AP Radiographs Research Articles

Heterotopic Ossification: A Challenging Complication of Total Hip Arthroplasty: Risk Factors, Diagnosis, Prophylaxis, and Treatment.

Background This review is intended to summarize the risk factors, classification, diagnosis, and treatment of heterotopic ossification (HO) of previously published studies. Results Heterotopic ossification is a common complication of total hip arthroplasty. Its prevalence is not the same in all of the patient groups. Frequency of HO varies from 15 to 90%. Hip ankylosis, male gender, and previous history of HO are said to be risk factors with a significant level. Diagnosis is based on a single AP radiograph: the Brooker classification that divides HO into four grades is the most commonly used. The confirmation test that can be used is a bone scan. A great amount of bone metabolic turnover markers have been tested, but none of them seems to be relevant in case of prevention or diagnosis of HO. The most effective prophylactic treatment is radiotherapy or administration of nonsteroidal anti-inflammatory drugs. Over the years a lot of different RT protocols have been tested. Nowadays the most often used regimen is 7 Gy given postoperatively in a single dose. The most commonly prescribed drug in prophylaxis of HO is indomethacin. Also, the efficacy of ibuprofen and diclofenac was proven. Recently researchers focused on selective COX-2 inhibitors. They appear to be as effective as nonselective NSAIDs having less side effects. The one and only treatment of HO is a revision arthroplasty.

Optimization of electronic prescription for parallel external fixator based on genetic algorithm.

For the parallel external fixator, there are some defects, such as uneven distraction rate, unbearable pain and uncontrollable movement trajectory in practical clinical applications. In order to solve the problems, a new deformity correction algorithm, which is used to calculate the elongation of the six struts, is developed. Meanwhile, the corresponding computer software for getting the electronic prescription is developed. First, the trajectory of the moving bone is planned by Cartesian coordinate path control. Next, the prescription is obtained from the trajectory by the inverse pose solution algorithm. Finally, the genetic algorithm is utilized to optimize the achieved prescription. From the year of 2015 to 2018, twenty-three patients with complicated tibia deformity are treated by using parallel external fixator and the developed computer software. All patients have standing, patella-forward, full-length post-operative AP and lateral radiographs of the lower limbs with the complete proximal ring for getting the deformity parameters and frame parameters. These parameters are input into the computer software to calculate a daily prescription schedule for strut adjustment. Radiographs are taken regularly to determine the effects of recovery during the correction process. The mean time of follow-up is 18months (range 11-40months). All patients reach the requirements for deformity correction, and their symptoms and appearance are improved significantly. No cases of wound infections or complications occur, and no severe pain came as well during the correction process. By using the computer-aided parallel external fixator for the correction of lower limb deformities, satisfactory outcomes can be achieved. Hence, this method greatly improved the treatment of these patients in a clinical application.

Radiostereometric Analysis of Subpectoral versus Suprapectoral Biceps Tenodesis with Interference Screw Fixation

Objectives: Biceps tenodesis is performed with increasing frequency for various pathologies of the long head biceps tendon (LHBT). Multiple surgical techniques and devices for tenodesis have been described with favorable outcomes. The subpectoral approach provides adequate clinical outcomes; furthermore, recent research suggests that similar outcomes can be achieved via arthroscopic suprapectoral biceps tenodesis. Previous studies have compared the biomechanical profile of suprapectoral and subpectoral biceps tenodesis. There is a paucity of data regarding the biomechanical behavior and construct stability of suprapectoral and subpectoral biceps tenodesis in vivo. The purpose of this investigation is to quantify and compare the behavior of the biceps tenodesis construct in arthroscopic suprapectoral (ASPBT) and open subpectoral (OSPBT) techniques, with radiostereometric analysis (RSA). Methods: This is a prospective cohort study comparing migration of the biceps tendon after suprapectoral and subpectoral biceps tenodesis with Polyetheretherketone (PEEK) interference screw fixation. Thirty consecutive patients were allocated to the subpectoral group, follow by thirty consecutive patients to the suprapectoral group. Patients aged 18-65 years with symptomatic biceps tendinopathy, anterior intertubercular groove tenderness, and positive biceps tension tests were included in the investigation. Patients undergoing revision biceps tenodesis, shoulder arthroplasty, or ruptured LHBT were excluded. A mini skin staple, functioning as a radiostereometric marker, was placed longitudinally within the tendon prior to final fixation with interference screw. Staple stability was confirmed with a hemostat to gravity. The distance from the most proximal portion of the mini skin staple and the most proximal aspect of the humeral head was measured. Following final fixation with an interference screw, AP radiographs were obtained intraoperatively. Follow-up radiographs were one week and 12 weeks post-operatively. A paired and non-paired students t-test were utilized to assess for intra-group and inter-group changes, respectively. Results: A total of 60 consecutive patients (30 per group) were enrolled and available for follow-up imaging at 1 and 12 weeks postoperatively. The average age was 43.5±10.5 years, average BMI was 28.3±5.4, and 50% of the patients were females. Groups were similar with respect to patient demographics and concomitant procedures (P>.05). In the OSPBT group, the average distance of the radiostereometic marker to the proximal humeral head increased on by 26.0 mm (SD, 15.7) from the immediate post-operative radiograph to 3 months postoperatively (P=0.002). In the ASPBT group, the average distance also significantly increased by 24.7 mm (SD, 14.9) from the immediate post-operative radiograph to 3-months postoperatively (P=0.001). The change in distal migration between the ASPBT and OSPBT was not found to be statistically significant (P> 0.05). Conclusion: Biceps tenodesis performed with a PEEK tenodesis screw results in significant distal migration of the biceps tendon by 3 months post-operatively; however, there was no significant difference in distal migration between the OSPBT and ASPBT groups.

DOES ACL TUNNEL PLACEMENT AFFECT QUALITY OF LIFE IN ADOLESCENTS?

Purpose: The aim of this study was to evaluate the influence of surgical experience of an orthopaedic surgeon on femoral and tibial tunnel placement during anterior cruciate ligament (ACL) reconstruction, and the effect of tunnel angle on patient self-report outcomes. Methods: We retrospectively reviewed 115 consecutive ACL reconstruction surgeries by a single fellowship-trained orthopaedic surgeon over his first 5 years in practice. 70 patients with hamstring (HS) and 44 patients with bone-patellar tendon-bone (BTB) autografts were included, all epiphyseal approaches, graft hybrids or allografts were excluded. Posterior distal femoral angle (PDFA), femoral and tibial tunnel angulation were measured on AP and lateral radiographs by 2 independent raters with high inter-rater reliability (ICC >0.8 for all measures). Tunnel angulation was compared to recently reported ideal femoral angle of 33.5°±1.8 or ideal tibial angle of 62.5°±5 (Luthringer et al, 2016). Complications and self-report outcomes - pediIKDC, Tegner-Lysholm and KOOSChild - were recorded, as well as demographics, injury and surgery characteristics (e.g. concurrent meniscal repairs, chondroplasty, tourniquet time). Average follow-up was 1.14 years. Continuous variables were analyzed using unpaired t-test, Wilcoxon rank sum test and Spearman correlation. Categorical variables were analyzed using Fisher’s exact test. Results: ACL reconstruction was performed at an average age of 16.7 years (range, 11.8 to 20.4 years), 59% males. Figure 1 shows tunnel angles over case groups of N=15. For HS autografts, femoral tunnel angle and tibial tunnel angle improved toward the ideal angle after 15 cases (ANOVA, p=0.020 and p=0.031, respectively). For BTB autografts, femoral tunnel angle and tibial tunnel angle did not demonstrate a significant change over cases (Figure 1). The tibial tunnel angle in HS cases showed a negative weak correlation with the selected outcome scores at 6 months and 1 year after ACL reconstruction, whereas the tibial tunnel angle in BTB cases showed a weak positive correlation with KOOSChild pain scores 6 months after initial surgery (Table 1). For either graft type, femoral tunnel angle was not correlated with any outcome measure. Overall, self-report outcome scores were similar between patients with ideal and non-ideal tunnel angles (data not shown). Of the 70 patients with HS autografts, 5 (7%) required a secondary surgery: 2 revisions for graft tear, 1 revision for a non-functional graft, 1 for arthrofibrosis and 1 for a prominent tibial screw. PDFA, femoral and tibial tunnel angle were similar between patients needing secondary surgery and those who did not (Table 2). Patients needing revision surgery had significantly lower Tegner-Lysholm and KOOSChild Pain scores at 6 months after the initial ACL reconstruction. Of the 44 BTB patients, 3 (6.8%) had complications: 2 patients developed arthrofibrosis and subsequently underwent surgery, and 1 patient experienced neuropathy. In these patients, the PDFA was significantly higher, the femoral tunnel angle significantly lower and tibial tunnel angle similar compared to those without a complication (Table 2). Demographic factors, injury and surgical parameters (concurrent meniscal repairs, chondroplasty, tourniquet time, aso) were similar between HS patients with or without additional surgery and between BTB patients with and without complications. Conclusion/Significance: Femoral and tibial tunnel angle improved towards the reported ideal angle after 15 cases for HS autografts. PDFA, femoral and tibial tunnel angle were not associated with surgical complications in HS patients. For BTB autografts, no significant changes were seen in tunnel placement with surgical experience. Patients experiencing complications after BTB autografts had a low femoral tunnel angle and high PDFA. Overall, tibial tunnel angle, but not femoral tunnel angle, correlated with outcome scores of patients with BTB and HS autografts. [Figure: see text][Table: see text][Table: see text]

The Fate of the Syndesmosis Screw in Syndesmotic Injuries

Summary Introduction: Ankle fractures are common orthopedic injuries. Some ankle fractures are associated with syndesmosis injuries and surgical treatment is indicated. Screw fixation is the gold standard for fixation of sindesmotic rupture. However, there are different opinions in terms of implementation and follow-up. The current literature advocates that it should be removed in 6-8. weeks, some recent publications and surgeon opinions suggest that screws need not to be removed. The aim of this study was to compare the clinical results of patients with and without sindesmotic screw removal. Material and Methods: Thirty-one patients with sindesmosis fixation were retrospectively reviewed. The minimum follow-up period is 12 months. In the clinical evaluation, the Manchester Oxford Foot Questionnaire (MOXFQ) and the visual pain scale (VAS) were used. The final state of the screw (removed, fractured, intact) was evaluated with standard AP and lateral radiographs. Measurements of ankle joint motion were measured by goniometer Conclusion: A total of 33 patients were included in the study. Sindesmotic screw was removed in 39.4% (n = 13) of the cases and it was observed that 60.6% (n = 20) had not been removed. There were no statistically significant differences between the two groups. Discussion: There was no statistically significant difference between the two groups with and without sindesmotic screw removal. We believe that the removal of the syndesmotic screw should not be recommended considering our limited experience and current literature.

Preoperative Evaluation of Intramedullary Tibial Nail Measurements-A Review of the Literature and a New Technique Using Contralateral Radiographs and Digital Planning.

Introduction:An accurate selection of tibial nail and screws measurements is paramount in purpose to achieve proper tibial fracture reduction and fixation, avoid irritation of the soft-tissue envelope, and enable extraction of the nail in the future, if needed. To this date, many methods were suggested to determine the length and diameter of an intramedullary tibial nail, preoperatively and intraoperatively. Each method has its disadvantages, and most are lacking in accuracy. Digital aids are currently available for preoperative planning for many types of surgeries.Methods:Retrospectively, 27 patients operated for diaphysial tibial fracture intramedullary nailing were selected. The contralateral leg was imaged using AP and lateral radiograph views. Six orthopaedic trauma surgeons used the TraumaCad program (Voyant Health) to plan the appropriate nail and distal locking screws measurements, while blinded from the actual hardware used in the operation. Later, they also conducted quality review regarding the operation carried out and suggested correction in measurements of the hardware. Intra-observer and inter-observer reliability was calculated.Results:The inter-correlation coefficient for the planned nails was 0.97 and 0.84 (P < 0.001) in AP view for length and diameter, respectively, and similarly 0.98 and 0.86 (P < 0.001) in lateral view. The interclass correlation coefficient (ICC) for the locking screws length was 0.7 (P < 0.02) and 0.82 (P < 0.01) for the proximal and distal medio-lateral screws, respectively, and 0.9 (P < 0.001). The ICC between AP and lateral views was 0.98 for length and 0.96 for diameter (P < 0.001). The scores and corrections given by the examiners to the actual selected nail were ICC of 0.98 and 0.96 (P < 0.001) for length and diameter, respectively. The examiners suggested they would correct, post-factum, the length of the nail in average 28% and the diameter in average 30%. The average observer resulted in ICC of 0.94 and 0.91 (P < 0.001) in length and only 0.77 and 0.67 (P < 0.001) in diameter (AP and lateral views, respectively) when comparing the actual nail used and the post-factum plan.Conclusion:Preoperative planning of tibial fractures' nailing using imaging of the contralateral leg and a digital graphic planning program is an accurate and reliable method. It may serve to reduce errors, surgical time, and radiation dose in the operating room. This method could also be applied for surgical debriefing.

A new radiographic acetabular cup anteversion measurement method in total hip arthroplasty: a clinical study.

The acetabular cup positioning is one of the most crucial steps affecting stability and wear rates in total hip arthroplasty. Different methods have been described for determining the anteversion of the acetabular cup in the literature. But there is still not a widely accepted method to assess the acetabular anteversion radiography. The aim of this study is to measure the acetabular anteversion angle on a single pelvis AP radiography with our method which was proven with an experimental study before. A total of 15 patients (8 males, 7 females) who underwent total hip arthroplasty and have had a pelvis computed tomography scans in our outpatient clinic were evaluated retrospectively. The anteversion angle was calculated in all of pelvis CT scans. For radiological measurement, the formula defined by the authors in an experimental model previously was used. Statistically significant difference was not determined between radiographic and CT-based measurements (p = 0.207; p > 0.05). A statistically significant agreement was observed at a level of 98.8% between radiographic and CT-based measurements (ICC = 0.988; 95% CI 0.966-0.996; p < 0.01). Assessment of the acetabular cup anteversion is very important to predict the possible complications after total hip arthroplasty. Although many methods have been defined for this purpose, each of these has advantages and disadvantages. In particular, with computed tomography method, the patient is exposed to excessive radiation, whereas we think that our method is a preferred method due to features not requiring additional equipment, low radiation exposure, being simple, cost-effectiveness, easily applicable and almost 100% accurate.

Evaluation of mid-term clinical and radiologic outcomes after open reduction and internal fixation of lisfranc fracture-dislocations: A case series

Aim: To evaluate the mid-term clinical and radiologic outcomes after surgical treatment of Lisfranc fracture dislocations. Material and Methods: Twenty unstable Lisfranc joint fracture dislocation patients treated with open reduction and internal fixation (ORIF) were evaluated retrospectively. Kirschner wire, screw or a combination of Kirschner wire (K-wire) and screw fixation were used in the internal fixation. American Orthopedic Foot and Ankle Society - Midfoot Scale (AOFAS-MS) score, Maryland foot score, Visual Analog Scale (VAS) and SF-36 survey were obtained at the last follow-up. Nonunion, implant failure, reduction quality and the degree of posttraumatic arthritis were evaluated on the AP, lateral and oblique foot radiographs. The outcome measures included the Kellgren-Lawrence grading of osteoarthritis and the Stein’s criteria for anatomic reduction.Results: The mean follow-up duration was 3.7±1.4 years. Mean AOFAS and Maryland foot scores were 75.3±1.72 and 71.8±2.3, respectively. Nonunion was developed in three patients (15%) and posttraumatic arthritis was observed in 7 patients (35%).Conclusion: Good overall clinical and radiologic outcomes can be obtained in the mid-term follow up after open reduction and internal fixation of Lisfranc fracture dislocations. However, higher-energy injuries such as open fracture-dislocations and Myerson type C2 injuries have poor outcomes.Keywords: Fracture dislocation; lisfranc; open reduction; arthritis.

Carpal Coalition: Is It Really Rare and Incidental Finding?

Objectives: Carpal coalition (CC) defines the combined development of two or more carpal bones. The diagnosis is often made incidentally by the radiographs. Incidence of CC changes with ethnicity. CC may cause various symptoms because of the coalition type and the affected bones. We aim to analyze the incidence of CC, affected bones, define the symptoms and find out the correlation between CC, demographic factors and associated hand anomalies. Methods: A total of 9457 hand and wrist AP radiographs were retrospectively analyzed. 9162 radiographs were included in the study. If a coalition was found, affected bones, patient’s age and gender, clinical findings and concomitant hand abnormalities were recorded. Results: 29 CC cases, including 16 female (55.2%) and 13 male (44.8%) patients were found. The CC incidence was %0.3. Mean age was 34.6 (range between 13-80). There were 25 (86.3%) lunotriquetral coalitions (LTC), 2 capitate-trapezoid coalitions (CTC) (6.9%), 1 (3.4%) hamate-pisiform coalition (HPC), and 1 (3.4%) trapezium-trapezoid coalition (TTC) in the study population. There was non-traumatic wrist pain in 8 (27.5%) cases, and there was limited wrist motion in 1 (3.5%) case. 7 of 8 non-traumatic wrist pain cases had LTC, and 1 of 8 had HPC. LTC was found in the case with limited wrist motion. There was bilateral CC in one patient and concomitant oligodactyly in another one. Conclusion: CC is a rare and often asymptomatic developmental anomaly in our study which is performed with one of the most extensive series in the literature. LTC is the most frequent form. CC should be kept in mind in patients with wrist pain and limited wrist motion.

Predictors of gleno-humeral bone loss in traumatic anterior shoulder instability

Purpose: Is to predict the risk factors causing gleno-humeral bone loss and affecting its size in patients with traumatic anterior shoulder instability. Patients and methods: At a median follow-up of 26 months, 60 patients having unilateral traumatic anterior shoulder instability were included in the study. The proposed risk factors for gleno-humeral bone loss were recorded. All patients underwent clinical evaluation and scoring. True AP radiography and CT scan of the shoulder were done to all patients to detect and quantify gleno-humeral bone loss. The collected data were analyzed to detect the factors correlating with the presence of gleno-humeral bone.Results: The number of dislocations was a significant risk factor for the presence of glenoid bone loss and large glenoid defect (P value: 0.023 and 0.001 respectively). Moreover, it was a significant risk factor for longer and deeper Hill-Sachs lesions (P value: 0.002 and 0.004 respectively). The age of 1st dislocation 20 years showed a negative correlation against larger Hill-Sachs lesions. Contact sports were a significant risk factor for the presence of glenoid bone loss and deeper Hill-Sachs lesions (P value: 0.002 and 0.003 respectively). Smoking was another but weak risk factor for large glenoid defects and longer Hill-Sachs lesions (P value: 0.050 and 0.034 respectively). The glenoid and humeral head bone loss showed highly significant correlation between each other.Conclusion: The number of dislocations, young age at 1st dislocation, contact sports and smoking are considered risk factors and predictors for gleno-humeral bone loss in traumatic anterior shoulder instability.Level of evidence: Case series study; Level of evidence, 4.

What Is the Prevalence of Cam Deformity After Prophylactic Pinning of the Contralateral Asymptomatic Hip in Unilateral Slipped Capital Femoral Epiphysis? A 10-year Minimum Followup Study.

Prophylactic pinning of the asymptomatic and normal-appearing contralateral hip in patients with unilateral slipped capital femoral epiphysis (SCFE) remains controversial. Understanding the minimal 10-year clinical, functional, and radiographic outcomes of the contralateral asymptomatic hip in unilateral SCFE may be helpful in the decision regarding whether the benefits associated with potentially preventing a SCFE are outweighed by the risk of additional surgery. Among patients with SCFE treated with prophylactic pinning of the asymptomatic and contralateral hip, we sought (1) to determine the complications and reoperations; (2) to evaluate the development of cam deformities and the frequency and severity of osteoarthritis progression; and (3) to characterize hip pain and function as measured by the Harris hip score (HHS) and the Hip Disability and Osteoarthritis Outcome Score (HOOS) at minimal 10-year followup. Between 1998 and 2005 all patients with SCFE seen at our institution were treated with the modified Dunn procedure and all were offered prophylactic pinning of the contralateral asymptomatic hip. Of the 41 patients who underwent the unilateral modified Dunn procedure and who had an asymptomatic contralateral hip, 37 patients (90%) underwent pinning of that contralateral hip. Of those, 33 patients (80%) were available for clinical and radiographic evaluation for this retrospective study at a minimum of 10 years (mean followup 12 ± 2 years) after surgery. Three patients of the 37 patients only had 10-year clinical followup, including questionnaires sent by mail and telephone, because they refused further radiographic followup and one patient was lost to followup. The group included 19 males and 17 females whose age at surgery was a mean of 13 ± 2 years. Medical charts were reviewed and patients were asked about complications and additional surgical procedures. Most recent postoperative radiographs were evaluated for measurement of the alpha angle, head-neck offset, epiphysis orientation, and osteoarthritis grading according to Tönnis classification and minimum joint space width. The presence of a cam deformity was defined by an alpha angle measurement > 60° on the AP radiograph and/or > 55° on the lateral radiograph. Hip function and pain were assessed by the HHS and HOOS outcome measures. No complications with prophylactic in situ pinning were recorded. Four of 36 (11%) patients underwent subsequent surgical treatment for cam-type femoroacetabular impingement (FAI), and hardware removal was performed in four hips (11%). The mean alpha angle was 53° ± 8° on the AP radiograph and 49° ± 8° on the lateral view at followup. In total, 10 of 33 hips (30%) had a cam morphology at the femoral head-neck junction and four (12%) were symptomatic and underwent FAI surgery. Six of 33 patients (18%) developed an asymptomatic cam morphology at the femoral head-neck junction; in three of 33 hips (9%), the cam deformity instead of lesion were visible only on the lateral projection, and 9% were visible on both the AP and lateral projections. The preoperative offset of the femoral head-neck junction was 10 ± 3 mm on the AP view and 11 ± 4 mm on the lateral view. At followup, the AP offset was 7 ± 3 mm and the lateral offset was 6 ± 3 mm, and on the lateral view, the offset was < 10 mm in eight hips (22%). No patient had radiographic signs of hip osteoarthritis (Tönnis Grade 0). The mean minimum joint space width was 4 ± 0.4 mm. The mean HHS for the 32 patients who did not undergo subsequent surgery was 97 ± 5 at latest followup. The mean postoperative HOOS was 94 ± 8 for the 32 patients at latest followup. At a minimum followup of 10 years after prophylactic pinning of a contralateral asymptomatic hip, most patients achieve excellent hip scores; however, a substantial proportion will develop a symptomatic cam deformity despite prophylactic pinning. No patient had signs of osteoarthritis at a minimum of 10 years, but almost one-third of the patients who underwent prophylactic pinning developed a cam deformity. Level IV, therapeutic study.

In Brief: The Lichtman Classification for Kienböck Disease.

In Brief: The Lichtman Classification for Kienböck Disease.

Ptosis of the hip: a new radiographic finding in patients undergoing femoroacetabular osteoplasty.

ABSTRACTPtosis is a newly described phenomenon appearing on AP radiographs of patients undergoing femoroacetabular osteoplasty (FAO), and refers to a reverse break down in Shenton’s Line. Thorough characterization of this phenomenon is needed to better understand the hip morphology and pathologic ramifications. Our goal was to define the radiographic hip parameters accompanying a break down in Shenton’s Line and to determine how these values compare with standard values in normal hips. Using two independent readers, we retrospectively reviewed the medical records and preoperative supine radiographs of 630 patients (1260 hips) who underwent FAO by a single surgeon between 2003 and 2016. Prevalence of hip pathology and 28 radiographic parameters in ptosis hips was measured, as well as a comparison between unilateral ptosis hips and contralateral normal hips. Of the 53 patients (106 hips) who fulfilled the criteria for the study, 94 hips had a Shenton’s Line break down of at least 5 mm. Sixty-nine percent of ptosis hips had femoroacetabular impingement (FAI), 70.2% had coxa profunda, and 52.1% had partial joint space narrowing. Ptosis hips had 1.05 mm less lateral subluxation (P = 0.012), 2.28° larger Center-edge angle (P = 0.046), 2.59° smaller Sharp angle (P = 0.011) and 2.49% smaller extrusion index (P = 0.016) compared with contralateral normal hips. FAI is prevalent in patients with a positive ptosis sign. The high prevalence of partial joint space narrowing could suggest eventual osteoarthritis. We believe our results demonstrate the importance of further investigation of a positive ptosis sign on AP pelvic radiographs.

Intrasubstance Anterior Cruciate Ligament Injuries in the Pediatric Population.

Pediatric intrasubstance anterior cruciate ligament (ACL) tears have a significant epidemiologic impact as their numbers continue to grow globally. This review focuses on true pediatric intrasubstance ACL tears, which occur >400,000 times annually. Modifiable and non-modifiable risk factors include intercondylar notch width, ACL size, gender, landing mechanisms, and hormonal variations. The proposed mechanisms of injury include anterior tibial shear and dynamic valgus collapse. ACL tears can be associated with soft tissue and chondral defects. History and physical examination are the most important parts of evaluation, including the Lachman test, which is considered the most accurate physical examination maneuver. Imaging studies should begin with AP and lateral radiographs, but magnetic resonance imaging is very useful in confirming the diagnosis and preoperative planning. ACL injury prevention programs targeting high risk populations have been proven to reduce the risk of injury, but lack uniformity across programs. Pediatric ACL injuries were conventionally treated nonoperatively, but recent data suggest that early operative intervention produces best long term outcomes pertaining to knee stability, meniscal tear risk, and return to previous level of play. Current techniques in ACL reconstruction, including more vertically oriented tunnels and physeal sparing techniques, have been described to reduce the risk of physeal arrest and limb angulation or deformity. Data consistently show that autograft is superior to allograft regarding failure rate. Mean durations of postoperative therapy and return to sport were 7 ± 3 and 10 ± 3 months, respectively. These patients have good functional outcomes compared to the general population yet are at increased risk of additional ACL injury. Attempts at primary ACL repair using biological scaffolds are under investigation.

Tibia fractures and NSAIDs. Does it make a difference? A multicenter retrospective study

PurposeThe purpose of this study was to compare healing time for diaphyseal tibia fractures (OTA/AO 42 A, B, C) treated with intramedullary nailing (IMN) in one geographic cohort using nonsteroidal anti-inflammatory drugs (NSAIDs) for post-operative pain control to that of another geographic cohort using opioid medications. The groups represent differing cultural approaches to post-operative pain control. We hypothesized there would be no difference in healing time. MethodsTibia fractures presenting at two level I trauma centers located in different countries between January 1, 2010 and December 31, 2017 were retrospectively screened for enrollment. Fractures classified as OTA/AO 42 A, B, or C that were treated with IMN and had radiographic follow up to union were included. At hospital discharge, one cohort (n = 190) was prescribed NSAIDs and the other (n = 182) was prescribed opioids for pain control. Each analgesic method represented the standard of care for that location. Fracture union was defined as cortical bridging in at least 3 out of 4 cortices on AP and lateral radiographs. The primary outcome was healing time on radiographic evaluation. ResultsThere was no statistically significant difference in healing time between the opioid and NSAID groups: 185 vs 180.5 days respectively (p = 0.64). Both groups had similar mean age. Student t-tests were run to compare rates of tobacco use, diabetes mellitus (DM), open fractures, and polytrauma between the two groups. The opioid cohort had statistically significant higher rates of tobacco use, DM, and polytrauma. The NSAID cohort, however, had a larger number of open fractures. ConclusionThe difference in healing time between the NSAID and opioid groups was not statistically significant. The deleterious effect of NSAID use on fracture healing has been debated for decades. Numerous animal studies have supported this theory; however, high quality clinical studies in humans have not provided convincing evidence to substantiate this negative effect. Our study suggests that NSAIDs may be used safely and effectively in the acute phase of fracture healing without significantly increasing the risk of delayed union or nonunion. Prospective randomized studies are necessary to rule out the negative effect of NSAIDS on bone healing.

The arcuate fracture: A descriptive radiographic study

PurposeTo assess plain radiographic morphology of arcuate fractures in order to identify patterns and help shape treatment algorithm for proximal fibula fracture. MethodsA search of radiographic reports at a level 1 trauma center from 2014 to 2016 using MONTAGE search software for the phrases “arcuate fracture”, “fibular head avulsion”, or “fibular head fracture” was conducted. Descriptive measurements were obtained including dimensions of the fragment, the displacement of the fragment from its anatomic position, and the orientation of the primary fracture line relative to the axis of the fibular diaphysis in both the sagittal and coronal plane. After review of the measurements and radiographs, fracture patterns were assessed based off previous knowledge previous knowledge of posterior lateral corner (PLC) anatomy. ResultsRadiographic reports of 48 knees (48 patients) met inclusion criteria. The distance of fractures from the proximal aspect of the fibula averaged 9.25 ± 5.53 mm on AP radiographs, and 9.42 ± 4.89 mm on lateral radiographs. The medial-to-lateral width of the proximal fragment averaged 20.09 ± 7.94 mm on AP radiographs, while the anterior-to-posterior width measured on lateral radiographs averaged 17.53 ± 8.48 mm. Orientation of the primary fracture line was calculated at an average of 23.04 ± 14.95° from the perpendicular on the AP view, and 21.55 ± 17.44° from the perpendicular on the lateral. Maximal displacement at the primary fracture line on the AP view was 4.95 ± 8.49 mm). Maximal displacement on the lateral measured 3.98 ± 7.01 mm. Recurring fracture patterns were identified and described. Assessment revealed 11 (22.9%) pattern 1 fractures, six (12.5%) pattern 2 fractures, 31 (64.58%) pattern 3 fractures, possibly correlating with anatomical features and fracture mechanism. ConclusionsThese measurements and recurring patterns in our study shows the heterogeneity of the size and displacement of these fracture fragments and demonstrates the need for further studies in order to create an anatomic descriptive classification for arcuate fractures, which could be used for clinically for treatment.

Wednesday, September 26, 2018 7:35 AM–9:00 AM ePosters: P29. Does the true AP radiograph for scoliosis differ from ancient convention? Lessons from 3D imaging

BACKGROUND CONTEXT Scoliosis is a three-dimensional deformity. As such, the rotational component must be considered during its evaluation and management. However, the severity of scoliosis has long been measured in the 2D coronal plane using the Cobb angle – a modality unable to account for axial vertebral rotation (VR). In the past, the Stagnara lateral radiograph has attempted to compensate for VR. To date, no similar radiographic view has been described for the AP plane. Recent advances in 3D CT imaging may allow clinicians to more accurately measure Cobb angles in scoliosis by compensating for axial VR. Here, we present a retrospective study comparing Cobb angle measurements taken from both traditional 2D radiographs, and rotationally compensated CT images. PURPOSE The purpose of this study is to compare Cobb angle measurements routinely made for AIS in both rotationally compensated and standard imaging. STUDY DESIGN/SETTING Retrospective matched cohort study. PATIENT SAMPLE A total of 66 patients diagnosed with AIS. OUTCOME MEASURES PT, MT, and TL/L curve Cobb angle values, coronal balance, thoracic and lumbar apical vertebral translation (T/L-AVT), thoracic and lumbar apical vertebral rotation (T/L-AVR), thoracic kyphosis, and sagittal balance. METHODS In this retrospective study, standard AP, lateral, and bending radiographs of 66 patients age 10-19 with AIS were obtained. Using multiplanar 3D CT, the coronal plane was reconstructed within the plane of the vertebral axis to form a rotationally compensated 3D CT image (RC-3DCT). The following measurements were made on both imaging modalities: PT, MT, TL/L curve, coronal balance, T/L-AVT, T/L-AVR, thoracic kyphosis, and sagittal balance. RESULTS Mean MT curve was found to be 40.56° on AP radiograph versus 35.39° on RC-3DCT (n=63, P=.00039). In 28 patients (42.4%), rotational compensation altered the end vertebra of the major curve by at least 1 level. The mean TL curve obtained on radiograph, was significantly larger than that of RC-3DCT (n=62; 35.34° vs. 30.98° ; P=.0046). AP films overstated coronal balance by over 50% when compared to RC-3DCT Mean T-AVT was measured to be 25.28 mm on conventional films and 19.46 mm on RC-3DCT (n=62; P=.00033). RC-3DCT L-AVT was significantly smaller than that of standard films (P=.0094). Mean T-AVT on standing film was 26.2±31.0°. The mean proximal thoracic kyphosis did not differ between the two modalities: 20.66° on radiograph versus 21.062° on RC-3DCT (P=.41). CONCLUSIONS Measurements traditionally made on AP radiograph to evaluate scoliosis may be inaccurate due to VR. Our data suggest that axial rotation of a patient 19° per Nash–Moe grade with respect to the coronal plane may adequately compensate for the rotational component of deformity without the need for CT. Additionally, rotational compensation may yield end vertebrae levels different from those obtained traditionally. In 42% of patients, VR compensation altered end vertebral designation by at least 1 level.

Wednesday, September 26, 2018 10:35 AM – 12:00 PM Cervical Spine Trauma: 27. The utility of in-hospital postoperative radiographs following surgical treatment of traumatic cervical spine injuries

BACKGROUND CONTEXT Postoperative radiographs are routinely obtained following the surgical treatment of traumatic cervical spine injuries. Previous studies have evaluated the utility of postoperative radiographs following elective cervical spine surgery for degenerative conditions, but there has been no study evaluating this exclusively in the trauma population. This routine imaging comes at a financial cost to the health care system in addition to exposing the patient to an increased radiation dose. We hypothesized that routine postoperative X-ray imaging following surgical treatment of cervical spine traumatic injuries are unwarranted in the absence of changes in clinical findings. PURPOSE To assess the utility of routine in-hospital postoperative radiographs following surgical treatment of traumatic cervical spine injuries. STUDY DESIGN/SETTING Retrospective study. PATIENT SAMPLE All patients who underwent surgical treatment of traumatic cervical spine injuries over an eight-year period between January 2008 and December 2016 at a Level I trauma center. OUTCOME MEASURES Requirement of revision surgery. METHODS A retrospective chart review of the patients who underwent surgical treatment of traumatic cervical spine injuries over an eight-year period between January 2008 and December 2016 at a Level I trauma center was performed. Prior to discharge, postoperative upright AP and lateral radiographs were obtained and reviewed by one of the surgeons as per standard protocol. Those patients who subsequently required revision surgery were identified and further analyzed to identify if the results of the radiographs obtained led to the subsequent intervention or if other indications for surgery were present. RESULTS A total of 295 patients (177 males and 118 females) were identified with a mean age of 57.4 years (range, 18-94) between January 2008 and December 2016 with mean follow up of 284 days. All had routine postoperative upright X-ray imaging as well as during follow-up visits. There were two occipito-cervical fusions, 128 C1-2 posterior spinal fusions (PSFs), 50 subaxial cervical PSFs, seven odontoid screws, 81 anterior cervical discectomy and fusions (ACDFs), four anterior cervical corpectomy and fusions (ACCFs) and eight 360° fusions. Ten patients required subsequent surgeries: five for wound complications, two for neurological decline requiring decompression, one for recurrent subluxation, and two for non-union or mal-union. Four other patients were noted to have broken/loose hardware that were managed conservatively. Advanced imaging (CT/MRI) was ordered in 13 patients, nine of which required additional surgery: In the cases requiring additional surgery, the postoperative radiographs added no value in guiding treatment in the absence of clinical findings. Every patient who underwent additional surgery had clinical findings (ie, wound breakdown, new-onset radiculopathy or continued pain) that were of concern. Cervical radiographs alone added an additional $545,868 of health care cost during the study period. CONCLUSIONS Routine in-hospital and postoperative radiographs following surgical treatment of traumatic cervical spine injuries are of little value, especially in the absence of changes in examination or symptoms. In our experience, only 2.3% (7/295) patients had hardware-related complications, four of which were asymptomatic and three of which required subsequent surgery. With today's increasing emphasis on cost efficiency and evidence-based practice, we recommend against obtaining routine postoperative imaging in the absence of new clinical findings. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

Wednesday, September 26, 2018 7:35 AM–9:00 AM ePosters: P41. Agreement of degenerative spondylolisthesis definitions on standing and supine lateral radiographs in consecutive patients

BACKGROUND CONTEXT Clinical guidelines recommend standing lateral radiographs as the most appropriate imaging for detecting degenerative spondylolisthesis. However, direct comparison on definitions of spondylolisthesis on standing and supine lateral radiographs in the same patients are lacking. PURPOSE To determine the extent of agreement on commonly used definitions of degenerative spondylolisthesis on clinically obtained standing and supine lateral radiographs among the same patients. STUDY DESIGN/SETTING Cross-sectional study in new patients presenting to the Oregon Health & Science University Spine Center with chief complaint of back pain or radiculopathy. PATIENT SAMPLE Consecutive new patients from 2010 to 2016, age ≥40years, and without a history of prior spinal surgery, vertebral fracture or scoliosis greater than 30°, who were clinically evaluated for degenerative spondylolisthesis. OUTCOME MEASURES Radiographic degenerative spondylolisthesis defined as anterior displacement of ≥3 mm, ≥5 mm and ≥5%. METHODS New patients received standing AP, standing lateral and supine lateral radiographs as a clinical standard. The presence of spondylolisthesis was assessed from L1 to S1. The anterior slip distance (mm) was obtained by measuring the displacement of the posterior surface the superior vertebral body in relation to the posterior surface of the inferior vertebral body. Vertebral body width (mm) was obtained by measuring the narrowest AP diameter of the inferior vertebral body. Percent slip was calculated by dividing the anterior slip distance by the inferior vertebral body width. Kappa statistics were estimated as the measure of agreement on definitions of spondylolisthesis on the pairs of films. RESULTS This study comprised 516 patients (246 (48%) men; 270 (52%) women; mean (sd) age of 60.0 (11) years). Of these, 206 (40%) patients had 239 vertebrae with any anterior displacement of ≥3mm. Spondylolisthesis was most often observed at L4-L5 (112 vertebrae) or L5S1 (96 vertebrae). Numbers and percentages of patients classified as without spondylolisthesis on standing radiographs but with spondylolisthesis on supine radiographs for the ≥3 mm, ≥5 mm and ≥5% definitions, respectively, were 4 (1.9%), 2 (1.3%), and 3 (1.4%). Conversely, numbers and percentages of patients classified as without spondylolisthesis on supine radiographs but with spondylolisthesis on standing radiographs for ≥3 mm, ≥5 mm and ≥5% definitions, respectively, were 37 (18.0%), 46 (30.3%) and 32 (14.5%). Kappa statistics for agreement on definition of degenerative spondylolisthesis on the standing and supine lateral radiographs for ≥3 mm, ≥5 mm and ≥5% were, respectively, 0.83, 0.75 and 0.86. CONCLUSIONS From 18% to 30% of patients with radiographically detectable spondylolisthesis were misclassified as without spondylolisthesis by supine radiographs, whereas less than 2% of patients were misclassified as without spondylolisthesis on standing radiographs. Agreement between standing and supine radiographs worsened with progressively larger slip required to define spondylolisthesis. These results in a large consecutive series of new patients support clinical guidelines to use standing lateral radiographs for diagnosis of radiographic degenerative spondylolisthesis.

Should the Tibiotalar Angle Be Measured Using an AP or Mortise X-ray?

Category: Basic Sciences/Biologics Introduction/Purpose: The tibiotalar angle(TTA) is an important radiographic tool to determine alignment or malalignment of the ankle and hindfoot.Two methods of measuring the TTA have been described. The midline TTA(MTTA) is when the first line is along the anatomical axis of the tibia, and the second line is along the superior articular surface of the talus. Another method measures a line along the lateral border of the tibia, and a line along the superior articular surface of the talus (the lateral TTA, LTTA). The aims of the study were to compare the two angles as measured on mortise and AP radiographs in normal and pathological cases.We also compared the MTTA and LTTA, to see if they are comparable and if both methods are reliable and reproducible. Methods: A retrospective radiograph review was performed of sequential ankle radiographs taken between 2016 and 2017 across 4 specialist orthopaedic centres in the United Kingdom. Patients were categorised into two distinct groups. In the Normal Group (NG), patients had no evidence of injury and normal radiological appearances. In the Arthritis Group (AG), patients had radiographic changes as per the Kellgren-Lawrence scale 2 to 4. All radiographs were weightbearing and classified as either AP or mortise views based on the position of the talus and overlap of the tibia and fibula. The MTTA and the LTTA were measured on each radiograph. Results: There were 320 radiographs for review;158 normal radiographs and 162 radiographs had arthritis.There were 117 AP and 203 mortise radiographs. The overall mean MTTA was 88.7±5.1 degrees(range 77-104), and the mean LTTA was 87.5±5.2 degrees(range 73-104);p&lt;0.01.There was no significant difference between the MTTA and LTTA in the normal group. There was a significant difference(p&lt;0.01) when comparing the MTTA and LTTA in the arthritis group(Table 1). There was no significant difference when the MTTA was measured between the AP and Mortise radiographs. There was a significant difference in the LTTA between AP and mortise radiographs(p=0.04). There was no significant difference between the MTTA or LTTA when measuring the angles on AP radiographs(p=0.09).However, there was a significant difference when measuring these angles in the mortise radiographs(p=0.02). Conclusion: Understanding the tibiotalar angle is key to planning for deformity correction. It is important that consistency of methods for measurement are used for reporting. In this paper we have shown the MTTA to be a reliable and reproducible tool for measuring the TTA, in both normal ankle radiographs and in patients with ankle arthritis. There is no significant difference when the MTTA is measured using an AP or a mortise radiograph. In contrast, we have shown that the LTTA to be unreliable and statistically different when measured on both AP and mortise radiographs.