Lawrence System Research Articles

Comparative evaluation of knee osteoarthritis: radiography vs. ultrasonography in Nepalese population: a cross-sectional study.

Osteoarthritis (OA) is a degenerative and long-term debilitating disease with rising prevalence, predominantly involving larger joints including the knee joint. While radiography has traditionally been the primary modality for joint evaluation, there is a growing trend towards using ultrasonography (USG) for musculoskeletal disorders, including joint assessment. This study aimed to find the role of USG in the evaluation of OA of knee joints with comparison to the radiographs. This was a cross-sectional study done on patients with signs and symptoms of OA of the knee who visited the radiology department for knee radiographs. Kellgren and Lawrence system was used for grading OA in radiographs. USG of knee joints was done with high-frequency probes and searched for joint space width, articular cartilage thickness, marginal osteophytes, meniscal extrusion, and other articular/ extra-articular abnormalities. The USG findings were correlated with findings in anteroposterior and lateral radiographs. The mean number of osteophytes was higher in USG compared to the radiographs (P<0.001). Mean joint spaces were comparable in both modalities. Meniscal extrusion was seen with USG, which significantly correlated with joint space width and cartilage thickness (P<0.005). USG also detected synovial changes, effusion, and Baker's cyst. Although radiography is the standard first-line radiological investigation for the diagnosis of OA of the knee joint, USG can be an adjunct as it well correlates with the radiograph findings and can provide more useful information.

Living at depth: ecophysiological condition of Boreomysis arctica in autumn and winter in the St. Lawrence estuary and gulf.

Mysids, besides krill, play a significant role in energy transfer and carbon sequestration. The ecology of coastal species is better understood than that of deep dwelling species such as Boreomysis arctica. The objectives of this study were to quantify spatiotemporal variations in body condition and the trophic level of B. arctica in autumn and winter, under sea-ice conditions in the St. Lawrence system, using a multimarker approach. We sampled along a 1000km transect. Mean abundances in winter were higher in the estuary compared to the Gulf of St. Lawrence. Body condition, measured as total lipid content, was higher in winter than in autumn. Lipids of B. arctica were mainly composed of wax esters, thereby B. arctica is richer in energetic lipids compared to the three dominant krill species. We also observed seasonal differences in the trophic level of B. arctica, revealing carnivorous behavior in autumn compared to omnivory in winter. High intra-specific variability in both energetic strategy and feeding behavior was found that is potentially due to opportunistic feeding. Energy rich reserves suggest that B. arctica could act as a valuable prey for both benthic and pelagic consumers and thus playing a key role in bentho-pelagic energy transfer.

Revisiting the influence of top-down and bottom-up pressures on Wa hia hé:ta (yellow perch Perca flavescens Mitchill, 1814) population dynamics in Kaniatarowanenneh (the Upper St. Lawrence River): implications for collaborative research

Kaniatarowanenneh (the St. Lawrence River) is the outflow of one of the world’s largest freshwater ecosystems and its ecological health has implications for resource management. The population dynamics of an ecologically and economically important fish, the Wa hia hé:ta, Mohawk for yellow perch ( Perca flavescens), are considered by including data that extend to the past century to redress temporal gaps in comparative literature. We found both a significant top-down effect from piscivorous fish as well as a significant bottom-up effect related to total phosphorus on yellow perch relative abundance in the Lake Ontario–Upper St. Lawrence system. Regarding the bottom-up effect, the current state of yellow perch reflects the population size prior to cultural eutrophication (pre-1940s/50s) likely responding to the re-oligotrophication of the system. These findings emphasize the importance of considering historical records in fish population dynamics research to incorporate shifting population baselines into fisheries management. The study also demonstrates the need for collaborative approaches that bring critical new insights and multivocality.

Automated knee degenerative arthritis reports generation through visual data analysis

Knee degenerative arthritis is a common medical condition that affects the knee joint.Knee Degenerative arthritis causes major disability in patients all over the world. The computerized reporting procedure requires effort and expertise. Manual diagnosis, segmentation of knee joints are still used in clinical practice. Manual diagnosis of this disease involves observing X-ray images of the knee area and classifying it under five grades using the Kellgren – Lawrence (KL) system. Despite the fact that they are time-consuming and sensitive to user variance. As a result, we have the proposed system employing the CNN model with Computer Vision to increase the clinical workflow efficiency and overcome the constraints of the generally used method. We can also implement the report generation system that generates medical reports based on X-ray image features. By extracting the relevant features such as joint space narrowing, and cartilage degeneration, the system generates detailed and objective reports.

Trace element variations in mussels' shells from continent to sea: The St. Lawrence system, Canada

Rare Earth Elements (REE) and several trace elements abundances in mussel's shells collected along the St. Lawrence River, the Estuary, and the Gulf of St. Lawrence (EGSL) reveal coherent chemical variations, with a sharp contrast between freshwater and seawater bivalves. In freshwater mussel's shells, Rare Earth Elements and Y (REY) patterns are rather flat. Their Mn and Ba concentrations are higher than those of EGSL mussel shells, which are much richer in Sr. Shale-normalized REY abundances in mussel's shells from the EGSL show positive anomalies in La and Y and well-marked negative anomalies in Ce, reflecting those of seawater. Prince Edward Island shells show light REE depletion relative to PAAS, positive La and Y anomalies, and negative Ce anomalies. Our data confirm the lack of detectable Gd pollution in the St. Lawrence River and in the EGSL, as well as Pb pollution at the mouth of the Saguenay Fjord and near Rimouski.

The Role of Matrix Metalloproteinase 13 and Vitamin D in Osteoarthritis: A Hospital-Based Observational Study.

Introduction Osteoarthritis (OA) is the most common form of degenerative joint disease characterized by the progressive degeneration of articular cartilage, osteophyte formation, and joint space narrowing. Matrix metalloproteinases (MMPs) are potential biomarkers for osteoarthritis. Aims and objective The study's aim is the estimation of serum and synovial fluid matrix metalloproteinase (MMP) 13 and serum vitamin D levels in the grade 3 and grade 4 stages of osteoarthritis according to the Kellgren and Lawrence (KL) system of classification. Materials and methods A total of 100 subjects were included; of them, 25 patients with grade 3 and 25 patients with grade 4 knee osteoarthritis diagnosed clinically and radiologically according to the Kellgren and Lawrence criteria have been enrolled in the study, and 50 patients with knee pain having a diagnosis other than degenerative OA of the knee were taken as controls. Venous blood and synovial fluid have been collected from all of them for the estimation of MMP-13 and vitamin D. The enzyme-linked immunosorbent assay (ELISA) and chemiluminescent microparticle immunoassay (CMIA) methods were used for the estimation of MMP-13 and vitamin D, respectively. Results The mean value of synovial fluid MMP-13 was found to be elevated in grade 4 as compared to grade 3 and the control group, whereas the mean value of serum MMP-13 was found to be elevated in grade 3 as compared to grade 4 and control. The level of serum vitamin D was found deficient in OA patients as compared to control. The Kruskal-Wallis test was performed to compare these groups, and there was a significant difference between these groups(p-value of <0.05). Summary and conclusion High synovial and serum MMP-13 is associated with knee structural abnormalities in patients with knee OA as compared to the control groupsuggesting that MMP-13 can be a biomarker in knee OA, whereas the decreased level of vitamin D may be associated with an increased risk for the progression of OA; hence, serum vitamin D may be a good indicator for the prediction of the initiation of OA.

A comparative clinical study of Janu Basti (medicated oil retention over knee) and Matra Basti (medicated oil enema) with Sahachara Taila along with Adityapaka Guggulu on osteoarthritis of knee joint

Background: Osteoarthritis (OA) of knee is a chronic inflammatory condition of knee joints characterized by pain, swelling, and functional restriction of the joint. In Ayurveda, it can be correlated with Sandhigata Vata. The two most promising therapies for the Ayurveda management are Janu Basti (medicated oil retention over knee) and Matra Basti (medicated oil enema). The present study was conducted to assess the comparative effect of the two Ayurveda procedure which could assist in clinical decision-making for maximum benefit and minimum discomfort for variable requirements of the patients. Aim: The aim of the study was to ascertain the better management among the two therapies. The objective of the study was to assess changes in pain in knee joints through the Visual Analog Scale (VAS) and disability through Western Ontario and McMaster Universities OA Index (WOMAC) from baseline to 30th day in both the therapies and compare the effect of the both therapies on pain and disability. Materials and methods: In this study, a total of 30 patients having the complaints of OA of knee joint were randomly divided into two groups. Fifteen patients were treated in group A with Janu Basti (external oleation through retention of oil over knee joints for 30 min) with Sahachara Taila along with Adityapaka Guggulu (oral medication) and 15 patients were treated in group B with Matra Basti (enema with medicated oil) with Sahachara Taila along with Adityapaka Guggulu. For the assessment, VAS for pain scoring, WOMAC for disability, Ritchie articular index for tenderness were used, and X-ray were graded on the basis of Kellgren–Lawrence system for OA severity. All the results were calculated by using InStat GraphPad 3 software. For intra-group comparison nonparametric data; “Wilcoxon matched-pairs signed ranks test” and “Paired-t-test” was used. For calculating the inter-group comparison, “Mann–Whitney test” and “unpaired-t-test” was used. All the statistical tests were interpreted as significance at 5% level (P &lt; 0.05). Results: There were significant changes in VAS, WOMAC score, and tenderness of the affected joint in both the groups. On intergroup comparison, Matra Basti with Sahachara Taila in group B has provided better relief in Sandhigatavata of Janu Snadhi along with Adityapaka Guggulu. Conclusion: The result shows that Ayurvedic management with Matra Basti and Janu Basti along with Adityapaka Guggulu are effective in the management of osteoarthritis (OA) of knee joint. However, Matra Basti along with Adityapaka Guggulu is a better management option than Janu Basti.

Otolith elemental fingerprints reveal source-sink dynamics between two Greenland halibut nurseries in the St. Lawrence Estuary and Gulf

In fisheries science, it is important to understand the population dynamics of commercial species and also their movements from the nursery to the population, especially for juvenile individuals, to avoid overfishing. To determine their migration patterns among nurseries, we collected juvenile Greenland halibut Reinhardtius hippoglossoides from 2 nurseries inside our study area, the Estuary and Gulf of St. Lawrence, in the summer of 2016. We measured the concentrations of chemical elements in their otoliths along a margin-core transect and used the margin elemental fingerprints of Mg, Mn, Sr, and Ba to infer migratory behaviour between 2 sample sites, the Estuary and North Anticosti nurseries. Using a random-forest analysis, we achieved an overall reclassification success of margin elemental fingerprints to their capture site of 77%. Most fish sampled from both sample sites originated from the estuary (82.5%), suggesting an important asymmetry in the source-sink dynamics between these nurseries. Juvenile Greenland halibut migrate towards the North Anticosti nursery at a smaller-than-expected size (approximately 26 cm) corresponding to 2.5-3 yr old fish. Despite sexual dimorphism in growth, sex does not affect migratory behaviour or timing of migration before sexual maturation. Our study highlights the recruitment dynamics of Greenland halibut and confirms the estuary as the main nursery in the St. Lawrence system.

Knee Osteoarthritis Detection and Severity Classification Using Residual Neural Networks on Preprocessed X-ray Images.

One of the most common and challenging medical conditions to deal with in old-aged people is the occurrence of knee osteoarthritis (KOA). Manual diagnosis of this disease involves observing X-ray images of the knee area and classifying it under five grades using the Kellgren-Lawrence (KL) system. This requires the physician's expertise, suitable experience, and a lot of time, and even after that the diagnosis can be prone to errors. Therefore, researchers in the ML/DL domain have employed the capabilities of deep neural network (DNN) models to identify and classify KOA images in an automated, faster, and accurate manner. To this end, we propose the application of six pretrained DNN models, namely, VGG16, VGG19, ResNet101, MobileNetV2, InceptionResNetV2, and DenseNet121 for KOA diagnosis using images obtained from the Osteoarthritis Initiative (OAI) dataset. More specifically, we perform two types of classification, namely, a binary classification, which detects the presence or absence of KOA and secondly, classifying the severity of KOA in a three-class classification. For a comparative analysis, we experiment on three datasets (Dataset I, Dataset II, and Dataset III) with five, two, and three classes of KOA images, respectively. We achieved maximum classification accuracies of 69%, 83%, and 89%, respectively, with the ResNet101 DNN model. Our results show an improved performance from the existing work in the literature.

Quantitative CT of the knee in the IMI-APPROACH osteoarthritis cohort: Association of bone mineral density with radiographic disease severity, meniscal coverage and meniscal extrusion

Osteoarthritis (OA) is a highly prevalent chronic condition. The subchondral bone plays an important role in onset and progression of OA making it a potential treatment target for disease-modifying therapeutic approaches. However, little is known about changes of periarticular bone mineral density (BMD) in OA and its relation to meniscal coverage and meniscal extrusion at the knee. Thus, the aim of this study was to describe periarticular BMD in the Applied Public-Private Research enabling OsteoArthritis Clinical Headway (APPROACH) cohort at the knee and to analyze the association with structural disease severity, meniscal coverage and meniscal extrusion. Quantitative CT (QCT), MRI and radiographic examinations were acquired in 275 patients with knee osteoarthritis (OA). QCT was used to assess BMD at the femur and tibia, at the cortical bone plate (Cort) and at the epiphysis at three locations: subchondral (Sub), mid-epiphysis (Mid) and adjacent to the physis (Juxta). BMD was evaluated for the medial and lateral compartment separately and for subregions covered and not covered by the meniscus. Radiographs were used to determine the femorotibial angle and were evaluated according to the Kellgren and Lawrence (KL) system. Meniscal extrusion was assessed from 0 to 3. Mean BMD differed significantly between each anatomic location at both the femur and tibia (p<0.001) in patients with KL0. Tibial regions assumed to be covered with meniscus in patients with KL0 showed lower BMD at Sub (p<0.001), equivalent BMD at Mid (p=0.07) and higher BMD at Juxta (p<0.001) subregions compared to regions not covered with meniscus. Knees with KL2-4 showed lower Sub (p=0.03), Mid (p=0.01) and Juxta (p<0.05) BMD at the medial femur compared to KL0/1. Meniscal extrusion grade 2 and 3 was associated with greater BMD at the tibial Cort (p<0.001, p=0.007). Varus malalignment is associated with significant greater BMD at the medial femur and at the medial tibia at all anatomic locations. BMD within the epiphyses of the tibia and femur decreases with increasing distance from the articular surface. Knees with structural OA (KL2-4) exhibit greater cortical BMD values at the tibia and lower BMD at the femur at the subchondral level and levels beneath compared to KL0/1. BMD at the tibial cortical bone plate is greater in patients with meniscal extrusion grade 2/3.

Effectiveness of Automatic Detection of Osteoarthritis using Convolutional Neural Network (CNN) Method with DenseNet201 on Digital Images of Knee Joint Radiography

The manual detection of osteoarthritis using Kellgren Lawrence system depends on experience and agreement between doctors. The study was conducted to develop DenseNet201 to assist doctors in making a diagnosis of osteoarthritis grading. This study analyzes the accuracy; sensitivity; specificity; positive predictive value (PPV) and negative predictive value (NPV) of DenseNet201 in grading osteoarthritis and compares the classification results between DenseNet201 and radiologists in detecting osteoarthritis on knee joint images. This study is an applied experiment that compares the classification results of DenseNet201 and radiology specialists. Firstly, DenseNet201 is built with the MATLAB R2021a. Tests are carried out by measuring accuracy, sensitivity, specificity, PPV and NPV of 75 images of knee joint. Lastly, the data is analyzed using the Wilcoxon statistical test. The study has shown that the performance of DenseNet201 was good in detecting osteoarthritis, with accuracy value 91.84%; sensitivity value 76.61%; specificity value 94.32%; PPV 82.60% and NPV 94.32%. There was no significant difference between classification results using DenseNet201 and radiologist with a value (p&gt;0.05) of 0.119. DenseNet201 can be considered as an alternative diagnostic tool for osteoarthritis with the condition that verification of the diagnostic decision still refers to the confirmation and justification of the radiologist.

Skin autofluorescence, a non-invasive biomarker of advanced glycation end products, and its relation to radiographic and MRI based osteoarthritis

Accumulation of advanced glycation end products (AGEs) in articular cartilage during aging has been proposed as a mechanism involved in the development of osteoarthritis (OA). Therefore, we investigated a cross-sectional relationship between skin AGEs, a biomarker for systemic AGEs accumulation, and OA. Skin AGEs were estimated with the AGE Reader™ as skin autofluorescence (SAF). Knee and hip X-rays were scored according to Kellgren and Lawrence (KL) system. KL-sum score of all four joints was calculated per participant to assess severity of overall radiographic OA (ROA) including or excluding those with prosthesis. Knee MRI of tibiofemoral joint (TFMRI) was assessed for cartilage loss. Sex-stratified regression models were performed after testing interaction with SAF. 2,153 participants were included for this cross-sectional analysis. In women (n=1,206) for one unit increase in SAF, the KL-sum score increased by 1.15 (95% confidence interval=1.00-1.33) but excluding women with prosthesis, there was no KL-sum score increase [0.96 (0.83-1.11)]. SAF was associated with higher prevalence of prosthesis [Odds ratio, OR=1.67 (1.10-2.54)] but not with ROA [OR=0.83 (0.61-1.14)] when compared to women with no ROA. In men (n=947), there was inconclusive association between SAF and KL sum score or prosthesis. For TFMRI (n=103 women), SAF was associated with higher prevalence of cartilage loss, full-thickness [OR=5.44 (1.27-23.38)] and partial-thickness [OR=1.45 (0.38-5.54)], when compared to participants with no cartilage loss. Higher SAF in women was associated with higher prosthesis prevalence and a trend towards higher cartilage loss on MRI. Our data presents inconclusive results between SAF and ROA in both sexes.

Association between diabetes mellitus, hypertension, and knee osteoarthritis in secondary referral hospitals in Indonesia with retrospective cross-sectional study

IntroductionOsteoarthritis is a disease with degenerative joints. There are some risk factors for osteoarthritis, including age, gender, diabetes mellitus, smoking, and hypertension. The preview study also showed a relationship between osteoarthritis and diabetes mellitus. Besides diabetes mellitus, hypertension may be a risk factor for osteoarthritis. However, research about the relationship between diabetes mellitus and hypertension based on the degree of osteoarthritis is still controversial. This study aims to determine the association between diabetes mellitus and hypertension with the severity of knee osteoarthritis in general and based on gender. MethodsThis research used a retrospective cross-sectional research study with a sample size of 35 patients in Orthopaedic and Traumatology in East Java, who suffered from knee osteoarthritis. Data was collected with medical records, the questionnaire, and the Kellgren & Lawrence system to assess the grade of knee osteoarthritis. ResultsThe Chi-Square test results showed no significant relationship (p > 0.05) between diabetes mellitus and hypertension on the severity of osteoarthritis, both in general and by gender. ConclusionThis study concludes that there is no association between diabetes mellitus and hypertension on the severity of knee osteoarthritis between male and female patients.

A multi-tracer approach to disentangle anthropogenic emissions from natural processes in the St. Lawrence River and Estuary

The ability to differentiate anthropogenic signatures from natural processes in complex hydrological systems is critical for environmental regulation perspectives, especially to curb pollution and implement effective water management strategies. Here, we report variations in the concentrations of 57 chemical variables, including nutrients, major, trace and ultra-trace elements, as well as the concentrations of Escherichia coli in different water masses along the St. Lawrence River-Estuary continuum. The constant ratios among major elements indicate consistent carbonate and silicate weathering processes in the drainage basins. We also suggest applying Ce anomalies to trace waters of low alkalinity and low complexing capacity as the dominance of Ce3+ free ion could promote Ce oxidation, and thus negative Ce anomalies. Furthermore, the positive Eu anomalies and elevated Tl concentrations could highlight the cation exchange processes on clay particles. In the fluvial and estuarine sections of the St. Lawrence System, we demonstrate significant contributions of wastewater discharge and discuss the suitability of several wastewater tracers, e.g., excess of B, Na, K, as well as Rb/Sr and Gd anomalies. We also highlight the inputs of several minor and trace elements (e.g., Mn, Fe, Cu, Co, Ni) from south-shore tributaries to the St. Lawrence System. However, the complex anthropogenic activities in the watersheds did not allow clear source partitioning. Finally, increased mixing of different river water masses upstream of Quebec City, together with the estuarine salt front and suspended sediments, are also responsible for releasing these minor and trace elements into the aquatic media. The results presented here help support further environmental actions to curb the emission of contaminants in the St. Lawrence System and provide more robust tracers of natural and anthropogenic processes in aquatic environments.

Correlation between Grade of Knee Osteoarthritis with Quality of Life of Patient in Secondary Referral Hospital in Indonesia

Background: Osteoarthritis (OA) is a disorder that occurs in the joints and is the leading cause of pain and disability in adults. In Indonesia, the prevalence of osteoarthritis is still high; it was 15.5% in men and 12.7% in women, out of around 225 million Indonesians. Several factors cause osteoarthritis, including aging, genetics, obesity, gender, and the type of work done by the patient.&#x0D; Aims: This study aimed to determine the relationship between the grade of knee osteoarthritis based on the Kellgren &amp; Lawrence system with a decrease in quality of life in patients and to determine the decrease in quality of life based on the gender of the patient at Baptis Hospital, Batu.&#x0D; Methods: This study used a cross-sectional design with a sample size of 31 people who suffer from knee osteoarthritis patients at Baptis Hospital, Batu City. Data collection was carried out directly from respondents using the Short-Form 36 (SF-36) questionnaire.&#x0D; Results: The results showed that 9 respondents (29%) had grade 1 osteoarthritis, 10 respondents had grade 2 osteoarthritis (32.3%), and 12 respondents (38.7%) had grade 3 osteoarthritis. 38.7% of patients have a good quality of life, whereas 61.3 patients have a poor quality of life. It shows that most of the 31 patients suffering from knee osteoarthritis who participated in this research have a poor quality of life. The Chi-Square test showed a significant relationship (p&lt;0.05) between an increase in the grade of knee osteoarthritis and a decrease in the quality of life of patients&#x0D; Conclusion: There was a significant relationship between the grade of knee osteoarthritis and quality of life, and there is no significant relationship between the grade of knee osteoarthritis and the quality of life based on the gender of patients.&#x0D; Keywords: quality of life, knee osteoarthritis, and SF-36.

CORR Insights®: What Is the Interrater and Intrarater Reliability of the Lawrence and Botte Classification System of Fifth Metatarsal Base Fractures?

1Professor, Department of Orthopaedics, Case Western Reserve University, Cleveland, OH, USA R. E. Marcus ✉, Department of Orthopaedics, Case Western Reserve University, 11100 Euclid Avenue, Cleveland, OH 44106, USA, Email: [email protected] This CORR Insights® is a commentary on the article “What Is the Interrater and Intrarater Reliability of the Lawrence and Botte Classification System of Fifth Metatarsal Base Fractures?” by Noori and colleagues available at: DOI: 10.1097/CORR.0000000000002131. The author certifies that there are no funding or commercial associations (consultancies, stock ownership, equity interest, patent/licensing arrangements, etc.) that might pose a conflict of interest in connection with the submitted article related to the author or any immediate family members. All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research® editors and board members are on file with the publication and can be viewed on request. The opinions expressed are those of the writer, and do not reflect the opinion or policy of CORR® or The Association of Bone and Joint Surgeons®.

What Is the Interrater and Intrarater Reliability of the Lawrence and Botte Classification System of Fifth Metatarsal Base Fractures?

Fractures of the proximal fifth metatarsal are common, and often they are classified using a three-part scale first proposed by Lawrence and Botte. A clear consensus on prognosis and treatment for these fractures is lacking, particularly for fractures in the middle classification, Zone 2; the reliability of the classification scheme itself may be partly at fault for this. The intra- and interrater reliability of the classification itself has never been established, and it remains unclear whether the three-part classification of fifth metatarsal fractures can be applied consistently enough to guide treatment. When used by experienced orthopaedic surgeons, (1) What is the overall interrater reliability of the three-part Lawrence and Botte classification of fifth metatarsal base fractures? (2) What is the overall intrarater reliability of the three-part Lawrence and Botte classification of fifth metatarsal base fractures? (3) What are these same metrics for the individual transitions within the classification (Zone 1-2 and Zone 2-3)? Thirty sets of initial presentation radiographs representing an equal number of fractures originally diagnosed by treating clinicians as Zone 1, Zone 2, and Zone 3 were evaluated and classified by three orthopaedic surgeons specializing in foot and ankle surgery and eight foot and ankle fellows to determine interrater reliability. Two weeks later, the same set of radiographs were reevaluated in random order to determine intrarater reliability. Kappa values for interrater and intrarater reliability were calculated. Additionally, the individual transitions between zones were separately analyzed by calculating kappa values for a hypothetical two-part classification based on each transition. The three-part Lawrence and Botte classification of fifth metatarsal fractures demonstrated an overall interrater agreement of κ = 0.66 (observed agreement 77% versus chance agreement 33%). Intrarater reliability for the 11 surgeons ranged from κ = 0.60 to κ = 0.90. A two-part scheme divided by the transition between Zone 1 and Zone 2 demonstrated an interrater agreement of κ = 0.83, and a two-part scheme divided by the transition between Zone 2 and Zone 3 demonstrated a much lower interrater reliability of κ = 0.66. The three-part Lawrence and Botte classification system demonstrated a concerningly low level of interrater reliability with an observed agreement of 77% compared with a chance agreement of 33%. The primary source of concern is the assessment of the interface between Zone 2 and Zone 3, which proved much less reliable than that between Zone 1 and Zone 2. This suggests that previous studies of isolated Zone 1 fractures likely contain a homogeneous fracture cohort, whereas studies of Zone 2 or Zone 3 fractures are likely to include a mixture of fracture types. In practice, the consensus treatment of fifth metatarsal fractures differs based on whether they represent a more proximal, avulsive injury or a more distal injury from indirect trauma. Our data suggest that the Lawrence and Botte classification should be abandoned. Further work should focus on developing a new classification scheme that demonstrates improved interobserver reliability and more directly corresponds to this treatment paradigm. Level III, diagnostic study.

Inter-Rater and Intra-Rater Reliability of the Lawrence and Botte Classification System of Fifth Metatarsal Base Fractures

Category:Trauma; Midfoot/ForefootIntroduction/Purpose:Fractures of the proximal fifth metatarsal are common injuries with a unique history. Treatment of these fractures is controversial, in part due to confusion regarding the nomenclature of the fracture subtypes. The most commonly utilized classification system is the Lawrence and Botte classification, which separates fractures into zones 1, 2, and 3 based on their relationship to the tuberosity and the 4th-5th intermetatarsal articulation. The purpose of this study was to evaluate the inter-rater and intra-rater reliability of the Lawrence and Botte classification of fifth metatarsal base fractures.Methods:Thirty sets of x-rays representing an equal number of zone 1, zone 2 and zone 3 fractures of varying chronicity were sent to eleven fellowship trained orthopedic foot and ankle surgeons. Surgeons were asked to classify each fracture according to the Lawrence and Botte classification system (round 1). No review of the classification system or visual aids were provided. Two weeks later, the same set of x-rays were reordered and renumbered in a random fashion. The surgeons then re-classified each fracture in a blinded fashion under the same conditions (round 2). Inter-rater and intra-rater reliability was summarized using the kappa statistic. To determine the source of variability between the zones, additional analyses were performed to determine the kappa statistic for a) combined zone 1 and 2 fractures versus zone 3 fractures and b) combined zone 2 and 3 fractures versus zone 1 fractures.Results:The Lawrence and Botte classification demonstrated substantial overall inter-rater agreement for both rounds 1 and 2 (kappa = 0.66 and 0.65, respectively). Zone 1 fractures demonstrated the highest inter-rater reliability (kappa = 0.83 and 0.83). There was moderate agreement for zone 2 fractures (kappa = 0.51 and 0.50). There was substantial agreement for zone 3 fractures (kappa = 0.64 and 0.65). Dichotomous evaluation of the zone 1 vs. combined zones 2-3 boundary yielded excellent agreement (kappa = 0.83, 0.83). The combined zones 1-2 vs. zone 3 boundary yielded a much lower agreement (kappa = 0.66, 0.65). Intra-rater reliability varied by individual, with kappa values ranging from 0.60 to 0.90, corresponding to modest to almost perfect agreement.Conclusion:The Lawrence and Botte classification system has overall substantial inter-rater and intra-rater reliability, but assessment of the interface between zone 2 and zone 3 fractures is much less reliable than that between zone 1 and zone 2. Previous studies of isolated zone 1 fractures most likely contain a homogenous fracture cohort, while studies of zone 2 or zone 3 fractures are likely to include a mixture of fracture types. Future studies may utilize supplemental imaging or modify the classification to best determine treatment of these more distal fractures.

РЕЗУЛЬТАТЫ ПЕРВОГО ОПЫТА СИМУЛЬТАННЫХ ОПЕРАЦИЙ ПРИ ВАРИКОЗНОЙ БОЛЕЗНИ И ГОНАРТРОЗЕ

Objective: To analyze the results of the first experience of performing simultaneous operations for saphenous varicose veins of the lower extremities and knee osteoarthritis. Methods: The results of simultaneously performed combined phlebectomy and arthroscopic knee surgery in patients with varicose veins (VV) were analyzed. A total of 15 female patients (mean age 52.8±1.9 years) were included in the study. In 5 patients, Clinical Class II, according to the Clinical Etiological Anatomical Pathophysiological (CEAP) classification, published in 1994 for chronic venous disease, was noted, and in 10 – class III. In 13 (86.7%) cases, there was a bilateral dilatation of the saphenous veins; and in 12 patients, there was a combined dilatation of both the Great Saphenous Vein (GSV) and Small Saphenous Vein (SSV). Perforator venous insufficiency was present in 5 patients. Among those examined, in 5 cases, clinical and laboratory findings of the КOA grade II, according to the Kellgren and Lawrence system (1957) for OA classification, were noted, and in 10 patients – grade III. Overweight was observed in 9 patients, and the mean weight was 77.5±3.8 kg. Assessment of the function of the knee joints before and three months after the operation was carried out according to Lequesne's algo-functional index (AFI). Results: The mean diameter of the GSV and SSV was 10.2±0.4 and 6.4±0.4 mm, respectively, and the diameter of insufficient perforating veins was 4.1±0.3 mm. The malleolar circumference before surgical treatment was 37.7±1.5 cm. In all cases, patients had pain and discomfort during the night (n=5 with movement and n=10 without), morning stiffness (n=9), and increased pain when walking a certain distance (n=8) or at the beginning of the movement (n=7). A positive correlation was found between pain and discomfort with age (r=0.53), KOA stage (r=0.70), malleolar circumference (r=0.58) and a negative correlation with body weight (r=-0.55) and recurrence of VV(r=-0.68). All patients complained of walking difficulties, and as a result, their walking distance was reduced. A direct correlation was found between walking distance and body weight (r=0.71), KOA stage (r=0.84), malleolar circumference (r=0.81), pain and discomfort during the night (r=0.66). In addition, in all cases, there was a decrease in daily life activities – the ability to climb one flight of stairs up or down at a moderate effort, squatting or kneeling, and limited ability to walk on uneven ground. The mean operative time of the combined operation's first step (phlebectomy) and arthroscopic knee surgery was 125.5±25.5 and 58.2±10.5 minutes, respectively. The development of postoperative seroma in the wound area was observed in only one case. The average hospital stay was 7.2±1.2 days, and sutures were removed within 10-12 days. A follow-up examination of patients after 1 and 3 months revealed a significant decrease in all the above parameters of Lequesne's AFI and malleolar circumference to 32.0±1.3 cm. Conclusion: Combined phlebectomy with arthroscopic knee surgery in VV comorbid with KOA results in a significant improvement in symptomatic KOA patients with increased walking distance and daily activity with no significant complications. Keywords: Varicose veins, knee osteoarthritis, phlebectomy, vein stripping, arthroscopic knee surgery, combined operations.

Effects of a periodized circuit training protocol delivered by telerehabilitation compared to face-to-face method for knee osteoarthritis: a protocol for a non-inferiority randomized controlled trial

BackgroundRegular exercise is an effective method for reducing pain and disability in patients with knee osteoarthritis (OA), as well as improving body composition. Thus, a combination of both resistance and aerobic training (circuit training) has shown to be promising for this population. However, access to physical therapy is limited by physical distance, social isolation, and/or treatment costs. Remote rehabilitation seems to be an effective way to minimize these barriers, but the benefits are dependent on the participants’ adherence to the interventions provided at a distance. The objectives of this protocol are to compare the effects of a periodized circuit training applied via telerehabilitation with the same protocol applied in the face-to-face model for individuals with knee OA.MethodsThis study presents a single-blinded protocol for a non-inferiority randomized controlled trial. One hundred participants diagnosed with knee OA (grades II and III Kellgren and Lawrence system), aged 40 years or more, and BMI < 30 kg/m2 will be randomly divided into two groups: telerehabilitation (TR) and face-to-face (FtF) circuit training. The FtF group will perform a 14-week periodized circuit training protocol supervised by a physical therapist, 3 times a week. The TR group will perform the same exercise protocol at home, at least 3 times a week. In addition, the TR group will be able to follow the execution and orientations of the exercises by DVD, a website, and online file sharing tools, and they will receive periodic phone calls in order to motivate, clarify, and inform some aspects of knee OA. The primary outcomes are changes in self-reported pain intensity (visual analog scale (VAS)) and physical function (Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC)), with a primary end-point of 14 weeks and a secondary end-point of 26 weeks. Secondary outcomes include changes in other clinical outcomes, in morphological characteristics, adherence, acceptability, and treatment perspective.DiscussionA circuit training through telerehabilitation may contribute to developing early intervention in the causative and potentiating factors of the knee OA, verifying the effects of a low-cost, non-pharmacological and non-invasive treatment.Trial registrationBrazilian Registry of Clinical Trials (ReBEC) ID: RBR-662hn2. Registered on 31 March 2019. Link: http://www.ensaiosclinicos.gov.br; Universal Trial Number (UTN) of World Health Organization: U1111-1230-9517.