Faizal Rayan

Validation of the classification system for acetabular chondral lesions identified at arthroscopy in patients with femoroacetabular impingement

There have been considerable recent advances in the understanding and management of femoroacetabular impingement and associated labral and chondral pathology. We have developed a classification system for acetabular chondral lesions. In our system, we use the six acetabular zones previously described by Ilizaliturri et al. The cartilage is then graded on a scale of 0 to 4 as follows: grade 0, normal articular cartilage lesions; grade 1, softening or wave sign; grade 2, cleavage lesion; grade 3, delamination; and grade 4, exposed bone. The site of the lesion is further classed as A, B or C based on whether the lesion is less than one-third of the distance from the acetabular rim to the cotyloid fossa, one-third to two-thirds of the same distance and greater than two-thirds of the distance, respectively. In order to validate the classification system, six surgeons graded ten video recordings of hip arthroscopy. Our findings showed a high intra-observer reliability of the classification system with an intraclass correlation coefficient of 0.81 and a high interobserver reliability with an intraclass correlation coefficient of 0.88. We have developed a simple reproducible classification system for lesions of the acetabular cartilage, which it is hoped will allow standardised documentation to be made of damage to the articular cartilage, particularly that associated with femoroacetabular impingement.

Is the frog lateral plain radiograph a reliable predictor of the alpha angle in femoroacetabular impingement

The radiological evaluation of the anterolateral femoral head is an essential tool for the assessment of the cam type of femoroacetabular impingement. CT, MRI and frog lateral plain radiographs have all been suggested as imaging options for this type of lesion. The alpha angle is accepted as a reliable indicator of the cam type of impingement and may also be used as an assessment for the successful operative correction of the cam lesion. We studied the alpha angles of 32 consecutive patients with femoroacetabular impingement. The angle measured on frog lateral radiographs using templating tools was compared with that measured on CT scans in order to assess the reliability of the frog lateral view in analysing the alpha angle in cam impingement. A high interobserver reliability was noted for the assessment of the alpha angle on the frog lateral view with an intraclass correlation coefficient of 0.83. The mean alpha angle measured on the frog lateral view was 58.71 degrees (32 degrees to 83.3 degrees ) and that by CT was 65.11 degrees (30 degrees to 102 degrees ). A poor intraclass correlation coefficient (0.08) was noted between the measurements using the two systems. The frog lateral plain radiograph is not reliable for measuring the alpha angle. Various factors may be responsible for this such as the projection of the radiograph, the positioning of the patient and the quality of the image. CT may be necessary for accurate measurement of the alpha angle.

Review of evolution of tunnel position in anterior cruciate ligament reconstruction.

Anterior cruciate ligament (ACL) rupture is one of the commonest knee sport injuries. The annual incidence of the ACL injury is between 100000-200000 in the United States. Worldwide around 400000 ACL reconstructions are performed in a year. The goal of ACL reconstruction is to restore the normal knee anatomy and kinesiology. The tibial and femoral tunnel placements are of primordial importance in achieving this outcome. Other factors that influence successful reconstruction are types of grafts, surgical techniques and rehabilitation programmes. A comprehensive understanding of ACL anatomy has led to the development of newer techniques supplemented by more robust biological and mechanical concepts. In this review we are mainly focussing on the evolution of tunnel placement in ACL reconstruction, focusing on three main categories, i.e., anatomical, biological and clinical outcomes. The importance of tunnel placement in the success of ACL reconstruction is well researched. Definite clinical and functional data is lacking to establish the superiority of the single or double bundle reconstruction technique. While there is a trend towards the use of anteromedial portals for femoral tunnel placement, their clinical superiority over trans-tibial tunnels is yet to be established.

Do physical diagnostic tests accurately detect meniscal tears

Thank you for your comment. We would like to congratulate Karachalios et al. [1] on the development of ‘The Thessaly Test’. This new test is user friendly and adds to the available array of diagnostic tests for detection of meniscus tears. While the points raised here are valid, they have already been discussed in our paper [2]. The fact that our study is a cohort study is evident from our methodology. The study was not designed to have a control group as a prospective randomized study. It was designed to assess a group of meniscal tears to see which tests were positive when there was a high likelihood that the test should be positive. The smaller study numbers and their effect on diagnosis in the presence of confounding knee injuries have been stated in the first paragraph of our discussion. The possibility of selection bias has also been addressed in our discussion. The study described by Karachalios et al. [1] was based on careful patient selection. The reality is that it does not reflect standard clinical practice. We have attempted the study in a clinical setting where patients may have confounding injuries. We believe that multiple factors have to be considered prior to the diagnosis of a meniscus tear. Various diagnostic tests and investigations help in the clinical decision analysis. They should be commended on a robust defense of their test but they should learn to accept its limitations. The sole use of any single diagnostic test as a selection tool for arthroscopic intervention cannot be supported based on currently available studies.

The Role of Impaction Grafting: The When and How

The challenges of acetabular revision include bone loss and poor bone biology. Favorable 10-year reports exist of uncemented acetabular revision using hemispherical uncemented sockets. In the presence of bone stock deficiency, adjunctive morsellized impaction bone grafting is a recognized means of restoring bone stock. We attempt to restore bone stock with impaction grafting beneath a cementless cup for contained defects, defects that can be rendered contained, and whenever there is capacity for rim fixation. The technique of bone graft preparation is important. We use a mixture of bone milling and bone chips of various sizes. Morsellized allograft is inserted, packed, and/or reverse reamed into any defects. The reconstruction relies on the ability to gain biological fixation of the component to the underlying host bone. This requires intimate host bone contact and rigid implant stability. The fixation is therefore augmented with screws in all cases. It is important to achieve host bone contact in a least part of the dome and posterior column. When this is possible, and particularly when there is a good rim fit, we have not found it absolutely necessary to have contact with host bone over >50% of the surface. Stability of primary fixation is a better predictor of outcome than volume of graft or percentage of host bone contact. The advantages of bone grafting in acetabular reconstruction include the ability to restore bone stock, rebuild a normal hip center and hip biomechanics, and increase bone stock for future revisions.

Common extensor origin release in recalcitrant lateral epicondylitis - role justified?

The aim of our study was to analyse the efficacy of operative management in recalcitrant lateral epicondylitis of elbow. Forty patients included in this study were referred by general practitioners with a diagnosis of tennis elbow to the orthopaedic department at a district general hospital over a five year period. All had two or more steroid injections at the tender spot, without permanent relief of pain. All subsequently underwent simple fasciotomy of the extensor origin. Of forty patients thirty five had improvement in pain and function, two had persistent symptoms and three did not perceive any improvement. Twenty five had excellent, ten had well, two had fair and three had poor outcomes (recurrent problem; pain at rest and night). Two patients underwent revision surgery. Majority of the patients had improvement in pain and function following operative treatment. In this study, an extensor fasciotomy was demonstrated to be an effective treatment for refractory chronic lateral epicondylitis; however, further studies are warranted.

Correction of neglected clubfoot deformity in children with Moebius syndrome.

The aim of this study was to present the functional results of treatment of neglected clubfoot in children with Moebius syndrome. A prospective analysis of seven patients with Moebius syndrome who had corrective surgery for clubfoot deformity was performed. Functional result using a modified American Orthopaedic Foot and Ankle Society (AOFAS) questionnaire at an average follow-up of 58 months was analysed. Five children were able to have their foot flat on the ground. Additional corrective surgery was required in eight feet. Our experience of treating neglected clubfoot deformity in children with Moebius syndrome shows that correction of the deformity allows them to have a reasonable independent living.

Preoperative digital templating of Birmingham hip resurfacing

The aim of our study was to determine the usefulness of preoperative digital templating of Birmingham hip resurfacing (BHR). This prospective cohort of 30 consecutive Birmingham hip resurfacings was templated digitally by two senior hip arthroplasty fellows (GM, JG) independently. A blinded observer then collated information on the actual implant sizes intraoperatively and used this to statistically analyse the correlation (Interclass correlation coefficient) between the digitally templated implant sizes and the actual implant sizes used. A significantly high rate of coincidence between digitally templated estimates and the actual implant sizes was noted for both groups of templates. The Intra class correlation coefficient (ICC) for the acetabular cup in the two groups were 0.798, p=0.013 and 0.870, p=0.0001. For the femoral component, the ICC values in the two groups were 0.888, p=0.005 and 0.784, p=0.003. Similarly a high reliability of digital templating was noted for both acetabular (0.823, 0.888) and femoral components (0.777, 0.8132). In conclusion, digital templating can reliably estimate implant sizes in Birmingham hip resurfacing.