Articular Margin Research Articles

Knee diagram for the documentation of arthroscopic findings of the knee — cadaveric study

There is a need for an accurate representation of arthroscopic knee findings on a diagram. The first time in the literature this Knee Diagram is generated, using three-dimensional projection of the four dissected cadaveric knees articular surfaces. Computer-aided design and drafting software is utilized to find the average dimensions of the four cadaveric knee surfaces. Mercator earth projection principle is applied in drawing the `latitude lines' on the femoral condyles at different degrees of knee flexion, corresponding to the anterior edge of the tibial articular surface as the reference point. This Knee Diagram using the tibial articular margin as a reference point, is not only useful for the accurate representation of the arthroscopic knee findings but also the most useful way to correlate the MRI findings of the femoral cartilage defect with the arthroscopic findings. Most useful of all are the reference latitude lines of the femoral condyles that remain a fixed landmark for that particular knee and thus helps to locate the same lesion at repeated arthroscopic evaluations, by different observers. A grid on the diagram helps to map the cartilage defect in millimetres. In this era of research on cartilage grafting, we think this Knee Diagram will be particularly useful to document and follow-up knee lesions in a more scientific way.

Tram Track Lesion of the Talar Dome

Summary: A distinctive lesion in the articular cartilage of the talar dome in anterior bony impingement syndrome of the ankle joint is reported. During arthroscopic treatment of anterior bony impingement syndrome of the ankle, we found six distinctive articular cartilage lesions in the talar dome. The cartilage lesions were full-thickness defects (grade IV), located in the anterior half of the medial aspect of the talar dome and were longitudinal with variable widths resembling a tram track; thus, “tram track lesion.” All six patients were professional or collegiate soccer players and had large osteophytes in the anteromedial ridge of the tibial articular margin. Instability test results were negative. All patients had the typical tenderness in the anteromedial corner of the ankle. Overall, good and excellent results were achieved in five patients at a mean follow-up of 27 months after arthroscopic excision of osteophytes and drilling using K-wires.Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 15, No 2 (March), 1999: pp 203–206

Arthroscopic posterior cruciate ligament reconstruction using a one-incision technique.

Thirty-seven patients with a posterior cruciate ligament injury underwent arthroscopic posterior cruciate ligament reconstruction using a one-incision technique with bone-patellar tendon-bone autograft or allograft. The tibial tunnel was started at the distal end of the graft donor site on the proximal tibia and exited posteriorly at the flat spot 15 mm below the articular margin and just lateral to the midline. The femoral tunnel was made through the lateral anterolateral portal. The 25 mm long proximal bone plug was passed easily through the tibial tunnel using a specially designed suture pusher and guided into the femoral tunnel by pulling the leading suture with the knee flexed 30 degrees. Firm proximal and distal fixations were achieved with interference screws. At a minimum 2 year followup (range, 24-68 months), average knee ligament evaluation scores were 91.1 (range, 67-99) in the Lysholm knee scoring scale and 89.3 (range, 67-99) in the Hospital for Special Surgery knee ligament rating form. The average side to side difference of the posterior translation measured by the KT 2000 arthrometer was 6.08 (range, 5-7 mm) mm preoperatively and 2.2 (range, 0-6 mm) mm postoperatively. There were no significant differences between the acute and the chronic cases. The results of the isolated posterior cruciate ligament injury group were better than the combined ligamentous injury group. The one-incision technique minimizes injury to the extensor mechanism, especially the vastus medialis obliquus muscle, and medial scar. Rigid fixation of the long proximal bone plug allows early rehabilitation.

A modified endoscopic technique for posterior cruciate ligament reconstruction using allograft

This article describes a modified endoscopic technique of posterior cruciate ligament reconstruction using bone-patellar tendon-bone or calcaneus tendon allografts. Three portals were used: a parapatellar anteromedial portal, a lateral anterolateral portal, and a proximal posteromedial portal. The tibial tunnel was made through the anterolateral tibial cortex 2 cm lateral to the tibial tuberosity to the posterior flat spot of the tibia 1 cm below the articular margin and just lateral to the midline. By this method, a less acute angle at the turning point of the tibial tunnel and a straighter alignment of the graft in the coronal plane can be obtained. The femoral tunnel was made through the lateral anterolateral portal without incision over the medial femoral condyle to minimize the injury to the vastus medialis obliques muscle. The 25-mm long proximal bone plug was easily passed through the tibial tunnel using a specially designed suture pusher and guided into the femoral tunnel by pulling the leading suture with the knee flexed 30 degrees. Firm graft fixation was achieved with absorbable interference screws or staples. Arthroscopy 1998 Sep;14(6):643-8

Index of Suspicion

Index of Suspicion

RADIOGRAPHIC APPEARANCE OF THE NAVICULAR BONE AND DISTAL INTERPHALANGEAL JOINT AND THEIR RELATIONSHIP WITH OSSIFICATION OF THE COLLATERAL CARTILAGES OF THE DISTAL PHALANX IN FINNHORSE CADAVER FOREFEET

Radiographic findings in the navicular bone and distal interphalangeal joint as well as the ossification status of the collateral cartilages of the distal phalanx were evaluated in 100 Finnhorse cadaver forefeet. The most common shapes of the proximal articular margin of the navicular bone were convex and straight. Remodeling of the navicular bone was common, especially on the lateral extremity. No bony fragments were identified at the distal flexor margin even though this area appeared irregular in several feet. Several large, rounded or lollipop-shaped synovial invaginations were identified in only six feet. The thickness of the flexor cortex varied considerably, and the corticomedullary junction was uni- or bilaterally indistinct in nine feet. The shape of the sagittal ridge of the flexor cortex was commonly flat but varied. It appeared locally irregular or indistinct in 17 feet, but changes elsewhere along the flexor cortex were rare. Osteophytosis on the dorsal and palmar margins of the distal interphalangeal joint and entheseophytosis on the dorsal aspect of the middle phalanx and on the extensor process of the distal phalanx were common. "Possibly significant" ossification of the collateral cartilages (high sidebones or separate centers of ossification) was present in 36 feet; all grades of ossification in the proximal/palmaroproximal direction as well as palmar ossification were seen. A statistically significant relationship was found between entheseophytosis on the proximal flexor margin of the navicular bone and "possibly significant" ossification. Osteophytosis on the palmarodistal margin of the middle phalanx was more common in feet with a relatively long distal phalanx, suggestive of palmar ossification. Radiographic changes in the navicular bone or in the distal interphalangeal joint did not otherwise appear to be associated with ossification of the collateral cartilages of the distal phalanx in Finnhorses.

Radiographic and intraoperative intercondylar notch width measurements in men and women with unilateral and bilateral anterior cruciate ligament tears.

The purpose of this study was to compare the measurements of the intercondylar notch width (NW) in men and women radiographically and intraoperatively, and to determine if the radiograph would demonstrate a difference in the patients with unilateral and bilateral anterior cruciate ligament (ACL) tears compared with non-injured patients. The control groups consisted of 100 men and 100 women from our young adult clinic population without a history of knee injury or clinical evidence of ligamentous deficiency. The study group consisted of 90 men with bilateral and 297 with unilateral ACL reconstructions (mean age 25.1 years, range 13-53 years) and 41 women with bilateral and 129 with unilateral ACL reconstructions (mean age 22.3 years, range 13-48 years). On 45 degrees flexion weight-bearing radiographs, we measured the intercondylar NW in controls and patients at one-half notch height from the lateral edge of the articular margin of the medial femoral condyle to the apex of the intercondylar notch. Intraoperatively, the surgeon took a direct measurement at the same site with sterile calipers. The surgeon was unaware of the radiographic measurement. The mean radiographic NW measurements for women were 12.8 mm in the bilateral group, 13.8 mm in the unilateral group, and 14.5 mm in the control group (P < 0.05) and, for men, 15.3 mm in the bilateral group, 15.8 mm in the unilateral group, and 16.9 mm in the control group (P < 0.05). The preoperative radiographic NW measurements correlated with actual intraoperative measurements (r = 0.72, P < 0.01). We conclude that the intercondylar NW of the femur is narrower in women than men, and, in both men and women, the NW is narrower in patients who sustain ACL tears compared with controls.

ACUTE ELBOW PAIN - BASKETBALL 1325

HISTORY - A 28-year old, right-handed male was hit in the right triceps during a pick up game of basketball. He felt his forearm was forcibly extended beyond its usual range and felt a sudden sharp pain. He continued to play with elbow soreness. Two hours later, he experienced increased pain with decreased range of motion and joint swelling. Prior to this injury, he recalled having a long standing decreased elbow range of motion since the age of 11, when he was a little league pitcher. At age 14, he experienced lateral elbow pain, had x-rays taken and was told he had “compressed cartilage.” He received ultrasound and some physical therapy. Through his 20's he found it increasingly difficult to complete a full round of golf and experienced elbow soreness and numbness with pitching, lifting and throwing a football. PHYSICAL EXAMINATION - Examination was done one day post injury. There was diffuse joint swelling and erythema. No ecchymosis was noted. He had tenderness to palpation over the medial and lateral epicondyles, and distal triceps. Passive elbow range of motion was restricted between minus 45° of extension and 95° of flexion. No valgus or varus instability. The right shoulder lacked 30° of internal rotation and a positive lateral scapular slide in positions 2 and 3 on the right. There was crepitus with supination and pronation. Wrist flexion and extension were within normal limits. Sensation was intact DIFFERENTIAL DIAGNOSIS - Loose body Traumatic bursitis Osteochondritis dissecans Humeral/supracondylar fracture Dislocation of the humeral-ulnar joint TESTS AND RESULTS - AP and lateral radiographs of the right elbow: Large joint effusion; decreased radial humeral joint space; small osteophyte seen on the articular margin of the coranoid process of the ulna; osteopenia of the radius and ulna; no fracture; no loose body. MRI elbow: Joint effusion, a 1.2 cm loose body noted in the olecranon fossa; possible additional loose body within the ventral aspect of the joint and measures only a few mm in size. Degenerative changes are noted within the capitellum with evidence of subchondral sclerosis and cystic changes, as well as osteophytosis. No other abnormalities noted. WORKING DIAGNOSIS - Loose body TREATMENT - NSAIDS, ice and rest initiated day after injury. Resolution of swelling led to a “fixed” range of motion between minus 20° extension and 120° flexion, he underwent an arthroscopic procedure to remove the loose body. Started range of motion and strengthening exercises two weeks post surgery. Returned to sports one month after surgery.

MR imaging of lipoma arborescens of the knee joint.

The purpose of this study was to define MR imaging of patients with lipoma arborescens of the knee. MR images showed villous lipomatous proliferation (100%) with signal intensity similar to that of fat on T1- and T2-weighted images, masslike subsynovial fat deposition (38%), joint effusion (100%), erosive bone changes at articular margins (38%), associated synovial cysts (25%), and degenerative changes (13%). MR imaging is a valuable technique for examining patients with lipoma arborescens of the knee and can support the diagnosis of this rare condition.

Retroversion of the proximal humerus in relationship to prosthetic replacement arthroplasty

Arthroplasty of the proximal humerus positions a prosthetic articular surface in relation to the humeral canal. Most descriptions of surgical technique recommend positioning the humeral component in 30 degrees to 45 degrees of retroversion. This study measured retroversion in relationship to the surgically reamed canal and introduced a method of measurement pertinent to prosthetic reconstruction. The canals of 21 cadaveric humeri were surgically reamed, the articular margins of the humeral heads were outlined with steel wire, and the trochlear axes were transfixed with Steinman pins. Under fluoroscopy the humeri were rotated on a jig that allowed rotation around the reamer and measurement of retroversion relative to the plane of the articular surface. Retroversion of the proximal humerus is highly variable, ranging in this study from 10 degrees to 55 degrees (mean 29.8 degrees). Anatomic reconstruction of the retroversion angle must be individualized. Palpation of the rotator cuff insertion is recommended prior to humeral head resection to avoid inadvertant cuff injury.

Diagnosis and treatment of osteoarthritis in dogs

Osteoarthritis (also known as osteoarthrosis or degenerative joint disease) is a term covering a broad spectrum of poorly understood joint disorders. Although it is preferable to think of osteoarthritis as a disease process with a variety of initiating factors, it may, for the purposes of this article, be defined as a disorder of synovial joints characterised by aberrant repair and eventual degeneration of articular cartilage and also by the formation of new bone at the articular margins, sclerosis of subchondral bone and variable low grade synovial inflammation. While the apophyseal joints of the spine can also be affected, the association between osteoarthritis of these joints, disc disease and the clinical signs is unclear. Discussion will, therefore, be limited to the joints of the appendicular skeleton.

Arthroscopic bankart repair with the suretac device. part II: experimental observations

Arthroscopic Bankart repair using the Suretac device (Acufex Microsurgical, Mansfield, MA) was developed as an alternative to both the staple and suture repair techniques. While offering some technical advantages compared with these other approaches, it's technical limitations and pitfalls have only been described anecdotally based on the clinical experience of several surgeons. The purpose of this study was to define these limitations and pitfalls. Eight cadaver shoulders underwent arthroscopic Bankart repair using the Suretac device after first arthroscopically creating a Bankart lesion. These shoulders were then dissected to reveal the placement of the Suretacs and the adequacy of the Bankart lesion repair. Glenoids were transected in the transverse plane and embedded in clear methylmethacrylate to show placement of the Suretac device relative to the articular surface. There were several technical errors that occurred: (1) Inadequate abrasion of the anterior and inferior juxta-articular scapular neck; (2) inadequate superior and medial shift of the inferior glenohumeral ligament before placement of the lowest Suretac, (3) medial placement of the Suretac relative to the articular margin; and (4) insufficient capture and compression of capsular tissue by the Suretac device. This procedure is technically difficult and careful attention must be paid to each step of preparation and repair. Recognition of the common errors may help the surgeon to avoid these pitfalls in the clinical situation.

Radiographic anatomy and technique for arthrography of the cubital joint in clinically normal dogs

Summary A technique for arthrography of the cubital joint in clinically normal large-breed dogs was developed with the objective of improving visualization of the articular margin of the medial coronoid process. A lateral approach to the cubital joint for injection of contrast medium was selected. Arthrography of 24 cubital joints was performed by using 14 dogs. Twelve combinations of iodinated contrast medium, consisting of various concentrations (3) and volumes (4), were used. Two sets of arthrograms for each of the 12 combinations of contrast medium were obtained. Five radiographic views were used for each set. All arthrograms were examined by 3 evaluators, and each articular surface received a numerical rating for how well it could be seen in each view. Results of the evaluation indicated that low volumes of contrast medium were preferable to high volumes, with 2 ml providing the best visualization. Concentration of iodine seemed less important than did volume. The numerical ratings also indicated that the articular margin of the coronoid process was clearly observed a maximum of only 24% of the time on a slightly supinated mediolateral projection. The articular margins of the head of the radius, trochlea humeri, and trochlear notch were well visualized &gt; 90% of the time. Arthrography of the cubital joint was technically easy to perform, and complications were not encountered, but arthrographic anatomy of the cubital joint is complex. Potential uses for arthrography of the cubital joint include diagnosis of osteochondrosis, intraarticular fragments, and joint capsule ruptures.

Brucellar sacroiliitis: findings in 63 episodes and current relevance.

Between 1974 and 1989 we prospectively observed 530 patients with brucellosis. The findings for 62 patients (42 males and 20 females; mean age, 34.7 years) with 63 episodes in which the sacroiliac joint was involved (the most frequent osteoarticular location [11.7%]) were analyzed. Ten of the older patients (mean age, 55.3 years) had concomitant spondylitis. Systemic symptoms were usually important, and characteristic pain and findings of sacroiliitis were observed in approximately 75% of cases. Blood cultures were positive for Brucella melitensis for 44 patients. The most frequent radiographic findings were blurring of articular margins (42 cases) and widening of the sacroiliac space (20 cases). No radiographic anomalies were detected in 13 cases. Results of 99mTc and gallium-67 bone scans were abnormal in approximately 90% of cases (abnormalities were often mild). Overall, clinical, radiographic, and isotopic bone scan findings were sensitive and useful, although they were occasionally minimal or difficult to evaluate, making diagnostic findings confusing or misleading. Brucellar sacroiliitis is a mild disease associated with a good outcome similar to that observed for patients with uncomplicated brucellosis.

Distal Tibial Articular Fractures in Racing Greyhounds: A Review of Six Cases

SummarySix spontaneously occurring distal tibial fractures extending into the posterior articular margin of young racing greyhounds were reviewed. Concomitant fractures of both malleoli occurred in three cases. Fracture patterns, methods of treatment and functional results were determined. Open anatomical reduction and rigid internal fixation promoted healing with minimal osseous reaction and showed better results than conservative treatment. Complications adversely affecting the outcome were periarticular deformity and osteoarthritis, these were observed as early as five to seven weeks following the operations.Six spontaneously occurring distal tibial fractures extending into the posterior articular margin of young racing greyhounds were reviewed. Fracture patterns, methods of treatment and functional results were determined.

Arthroscopic approach and intra-articular anatomy of the palmaroproximal or plantaroproximal aspect of distal interphalangeal joints.

An arthroscopic approach to the palmaroproximal or plantaroproximal pouch of the distal interphalangeal joint was developed in six cadaver limbs and seven limbs of three clinically normal horses. The dorsal aspect of the proximal border and the proximal articular margin of the distal sesamoid (navicular) bone, the palmar aspect of the distal articular margin of the middle phalanx, the collateral sesamoidean ligaments of the distal sesamoid bone, and the joint capsule attachments were readily accessible. Distending the joints with fluid gave access to portions of the articular surface between the distal sesamoid bone and the middle phalanx in all joints, and to a small portion of the distal phalanx in two hind distal interphalangeal joints. Two horses allowed to recover from anesthesia were not lame on days 30 and 37, respectively. Problems encountered initially were difficulty entering the joint, hemarthrosis, and minimal iatrogenic cartilage damage.

Mechanical and morphometric analysis of the third carpal bone of Thoroughbreds

SUMMARY The third carpal bone (C3) was collected from both forelimbs of 27 Thoroughbreds. On the basis of age, training, and history, specimens were assigned to 1 of 5 groups: yearling, untrained horses (group 1, n = 4); 2- to 3-year-old, untrained horses (group 2, n = 7); trained 2-year-old horses (group 3, n = 6); trained 3-year-old horses (group 4, n = 6); and 3-year-old, trained horses with carpal pathologic features (group 5, n = 4). A transverse section of subchondral bone 5-mm thick was cut in a precise fashion 10 mm below the proximal articular surface of all specimens. After high-detail radiography was done, indentation testing was performed on the proximal surface of the section at points 5 mm apart. The stiffness of the subchondral cancellous bone was determined from the slope of the load vs displacement curve. Topographic plots of stiffness measurements were compared with radiographs of each specimen. Point determinations were averaged to derive measures for the radial and intermediate facets, and for regions 5, 10, 15, and 20 mm from the dorsal margin of C3. Area fraction (1-p; p = porosity) was measured for the radial and intermediate facets, using an automated image analysis system. Significant (P &lt; 0.05) increases in stiffness and area fraction were found in the C3 from trained horses (groups 3 to 5), compared with untrained horses (groups 1 to 2). Stiffness and area fraction of the radial facet of pathologic C3 were significantly higher than the same variables measured in C3 from any other group. A typical profile of regional subchondral stiffness was identified in C3 from normal horses, with maximal stiffness measured 10 mm from the dorsal articular margin. A different pattern was found in pathologic C3, with significantly greater stiffness 15 and 20 mm from the dorsal articular margin when compared with normal horses. A highly significant (P &lt; 0.0001) direct linear correlation between stiffness and area fraction at the radial facet was found. Topographic and radiographic analysis demonstrated good correlation between stiffness and radiographic density of the bone sections. The observed patterns of normal and pathologic C3 were contrasted. In particular, a large gradient in subchondral stiffness was identified in pathologic C3 at the dorsomedial aspect of the bone.

The third carpal bone

equal prevalence of distal radial carpal (DRC) and third carpal (C3) injury but in Standardbreds, C3 is more commonly damaged. The medial aspect of the intercarpal joint is highly susceptible to overload because of the greater load on the medial aspect of the joint and the hinge-type closing of the joint. The typical distalradial carpal (DRC) chip fracture occurs in the middle of its articular rim just lateral or adjacent to the attachment of a small ligament that courses distally and medially to merge with the capsular attachments to the face of the second carpal bone. The typical chip is therefore best visualized on the DLPMO and flexed lateral views. The flexed view is important to assess since loss of normal subchondral density extending palmarly away from the fracture is a sign of extensive articular damage and a poor prognosis. Thebest DRC chips are triangular in outline and relatively narrow along their articular margin. A second very common site of DRC injury is the dorsal lateral comer of the bone. This is the most common site for an osteophyte to develop (and subsequently fracture) in the horse. Such lesions can be difficult to diagnose radigraphically and are best seen on a well-positioned, well-exposed skyline or a wellpenetrated DMPLO projection. They are rarely found as a solitary lesion. Arthroscopic removal is the preferred management for most carpal fractures although it certainly should be acknowledged that many small carpal chips can be managed medically. If surgery is an option, in terms of the horse's value, repeated injections should be avoided and, in particular, repetitive corticosteroids should be avoided. Early intervention affords a better prognosis so a decision concerning surgery should be made shortly after diagnosis. Following ar throscopic surgery for atypical chip fracture, horses are rested for about two weeks with hand grazing only allowed. They then begin a program of handwalking that begins with five minutes/day and increases weekly by five minute increments until they are walking 30-40 minutes/day. Swimming is also a rehabilitative option that can begin any time after two weeks. Passive flexion is advised for the first month following surgery. Sodium hyaluronate is usually injected five to seven days following surgery and repeated when the horse returns to training if an effusion persists. A horse with a typical distal lateral radius chip fracture will start jogging about six weeks postoperatively, whereas most serious intercarpal injuries receive two to three times as long a convalescence. THE THIRD CARPAL BONE

MRI demonstration of hypertrophic articular cartilage repair in osteoarthritis

Transection of the anterior cruciate ligament in the dog produces changes in the unstable joint typical of osteoarthritis, although full-thickness cartilage ulceration is rare. Information concerning the late fate of the cartilage after transection is meager. In the present study magnetic resonance imaging (MRI) was used to evaluate cartilage abnormalities 3 years after transection. Plain radiographs of the osteoarthritic and contralateral knees were obtained serially. MRI was performed 3 years after anterior cruciate ligament transection, at which time all three animals exhibited knee instability. Radiographs of the osteoarthritic knees showed osteophytes and subchondral sclerosis with progression between 2 and 3 years. On MRI, articular cartilage margins in the knee were indistinct, and the cartilage was thicker than that in the contralateral knee (maximum difference = 2.7 mm). This increase in thickness is consistent with biochemical data from dogs killed up to 64 weeks after creation of knee instability, which showed marked increased in cartilage bulk and in proteoglycan synthesis and concentration. The findings emphasize that increased matrix synthesis after anterior cruciate ligament transection leads to functional cartilage repair sustained even in the presence of persistent alteration of joint mechanics.

Role of Computed Tomography in the Evaluation of Suspected Sacroiliac Joint Disease

Computed tomography (CT) was compared with plain radiography in 41 examinations of selected patients with a clinical history suggestive of sacroiliac joint disease. The obliquity of the sacroiliac joints renders radiographic interpretation difficult. In the 41 cases who were examined with standard anteroposterior and posteroanterior radiographs of the sacroiliac joints, four were normal, eight abnormal and 29 were equivocal. Equivocal findings included indistinct and possibly irregular articular margins to the joints and subarticular sclerosis. Of the 29 equivocal studies, nine were normal on CT and 20 were abnormal. CT demonstrated definite changes of sacroiliac joint disease in 29 of the 41 examinations, 16 of which were sacroiliitis and 13 osteoarthritis. With plain radiography four of the eight abnormal studies were consistent with sacroiliitis, and four with osteoarthritis. It is concluded that CT is more sensitive than plain radiography in the evaluation of sacroiliac joint disease, and is especially valuable when there are equivocal plain radiographs.