Normal Joint Space Research Articles

Early and middle term results after surgical treatment for slipped capital femoral epiphysis

To evaluate the early and middle-term results of in situ single screw fixation and subtrochanteric osteotomy of the femur with external fixator for slipped capital femoral epiphysis (SCFE). From June 1998 to July 2008, 11 patients (seven male [eight hips] and four female [four hips]) of average age 14.3 years (range, 9-18 years) were treated in our hospital. According to the Southwick measurement, seven hips were mildly affected (<30°), two moderately (30-50°), and three severely (>50°). The average body mass index (BMI) was 31.1 g/m(2) (range, 27-35 g/m(2) ). All the mild and moderate cases underwent in situ single screw fixation, and the three severe cases subtrochanteric osteotomy of femur with external fixator. All cases were evaluated both clinically and radiographically at 3 months, 6 months and every year postoperatively. All cases were followed up for 2-12 years (average 5.6 years). The Harris hip score increased from a mean of 74.8 (70 ∼ 85) points preoperatively to 90.6 (70 ∼ 100) points postoperatively. X-ray films showed epiphyseal closure in the in situ single screw fixation cases, and no further increase in epiphyseal-shaft angle. Partial reduction of slipped epiphysis with normal joint spaces was observed after subtrochanteric osteotomy of the femur in the external fixator cases. In situ single screw fixation for treating mild and moderate SCFE has a satisfactory clinical outcome, and the advantage of prevention of further slippage. Subtrochanteric osteotomy of the femur with external fixator is suitable for severe SCFE with late deformity; the realignment procedure can correct deformity and postpone or prevent subsequent osteoarthritis.

Outcomes of Posterior Wall Fractures of the Acetabulum Treated Nonoperatively After Diagnostic Screening with Dynamic Stress Examination Under Anesthesia

Dynamic stress fluoroscopy with the patient under general anesthesia has been advocated as a clinical measure of hip stability and congruity in patients with a posterior wall acetabular fracture. The purpose of this study was to establish the predictive value of the dynamic stress fluoroscopic examination for these fractures by evaluating clinical and radiographic outcomes after nonoperative treatment of fractures found to be stable with this examination. Twenty-one consecutive patients with an acute posterior wall fracture of the acetabulum who were shown to have a stable hip joint by dynamic stress fluoroscopy while they were under general anesthesia were treated nonoperatively. At the time of follow-up, the patients underwent clinical and/or radiographic evaluation. Clinical follow-up was performed for eighteen patients at a minimum of two years after injury, at which time the average modified Merle d'Aubigné score was very good, with no one having less than a good clinical outcome. Fifteen of these eighteen patients had radiographic evaluation at a minimum of two years, and all were found to have a congruent joint with a normal joint space and no evidence of posttraumatic arthritis. Hip joint stability determined with dynamic stress fluoroscopy with the patient under general anesthesia after a posterior wall acetabular fracture is predictive of hip joint congruity, an excellent radiographic outcome, and a good-to-excellent early clinical outcome after nonoperative treatment.

Early and middle-term results after surgical treatment for slipped capital femoral epiphysis

Objective To evaluate the early and middle-term results of in-situ single-screw fixation and subtrochanteric osteotomy of femur with external fixator for slipped capital femoral epiphysis(SCFE).Methods From June 1998 to July 2008, eleven patients (12 hips) with SCFE were treated, including 7males (8 hips) and 4 females (4 hips) with an average age of 14.3 years (range, 9-18). The average BMI was 31.1 g/m2. According to the Southwick measurement, mild (＜30°) in 6 cases (7 hips), moderate (30°-50°) in 2 cases (2 hips), and severe (＞50°) in 3 cases (3 hips). All the mild and moderate cases were undergone insitu single screw fixation, and three severe cases were performed subtrochanteric osteotomy of femur with external fixator. All the cases were evaluated at 3 months, 6 months and every year postoperatively. Results All the cases were followed up for average 5.6 years (range, 2-12). The Harris hip score increased from mean 74.8 points preoperatively to 90.6 points postoperatively, with 10 hips excellent, 1 hip good, 1 hip fair and 0 hip poor. The excellent and good rate was 91.7% (11/12). The X-ray showed the epiphyseal closure in in-situ single screw fixation cases, and no further increase in epiphyseal-shaft angle. Partial reduction of slipped epiphysis with normal joint spaces was observed in subtrochanteric osteotomy of femur with external fixator cases. Conclusion In-situ single screw fixation provides a surgical treatment option to treat mild and moderate SCFE with satisfactory clinical outcome, and profit to the prevention further slip. Subtrochanteric osteotomy of femur with external fixator is suitable for severe SCFE with late deformity. The realignment procedure can correct deformity and postpone or avoid the occurrence of osteoarthritis. Key words: Femur head; Epiphyses; Osteotomy; External, fixators

The Role of Arthroscopy in Treating Osteoarthritis of the Knee in the Older Patient

Arthroscopy of the osteoarthritic knee is a common and costly practice with limited and specific indications. The extent of osteoarthritis (OA) is determined by joint space narrowing, which is best measured on a weight-bearing radiograph of the knee in 30° or 45° of flexion. The patient older than 40 years with a normal joint space should have a magnetic resonance image taken to rule out focal cartilage wear and avascular necrosis before recommending arthroscopy. Randomized controlled trials of patients with joint space narrowing have shown that outcomes after arthroscopic lavage or debridement are no better than those after a sham procedure (placebo effect), and that arthroscopic surgery provides no additional benefit to physical and medical therapy. The American Academy of Orthopedic Surgeons guideline on the Treatment of Osteoarthritis of the Knee (2008) recommended against performing arthroscopy with a primary diagnosis of OA of the knee, with the caveat that partial meniscectomy or loose body removal is an option in patients with OA that have primary mechanical signs and symptoms of a torn meniscus and/or loose body. There is no evidence that removal of loose debris, cartilage flaps, torn meniscal fragments, and inflammatory enzymes have any pain relief or functional benefit in patients that have joint space narrowing on standing radiographs. Many patients with joint space narrowing are older with multiple medical comorbidities. Consider the complications and consequences when recommending arthroscopy to treat the painful osteoarthritic knee without mechanical symptoms, as there is no proven clinical benefit.

Morbid anatomy of ‘erosive osteoarthritis’ of the interphalangeal finger joints: an optimised scoring system to monitor disease progression in affected joints

ObjectivesTo develop and validate a quantitative radiographic scoring system, the Ghent University Scoring System (GUSS), with better ability to detect progression over a shorter period of time in erosive osteoarthritis...

Concepts For Assessment Of Anterior Knee Pain In Relation To Muscle Function

PURPOSE: Anterior knee pain in the young adult is associated with patello femoral rather than femoral tibial dysfunction (Kristin M Houghton 2007). The relationship between vastus medialis oblique strength and anterior pain and disability has been suggested (S. O'Reilly 1998). The lack of consistent methodology in objective measurement of the quadriceps muscles have made evaluation of the link between pain and altered muscle function difficult to assess. Using a novel methodology we demonstrate a biomechanical protocol to access the deficiency of the quadriceps muscles in patients with anterior medial knee pain. METHODS: A biomechanical evaluation was conducted on 54 patients with anterior medial knee pain (34 females and 20 males). All patient x-rays were normal (alignment and joint space between the femur and the tibia as well as between the femur and the patella) through interpretation by a blinded radiologist. A Kistler force plate, a VICON motion analysis system and surface electromyography were used to quantify biomechanical function during isometric, walking and squatting exercises. RESULTS: For 42 of the 54 (78%) subjects, during isometric and walking exercises we observed that activation of the VMO, rectus femoris (RF) and vastus lateralis (VL) muscles of the symptomatic leg was not significantly different from those of the asymptomatic leg (p<0.01). However, for 31 patients (57%) during the eccentric phase of the squat exercises, the symptomatic leg presented with high activation of VL compared to VMO and RF (p<0.01). During the concentric phase, 45 patients (83%) presented with higher activation of the VL compared to the VMO. CONCLUSION: VMO activity during squatting for the symptomatic (patient with anterior medial knee pain) leg differs fundamentally during walking and isometric exercise compared to squatting tasks. Moreover, the relative contribution of the VL compared to the VMO during the eccentric phase of the squat exercises was different to those recorded during the concentric phase. Therefore, we suggest that maximal isometric and or isokinetic exercises are not sufficient to access the quadriceps function in relation to anterior knee pain. A thorough biomechanical assessment, including functional testing to reproduce the patient's pain and locate the nature of the symptoms is suggested.

Evaluation of the severity of temporomandibular joint osteoarthritic changes related to age using cone beam computed tomography

The aim of this study is to evaluate and correlate with age the severity of temporomandibular joint (TMJ) osteoarthritic changes using cone beam CT (CBCT). The images of 71 patients with findings of degenerative arthritis were retrieved from the computer data base. All patients had been examined with CBCT (NewTom 9000 QR-DVT). Left and right TMJs were evaluated independently for each patient. TMJ evaluation included: (a) bony changes of the condyle (flattening, erosion, sclerosis, osteophytes, resorption); (b) joint space (normal, increased, reduced, bony contact between the condyle and the mandibular fossa); and (c) bony changes of mandibular fossa (normal, sclerosis, erosion, resorption). The radiographic findings were statistically analysed. Significant differences in the mean age were found: (a) between absent and moderate erosion (P = 0.019), as well as between absent and extensive erosion (P = 0.048); (b) between absent and extensive formation of osteophyte (P = 0.003), as well as between slight and extensive formation of osteophyte (P = 0.025); (c) between normal joint space and bony contact (P = 0.0002), as well as between reduced joint space and bony contact (P = 0.001). Degenerative arthritis is an age-related disease. The progression and severity of osseous changes in the condylar head and mandibular fossa are increased with age. In older age groups, patients are expected to have more frequent and severe progressive degenerative bony changes due to the development of TMJ osteoarthritis than patients in younger age groups.

Arthroscopic Repair of the Posterior Horn of the Medial Meniscus with Opening Wedge High Tibial Osteotomy

Simultaneous repair of a radial tear at the tibial attachment site of the posterior horn of the medial meniscus under special circumstances requiring tibial valgus osteotomy is technically difficult. First, most patients who need an osteotomy have a narrowed medial tibiofemoral joint space. In such a situation, the pull-out suture technique is more difficult to perform than in a normal joint space. Second, pulling out suture strands that penetrate the posterior horn of the medial meniscus to the anterior tibial cortex increases the risk of transection during osteotomy. We performed a meniscus repair combined with an opening wedge tibial valgus osteotomy without complications and present our technique as a new method for use in selective cases necessitating both meniscus repair of a complete radial tear and opening wedge tibial osteotomy.

Postpartum bilateral transient osteoporosis of the hip: MR imaging findings in three cases

Transient osteoporosis of the hip (TOH), associated with pregnancy, is a self-limiting skeletal disorder affecting women, usually in the third trimester, which resolves spontaneously within few months postpartum. Bilateral involvement is rare. Involvement postpartum has not been described. We report three patients with postpartum presentation of bilateral TOH. Three pregnant women who presented with acute bilateral hip pain just after delivering their first child are reported. None of them had any past history of joint problems, recent injury, alcohol abuse or corticosteroid administration. Magnetic resonance (MR) imaging examinations were performed on 1.5-Tesla magnets using standard protocols. Bone marrow oedema, with normal joint space and intact articular surfaces, was depicted in all six hips. MR imaging findings with clinical correlation confirmed the diagnosis of TOH. TOH associated with pregnancy does not necessarily occur in the third trimester of pregnancy and may be bilateral.

Evaluations of radiographic joint space – do they adequately predict cartilage conditions in the patellofemoral joint of the patients undergoing total knee arthroplasty for advanced knee osteoarthritis?

To determine whether assessments of patellofemoral (PF) joint space reliably predict the cartilage conditions in the PF joint of the patients undergoing total knee arthroplasty (TKA) for advanced knee osteoarthritis. Radiographic joint spaces and gross cartilage conditions in the PF joint were assessed in 151 osteoarthritic knees undergoing TKA. Minimum joint space widths (MJSWs) in the medial and lateral compartments of the PF joint were measured separately on Merchant radiographs. Degrees of joint space were graded as normal, narrowed and obliterated, and expected locations of significant cartilage lesions were classified as medial, lateral, and global. Cartilage lesions were grossly assessed in terms of their severity (depth and size) and location. Cross-table analyses and kappa statistics were used to determine the level of agreements between radiographic and gross assessments and the diagnostic accuracies of the radiographic assessments. The agreements between the radiographic assessments and the gross assessments on the lesion severities and locations were only fair [kappa coefficient (k)=0.288 and 0.211, respectively]. The cross-table analyses demonstrated that 45 (47.4%) of 95 knees with a normal radiographic joint space had moderate or severe cartilage degeneration of the PF joint identified with gross assessments. In the radiographic assessments, the lateral compartment of the PF joint was the most frequent location of joint space narrowing (71.4%) whereas in the gross assessments, the medial compartment of the PF joint was the most frequent location of significant cartilage lesion (48.1%). Diagnostic accuracies on the lesion severities and locations were generally poor. This study demonstrates that prediction of the cartilage conditions of the PF joint by the radiographic joint space can be inaccurate.

Persistent Ankle Pain-Running

HISTORY: A 29 year-old female long-distance runner presented with a five-year complaint of left ankle pain after an inversion-supination injury while running. She described her ankle pain as a constant aching and throbbing which radiated proximally toward her knee and worsened with any use of her ankle, particularly running. Mild improvement was observed with rest and NSAID's but no other therapies alleviated her pain. Since her injury five years ago, she has been evaluated by five orthopedic surgeons, a rheumatologist, and a pain specialist. Her therapies have included two weeks in a solid cast, several rounds of physical therapy, six weeks of non-weightbearing, several local corticosteroid injections, two lumbar sympathetic nerve root blocks, ankle arthroscopy, a Bromstrum ankle reconstruction, NSAID's, gapapentin, and several antidepressants from various classes. She had been given a presumptive diagnosis of reflex sympathetic dystrophy. PHYSICAL EXAMINATION: Examination of her right leg did not show deficits in strength or sensation. Examination of her left leg revealed a positive Tinel's to percussion over the extensor retinaculum at the ankle. A decrease in pinprick sensation was observed over the first web space. She was tender to palpation only over the lateral malleolus. Strength throughout her leg was rated as 5/5 except toe extension which was 4/5. Her left foot was noted to be slightly darker than the right but a temperature difference was not appreciated. Normal reflexes and pulses were present bilaterally. DIFFERENTIAL DIAGNOSIS: Talar osteochondral injury Reflex sympathetic dystrophy Ankle instability Syndesmotic injury Peroneal neuropathy Osteoarthritis TESTS AND RESULTS: X-rays: normal joint spaces, age-appropriate degenerative changes Bone Scan: slightly increased uptake in the left midfoot. MRI: No signal abnormality in bone or articular cartilage. Postoperative changes along lateral malleolus. EMG/NCV: Axonapraxia of the deep peroneal nerve at the distal leg/ankle consistent with anterior tarsal syndrome. FINAL WORKING DIAGNOSIS: Entrapment of the deep peroneal nerve at the ankle. TREATMENT AND OUTCOMES. Topiramate for long-standing neuropathic pain. Surgical decompression of the deep peroneal nerve with postoperative reduction of her pain from eight to three on a visual analog scale (VAS). She returned to running five months postoperatively, but has been unable to tolerate the same distances she ran premorbidly and currently runs 5–10 kilometer races instead of marathons. Her pain has not completely resolved and her VAS score worsens from three to five when topiramate is discontinued.

Assessing hip osteoarthritis severity utilizing a probabilistic neural network based classification scheme

A computer-based classification system is proposed for the characterization of hips from pelvic radiographs as normal or osteoarthritic and for the discrimination among various grades of osteoarthritis (OA) severity. Pelvic radiographs of 18 patients with verified unilateral hip OA were evaluated by three experienced physicians, who assessed OA severity employing the Kellgren and Lawrence scale as: normal, mild/moderate and severe. Five run-length, 75 Laws’ and 5 novel textural features were extracted from the digitized radiographic images of each patient's osteoarthritic and contralateral normal hip joint spaces (HJSs). Each one of the three sets of textural features (run-lengths, Laws’ and novel features) was separately utilized for assigning hips into the three OA severity categories, by means of a probabilistic neural network (PNN) classifier based hierarchical tree structure. The highest classification accuracy (100%) for characterizing hips as normal, of mild/moderate or of severe OA was obtained for the novel textural features set. Additionally, the novel textural features were used to design a mathematical regression model for providing a quantitative estimation of OA severity. Measured OA severity values, as expressed by HJS-narrowing, correlated highly ( r = 0.85, p < 0.001) with the predicted values by the mathematical regression model. The proposed system may be valuable in OA-patient management.

Coexistent gout and rheumatoid arthritis: a case report

A 56-year-old Brazilian man, non-alcoholic, with no family history of arthritis, complained of weight loss and fever during haemodialysis. Over the previous 3 years he had asymmetric podagra responsive to colchicine and allopurinol, and developed subcutaneous nodules in fingers and forearms, where tophi of monosodium urate crystals were found on needle aspiration. He also had recurrent symmetric polyarthritis in wrists and hands without morning stiffness. On admission his temperature was 36.5°C. The heart was rhythmic at 99 beats per minute and blood pressure 190/110 mmHg. The lungs were clear and respiratory rate 20 incursions per minute. The liver was normal and the spleen was enlarged. Symmetric nodules were found in the third proximal interphalangeal hand joints (Figure 1) and near the elbows (Figure 2) without rheumatoid deformities. The results of blood tests were as follows: erythrocytes 2.77×106/mm3, haemoglobin 8.1g/dl, haematocrit 25.9%, leukocytes 13 100/mm3 (neutrophils 72%, lymphocytes 20%), platelets 280 000/mm3, erythrocyte sedimentation rate 89 mm/hr, albumin 3.6 g/dl, globulins 4.8 g/dl, Bence-Jones proteinuria negative, uric acid 11.3 mg/dl, iron 57 μg/dl, glucose 84 mg/dl, urea 93 mg/dl, creatinine 8.4 mg/dl, sodium 135 mEq/litre, potassium 4.8 mEq/litre, calcium 1.44 mmol/litre, phosphorus 5.3mg/dl, aspartate transaminase 20U/litre, alanine transaminase 33U/litre, gamma-glutamyl transpeptidase 170 UI/litre, triglycerides 101 mg/dl, cholesterol 117 mg/dl. C-reactive protein 4.8 mg/dl, acid alpha1-glycoprotein 235 mg/dl, rheumatoid factor 82.3 UI/dl, antinuclear, anti-DNA, and anti-microsomal antibodies negative. Complement levels were C3 116 mg/dl and C4 55 mg/dl. Tests for hepatitis C and toxoplasmosis immunoglobulin G were positive; and hepatitis B, brucellosis, mononucleosis, syphilis and human immunodeficiency virus were negative. Radiograph of hands showed cortical erosions in the third proximal interphalangeal joints, with normal joint spaces, erosions and cysts in metacarpal epiphyses, with symmetrical periarticular osteoporosis and soft tissue swelling (Figure 3). Medial epicondyle erosion with overhanging edges and fluffy calcifications of chronic tophaceous gout (Monu and Pope, 2004) were seen in the left olecranon. Biopsy of subcutaneous nodule disclosed granulomas with central zones of fibrinoid necrosis surrounded by palisades of mononuclear cells (Figures 4 and 5), and characterized rheumatoid arthritis coexistent with gout.

Cemented Total Knee Arthroplasty in Patients with Juvenile Rheumatoid Arthritis

The optimal techniques and implants for total knee arthroplasty in patients with juvenile rheumatoid arthritis are controversial. We report the functional outcomes and complications of a series of 17 cemented total knee arthroplasties done by one surgeon during a 10-year period in which off-the-shelf implants were used, the posterior cruciate ligament was excised, and a lateral retinacular release was done. Preoperatively, all knees had severe loss of normal joint space and osteopenia on 3-foot, standing AP radiographs, lateral radiographs, and patellofemoral views. The patients were evaluated after a mean followup of 74 months (range, 36-116 months). The Knee Society scores improved from a mean of 38.9 +/- 23.9 points (range, 10-81 points) preoperatively to 81.9 +/- 16.6 points (range, 39-99 points) postoperatively. Range of motion showed significant improvement in all patients at the most recent followup. Ambulation scores improved significantly; nine of 10 patients (15 knees) were ambulatory after surgery. Complications included two transient regional pain syndromes and one patellofemoral subluxation requiring realignment. Cemented total knee arthroplasty with off-the-shelf implants, excision of the posterior cruciate ligament, and lateral retinacular release in patients with juvenile rheumatoid arthritis can provide substantial improvement in pain, deformity, ambulation, and function. Therapeutic study, Level IV (case series--no, or historical control group). See the Guidelines for Authors for a complete description of levels of evidence.

Idiopathic avascular necrosis of the femoral head in adolescents: Diagnostics and management

Idiopathic avascular necrosis of the femoral head still represents incompletely explained clinical entity. In the period 1978-2003. we have treated sixteen hips in ten patients with this condition in the IOHB "Banjica". Diagnosis have been founded on clinical and radiographic features, in addition to MRI findings. One patient have been operated, curretaging necrotic part of the femoral head and placing homografts instead. The other fifteen patients have been treated by the same procedure: skin traction for several months following immediate rehabilitation of the hip. The goal of treatement was reducing the pain, increasing the range of movements and preservation of the normal joint space. Evaluation of the treatement was based on unique criteria founded on Howorth-Ferguson index, clinical and radiographic features.The follow-up period was 2-7 years. The authors have stressed the following advantages of the non-operative treatement in adolescents with idiopathic avascular necrosis if the femoral head: increased range of joint movements, decreased pain and low risk rate of any complications following surgical procedures. Formed changes in the femoral head are irreversible, and they are real basic for premature arthrosis of the hip.

Tuberculosis of the Knee

Fifty-two children with tuberculosis of the knee treated from 1979 to 1999 were reviewed retrospectively. The radiologic appearance of the joint at presentation was predictive of the outcome. Ninety-two percent of the patients had Stage 1 or Stage 2 involvement (synovitis) with or without bony erosions, but had a normal joint space. Treatment with antituberculous chemotherapy without synovectomy had an excellent or good result in all patients with Stage 1 or Stage 2 disease, and there was no difference in outcome whether the knee was immobilized or mobilized. Patients with Stage 3 and Stage 4 disease who had a narrow joint space (arthritic) at presentation had a fair or poor result. In patients with monoarthritis of the knee with nonspecific histologic features and a negative culture, the differential diagnosis between tuberculosis and pauciarticular juvenile rheumatoid arthritis is problematic. The histologic evaluations of biopsy specimens of the synovium of 25 knees from 25 patients were reviewed for synovial lining hyperplasia. The sensitivity for the 17 knees that subsequently were diagnosed as having juvenile rheumatoid arthritis was only 53%. Deoxyribonucleic acid from 13 consecutive joints was subjected to polymerase chain reaction for Mycobacterium tuberculosis infection with only 40% sensitivity for tuberculosis.

KNEE PAIN AND GIVING WAY - ACTIVE ADOLESCENT

HISTORY: Fifteen-year-old female was seen for an episode of right knee giving way walking downstairs. No previous problems. No other joint complaints. Family history is significant in that her father has congenital knee abnormality for which he may require total knee replacements. PHYSICAL EXAMINATION: Right knee range of motion of 20–110. Mild effusion. There was tenderness over the medial femoral condyle (MFC). Mild pain on lateral patellar subluxation maneuvers. Ligaments stable. There was no palpable loose body. No joint line tenderness. DIFFERENTIAL DIAGNOSIS: Osteochondritis dissecans medial femoral condyle. Osteochondral fracture. Loose body. Medical meniscus tear. Patellar subluxation. TEST AND RESULTS: Plain radiographs of AP, notch, lateral, and patellar views show radiolucency of the medial femoral condyle. This appears to be central weight bearing area on the lateral view. There are no radiopaque loose bodies, no fractures. The lesion on notch view measures 26 mm in width. Radiographs of AP, lateral, notch, and sunrise view show a loose body. MFC appeared normal. Arthroscopy again was suggested and was performed. The findings at the time of arthroscopy were a 2.5 × 2.5 × 1.5 cm osteochondral loose body which was removed. The OCD lesion of the MFC was completely healed in the medial femoral condyle without any area of abnormality on probing. Postoperatively, she did well. FINAL/WORKING DIAGNOSIS: Loose body, OCD medial femoral condyle. Completely healed MFC lesion. TREATMENT AND OUTCOMES: She was seen nine years postop for left knee pain. Follow up weight bearing radiographs revealed normal and symmetrical joint spaces and normal-appearing MFC. She was having no problems with her right knee.

Sonography of the normal scapholunate ligament and scapholunate joint space.

The aims of this study were to assess the visibility of the normal scapholunate ligament on sonography and to establish the normal scapholunate joint space width in the neutral position and radial and ulnar deviation. Two hundred normal wrists in 100 subjects (55 men and 45 women; mean age, 40 years; range, 19-83 years) were examined with high-resolution sonography (5-12-MHz linear-array transducer). The visibility and thickness of the scapholunate ligament were recorded. The width of the scapholunate joint space, or interval, was measured in the neutral position and radial and ulnar deviation. The width of the distal radius was recorded as a comparative standard for the patients' body habitus. The dorsal scapholunate ligament was completely (100%) visible in 95 wrists (48%), partially (> or = 50%) visible in 60 (30%), barely (< 50%) visible in 15 (8%), and not visible in 30 (15%). The volar scapholunate ligament was completely visible in 13 wrists (7%), partially visible in 17 (9%), barely visible in 15 (8%), and not visible in 151 (76%). The proximal component of the ligament was not visible in any subject. Measurement of the scapholunate interval was limited by the lack of identifiable anatomic marks for reference. The mean width of the dorsal scapholunate interval was 4.2 mm (range, 2.3-6.3 mm) in the neutral position. The interval did not differ more than 2.5 mm between the left and right wrists. No predictable change in width on ulnar or radial deviation was evident. The mean scapholunate intervals and mean distal radial width were significantly wider in men than in women and on the right side than on the left side. The dorsal scapholunate ligament is completely or partially visible in 78% of normal wrists. Its detection following injury may help to exclude the possibility of scapholunate dissociation. There is a quite wide variation in scapholunate interval widths on sonography and an unpredictable response with stress testing. The absence of a visible scapholunate ligament on sonography does not indicate injury.

The role of subchondral insufficiency fracture in rapid destruction of the hip joint: a preliminary report.

The pathophysiology of rapidly destructive arthrosis of the hip joint (RDA) is unknown. The purpose of this study was to document cases of subchondral insufficiency fracture of the femoral head, which has similar clinicoradiologic features to those of early-stage RDA. This study was based on a retrospective review of 11 cases of subchondral insufficiency fracture of the femoral head that were confirmed histopathologically and for which radiographs both at the onset of hip pain and at the time of surgery were available. All patients were > 60 years of age (range 61-78 years, mean age 69), and 9 were women. On plain radiographs, the normal joint space had undergone rapid narrowing and/or disappeared within 9 months (mean 5.8 months). Magnetic resonance imaging, available in 2 cases, showed a pattern of bone marrow edema from the upper portion of the femoral head to the intertrochanteric region, with an associated focal low-intensity band on T1 paralleling the articular surface. In all cases, evidence of subchondral insufficiency fracture was confirmed histopathologically. In addition, in the marrow space, there were several round-to-oval granulomatous foci, which consisted of amorphous debris, fragmented bone, and articular cartilage surrounded by reactive histiocytes and giant cells. All 11 patients were osteopenic, as shown both radiologically and histopathologically. Subchondral insufficiency fracture resulting from osteopenia may lead to a rapid breakdown of the hip joint.

Foot amputation by the Moche of ancient Peru: osteological evidence and archaeological context

Three probable cases of foot amputation, with healing, in skeletal remains associated with the Moche culture (AD 100–750) of northern coastal Peru are described. Each case exhibits non-functional tibio-talar joints with proliferative bone occupying the normal joint space. The robusticity of the tibiae and fibulae suggest renewed weight-bearing and mobility following recovery. The osteological evidence is consistent with details shown in Moche ceramic depictions of footless individuals. A footless Moche skeleton with wooden prostheses, described in 1913 by Peruvian physician Vélez López, appears to represent a fourth example of this procedure. The Moche surgical approach was similar to a technique that would be pioneered in western medicine by the Scottish surgeon Sir James Syme some 1500 years later. Copyright © 2000 John Wiley & Sons, Ltd.