Douglas N. Mintz

The incidence of soft tissue injury in operative tibial plateau fractures. A magnetic resonance imaging analysis of 103 patients

Objectives: The goal of this study was to determine the incidence of injury to soft tissue structures of the knee in tibial plateau fractures scheduled for surgery. Design: Prospective cohort. Setting: Level I academic medical center. Patients/Participants: One hundred three consecutive patients with acute tibial plateau fractures indicated for operative intervention. Intervention: Standard x-ray examinations, including anteroposterior, lateral, and oblique views, were performed in the emergency department. Subsequently all patients had magnetic resonance imaging performed. The Schatzker and AO/OTA classifications were used to classify each fracture pattern based solely on the x-rays. Soft tissue injuries were assessed by magnetic resonance imaging. Main Outcome Measurements: Fifteen categories of injury were determined as positive or negative on each magnetic resonance imaging, which included tears of the cruciates, collateral ligaments, menisci, and posterolateral corner. Results: The overall incidence of injury to soft tissues was higher than previously reported. Only 1 patient (1%) in the series had complete absence of any soft tissue injury. Seventy-nine patients (77%) sustained a complete tear or avulsion of 1 or more cruciate or collateral ligaments. Ninety-four patients (91%) had evidence of lateral meniscus pathology. Forty-five patients (44%) had medial meniscus tears. Seventy patients (68%) had tears of 1 or more of the posterolateral corner structures of the knee. The most frequent fracture pattern was a lateral plateau split-depression (Schatzker II) (60%). No pure depression injuries (Schatzker III, AO/OTA 41-B2) were seen. Conclusions: The incidence of complete ligamentous or meniscal disruption associated with operative tibial plateau fractures was higher than previously reported. Though the clinical importance of injury to each of these structures is unknown, the treating surgeon should be aware that a variety of soft tissue injuries are common in these fractures. In addition, all fractures had at least 1 cortical split visible on magnetic resonance imaging, implying that pure depression patterns are very rare or may not exist.

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, …

Power Doppler sonography in the diagnosis of hemophilic synovitis – a promising tool

Summary.  Background: Recurrent hemarthroses in hemophilia results in synovitis and joint arthropathy. Primary prophylaxis when universally instituted at current doses can prevent joint deterioration but is expensive. Alternatively, the selective implementation of prophylaxis would require a more sensitive tool for detecting synovitis than possible with clinical surveillance or plain radiographs. Magnetic resonance imaging (MRI) is such a tool and is utilized for the evaluation of hemophilic joint disease (HJD). However, it is expensive, and requires sedation in younger children precluding its utility for monitoring of synovitis. Ultrasonography (USG) with power Doppler (USG‐PDS) has been utilized to detect and quantitate synovial vascularity in other arthritides and could provide an equally effective but less costly tool for HJD, particularly in children who would not require sedation. Objectives: To determine whether USG‐PDS is comparable to MRI in the evaluation of hemophilic synovitis. Patients: A prospective cohort of 31 subjects including 33 joints (knees, elbows, ankles) underwent dynamic contrast enhanced (DCE)‐MRI and USG‐PDS. Results: USG‐PDS measurements of synovial thickness(r = 0.70, P < 0.0001) and synovial vascularity (r = 0.73, P < 0.0001) correlated strongly with those obtained with DCE‐MRI. A cutoff of PDS intensity of 1.3 decibels (dB) per mm2 was found to yield a sensitivity of 100% and a specificity of 94.1% in 17 joints with/without a history of hemarthroses. Pettersson radiographic scores correlated significantly with synovial thickness in adults but not children. Conclusions: Our data suggest that USG‐PDS may be an inexpensive and easily implemented imaging tool for detecting hemophilic synovitis and could be useful in tailoring effective prophylaxis.

Long-Term Magnetic Resonance Imaging Follow-up Demonstrates Minimal Transitional Level Lumbar Disc Degeneration After Posterior Spine Fusion for Adolescent Idiopathic Scoliosis

Study Design. Retrospective cohort study. Objective. To describe long-term clinical and imaging results focusing on the uninstrumented lumbar spine after posterior spinal fusion for adolescent idiopathic scoliosis. Summary of Background Data. Although previous studies found rates of low back pain after long fusion for adolescent idiopathic scoliosis which are comparable to rates found in the general population, many surgeons believe that the long lever arm associated with the fusion mass will result in increased stress at uninstrumented caudal intervertebral discs and accelerated degenerative changes. Methods. This is a retrospective chart and imaging review of adolescent idiopathic scoliosis patients treated with posterior fusion and segmental instrumentation. Patients completed follow-up examination, outcome questionnaires, radiographs, and magnetic resonance (MR) imaging. MR images were scored for evidence of degeneration of lumbar discs below the level of the fusion. Results. Twenty patients participated in the study, providing 90 discs below fusions for evaluation. The average follow-up was 11.8 years. The distal level of fixation was at L1 on average. The major curve averaged 55° ± 11° before surgery and was corrected to 25° ± 10° at follow-up. Follow-up MR imaging demonstrated new disc pathology in 85% of patients enrolled. Only one patient demonstrated significant degenerative disc disease at the junctional level, whereas most pathology was seen at the L5–S1 disc. The average Pfirrmann grade at uninstrumented levels deteriorated from 1.1 before surgery to 1.8 at follow-up. The greatest degree of degeneration was seen at the L5–S1 disc space where average degenerative scores increased from 1.2 before surgery to 2.3 after surgery. Three patients with severe disc disease were taking nonsteroidal anti-inflammatory drugs for pain, but no narcotics. Only mild scoliosis research society (SRS) and Oswestry changes were noted in this severe degeneration group. Conclusion. Despite demonstrating an accelerated rate of L5–S1 disc degeneration, our study group has good functional scores and maintenance of correction over 10 years postfusion. In this long-term MR imaging follow-up study, disc degeneration was found remote to the lowest instrumented vertebra.

MRI features of confirmed "pre-slip" capital femoral epiphysis: a report of two cases

Abstract.We describe the morphologic and signal changes detected about the proximal femoral growth plate in two patients with hip pain preceding the progression to slipped capital femoral epiphysis using magnetic resonance imaging.

SPECT/CT in the Management of Osteochondral Lesions of the Talus:

Background: The treatment of osteochondral lesion of the talus (OLT) is mainly based upon the stage of the disease so accurate imaging is crucial. SPECT/CT combines bone scan with high-resolution CT and can provide functional-anatomical images in a single stage. The purpose of this study was to assess the value of SPECT/CT in the management of OLT. Materials and Methods: From 2004 to 2009, 22 patients with OLT were identified that had both SPECT/CT and MRI of the foot and ankle. All charts were reviewed to ascertain the reason for ordering the SPECT/CT and the additional information obtained. AOFAS outcome scores were calculated at the time of followup. Results: Twelve patients underwent ankle arthroscopy for debridement or drilling of the osteochondral lesion. The mean AOFAS score in these 12 patients was 83.6. SPECT/CT helped preoperative planning by identifying the exact location of the active lesion, especially in multifocal disease or revision surgeries while showing the depth of the active lesion. Ten patients had conservative management due to minimal or no activity over the lesion on SPECT/CT images. The mean AOFAS score in these ten patients was 78.8 which was comparable to the operative group. Conclusion: We believe SPECT/CT was able to provide additional diagnostic value by demonstrating a co-existing pathology as a potential cause of pain and in preoperative planning by showing the depth of activity and the precise location of the active segment in multiple lesions. Level of Evidence: III, Retrospective Case Control Study

Dermatomyositis and calcific myonecrosis in the leg: ultrasound as an aid in management

Calcific myonecrosis, often reported in the setting of prior trauma or compartment syndrome, has traditionally been treated with surgical debridement; however, these cases are often complicated by poor wound closure and poor healing. Serial percutaneous aspirations, instead, have been proposed as an alternative treatment option. This is the first report, to our knowledge, of the use of ultrasound guidance in the aspiration of calcific myonecrosis as an aid in management.

Thromboembolic Disease After Combined Anterior/Posterior Reconstruction for Adult Spinal Deformity : A Prospective Cohort Study Using Magnetic Resonance Venography

Study Design. Thromboembolic disease (TED) after anterior/posterior spinal reconstructions was prospectively evaluated in 66 consecutive patients. Objective. Determine the incidence of TED after anterior/posterior spinal reconstruction. Summary of Background Data. Few studies have examined the rate of TED after potentially high-risk combined anterior/posterior reconstructions. Magnetic resonance venography (MRV) is more effective at detecting pelvic deep venous thrombosis (DVT) than conventional screening, but has not been used in these patients. Methods. We undertook a prospective cohort study of 66 consecutive adult patients (mean, 52.7 ± 9.6 years) undergoing combined anterior/posterior spinal reconstructions for spinal deformity. All patients received only mechanical DVT prophylaxis. After surgery, MRV and bilateral lower extremity Doppler ultrasounds were obtained to screen for DVT, and contrast-enhanced spiral computed tomography scans were obtained for clinical suspicion of pulmonary embolism (PE). Results. The total incidence of postoperative TED was 13.6% (9 patients). The overall rate of DVT was 9.1% (6 patients), one-third occurring in the pelvis. PE developed in 7.6% (5 patients). In 2 patients, PE developed less than 48 hours after positive dopplers. In 3 patients, PE developed despite negative screening studies. Right-sided thoracoabdominal approaches were associated with an increased risk of developing DVT (P = 0.03, Odds Ratio 9.8), PE (P = 0.01, Odds Ratio 20), and TED (P = 0.004, Odds Ratio 12). Conclusion. We report a high rate of TED after extensive anterior/posterior spinal reconstructions, for which a right-sided thoracoabdominal approach is an independent risk factor and screening ineffective at preventing PE. These patients should be considered at high risk for postoperative TED.

MR imaging of the sternoclavicular joint following trauma

The purpose of this study is to describe the magnetic resonance imaging (MRI) findings of the sternoclavicular (SC) joint seen in patients who presented to our department with joint pain related to trauma. Clinical history and MRI findings on 41 patients were reviewed retrospectively to establish types and frequencies of soft tissue injuries and subluxations. Because both SC joints were imaged, the asymptomatic joints were used as a control group. Articular disk injuries were seen in 80% of patients. Injuries of the anterior, posterior, interclavicular and costoclavicular ligaments were seen in 73%, 39%, 29% and 14% of patients, respectively. Most clavicular subluxations were in the superior and posterior directions. Posterior impingement of mediastinal structures was seen in cases of posterior clavicular subluxation as well as in cases of retrosternal inflammatory or fibrotic tissue without clavicular subluxation. Biomechanical models of the SC joint are discussed to explain how different ligamentous injuries typically result in different types of subluxations.

The use osteochondral allograft in the treatment of a severe femoral head fracture.

This study reviews the second case in the literature involving the use of frozen osteochondral allograft to reconstruct a femoral head fracture-dislocation. The case involved significant, unreconstructable damage to the weightbearing area of the femoral head in an 18-year-old male. Clinical and diagnostic imaging follow up at 46 months revealed that despite magnetic resonance imaging and radiographic evidence of progressive arthrosis in the hip, including subchondral cystic change in the femoral head and localized cartilage loss in the acetabulum and femoral head, the patient had excellent function with no complications (Harris hip score 100, hip dysfunction and osteoarthritis outcome score 62, musculoskeletal function assesment score 22, SF-36 score 81). The use of osteochondral allograft may serve as a useful tool for the orthopaedic surgeon faced with an unreconstructable femoral head fracture-dislocation in a young patient.