed nonoperatively. Methods: Twenty-five patients 18 years or younger underwent treatment of 26 PCL injuries (1 bilateral) at a single institution between 1993 and 2009. Fourteen patients (15 knees) underwent operative treatment, while 11 patients were treated nonoperatively. Demographic and clinical features of each group were reviewed, and validated functional outcome measures [Pediatric International Knee Documentation Committee (Pedi-IKDC), Lysholm, and Tegner scores] were analyzed. Results: Eleven patients (6 females; mean age, 14.4 y) who sustained PCL injuries were treated nonoperatively, At a mean clinical follow-up of 26.7 months, none of the patients who underwent nonoperative treatment had symptomatic instability, with a 100% return-to-play rate. The mean Pedi-IKDC, Lysholm, and Tegner scores were 87.4, 89.0, and 7.5, respectively. In the 15 knees of 14 patients who underwent surgery (4 female; mean age, 15.1 y) mean clinical follow-up was 27.8 months. All of the patients achieved full or near-full range of motion, and none of the patients showed growth arrest or angular deformity. However, 1 patient showed mild joint-space narrowing, and the mean Pedi-IKDC, Lysholm, and Tegner scores were 81.3, 80.1, and 7.2, respectively. Patients who had sustained knee dislocations had lower Pedi-IKDC scores than those who had not dislocated, 70.2 versus 85 (P=0.047). Conclusions: Outcomes for nonoperative treatment of partial PCL tears or nondisplaced avulsion injuries are good in young patients. PCL repair or reconstruction is a safe and viable treatment option in pediatric and adolescent patients with multiligament injuries or those with isolated PCL injury who have failed conservative treatment, with outcomes related to the severity of the initial injury. Level of evidence: Level IV, retrospective case series.

Effect of timing of ACL reconstruction in surgery and development of meniscal and chondral lesions.

Abstract Purpose: To investigate whether a delay in the timing of surgery of > 6 months compared with performing the surgery > 6 months after the anterior cruciate ligament (ACL) injury leads to an increased risk of injuries or degenerative changes in the ACL-deficient knee. Methods: Patients who underwent primary ACL reconstruction at an academic tertiary care center, and had preoperative magnetic resonance imaging (MRI) performed within 2 months of the time of the ACL injury were included. The prevalence of degenerative changes at the time of surgery was assessed and related to the timing of ACL surgery, with “early reconstruction” defined as a surgery performed ≤ 6 months and “delayed reconstruction” defined as surgery performed > 6 months after ACL injury. “New” meniscal tears were defined as lesions detected at the time of surgery that were not detected by MRI. Results: Of 195 patients who were selected based on inclusion criteria, 171 patients underwent surgery ⩽ 6 months after their ACL injury, and 24 patients underwent surgery > 6 months after their ACL injury. The prevalence of new medial meniscal tears in the early reconstruction group was 4.1%, while in the delayed reconstruction group, the prevalence was 16.7% (P = 0.012). Conclusion: A delay in the timing of ACL reconstruction from ≤ 6 months to > 6 months following injury is associated with a significant increase in the prevalence of medial meniscal tears (P = 0.012), with a relative risk of 4.07 (CI, 1.29-12.88). Conclusion: A delay in the timing of ACL reconstruction from > 6 months to < 6 months following injury is associated with a significant increase in the prevalence of medial meniscal tears (P = 0.012), with a relative risk of 4.07 (CI, 1.29.12.88).