Orthopaedic Clinicians Research Articles

AB1005 Glycosaminoglycan in Synovial Fluid of Osteoarthritis Patients Validates Kellgren-Lawrence Score as a Useful Indicator for Disease Progression and Cartilage Degradation

BackgroundCartilage is a marvel design, which handles a remarkable pressure in weight bearing joints yet facilitates resilient movement. Osteoarthritis (OA) is a disease characterised by progressive degeneration of cartilage, which...

Welcome to the medico-legal section

Bone & Joint360 launched in February 2012 with the aim of keeping busy orthopaedic researchers and clinicians up to date by summarising key messages from the worldwide orthopaedic literature. Many orthopaedic surgeons are involved in giving opinions as expert witnesses in medico-legal cases following both personal injury and, increasingly, in the field of medical negligence. Therefore, it was felt that a section within 360 on medico-legal issues would be relevant to the national and …

Interpretation of Normal Foot and Ankle Radiographs by Accident & Emergency and Orthopaedic Clinicians

The purpose of this study was to assess the ability of clinicians dealing with foot and ankle trauma to interpret plain radiographs of the foot and ankle in standard views. A survey of 47 clinicians was conducted between November and December 2010. House officers, senior house officers (SHOs) and specialist registrars (SpRs) from the Emergency and Orthopaedic departments were recruited. Participants were supervised identifying 12 standard bones/landmarks on four images of normal foot and ankle radiographs. A significant difference was found between Emergency and Orthopaedics clinicians (p=0.01), in favour of the Orthopaedic group. Emergency SHOs correctly identified only seventy per cent of the structures assessed in this study. Orthopaedic trainees scored higher. Failure to recognize these bony landmarks may give rise to problems regarding the identification of fractures and dislocations. There is a deficiency in the knowledge and application of radiographic anatomy across Emergency clinicians, particularly evident in SHOs.

Journals Publish “It Takes a Team”

Published jointly by JOSPT and The Journal of Bone & Joint Surgery (JBJS), “It Takes a Team: Working Together Works for Patients” is a first-of-its-kind publication that describes how collaboration among orthopaedic surgeons, physical therapists, and other healthcare clinicians working in a variety of clinical settings has improved patient outcomes. This Special Report is available as a free download from JOSPT's website. J Orthop Sports Phys Ther 2013;43(3):117. doi:10.2519/jospt.2013.0103

Evaluating Implants in Orthopaedic Trials: Tips for Conducting Research

The availability of quality research on orthopaedic implants is important for orthopaedic clinical practice, though in many cases such research is deficient in the literature. Randomized trials are dwarfed in number by observational studies which, though also valuable, do not provide the same validity of evidence. This is partly due to the unique challenges faced by orthopaedic clinicians when attempting to conduct randomized trials in areas such as randomization, blinding, and follow-up. These challenges can be addressed with the use of techniques such as expertise-based randomization, assessment that is objective and independent, and implementation of a protocol for consistent follow-up before the study is underway. Although they do not eliminate all of the hurdles faced in implant evaluation trials, the tips outlined in this article have the potential to significantly ease the burdens of conducting high-quality research.

Seminal papers in paediatric orthopaedics

Evidence Based Medicine is at the heart of contemporary clinical practice, underpinning modern orthopaedics. Orthopaedic surgeons have always had an affinity for the historical origins of their speciality, and lessons learned from the early pioneers continue to influence current practice. We present a concise review of some of the influential papers in the field of children's orthopaedics. Reference to historical work informs current practice, in respect of pathology, classification, management principles, and potential pitfalls. Although all training programmes develop orthopaedic clinicians to the level of a generalist, as orthopaedic practice has become increasingly sub-specialized, paediatric orthopaedics has evolved into a well-defined and distinct discipline. As an aide memoire to those in established practice, and as a revision aid to those preparing for their exit examinations, we outline eight seminal papers in children's orthopaedics. These papers have been selected both for their importance in modern everyday practice and their recognition within orthopaedic teaching.

Reliability of the Jones Patellofemoral Osteoarthritis Score for Radiological Assessment of Patellofemoral Degenerative Changes: Comparing a Physiotherapist to Doctors

Radiological measurement scores are used by orthopaedic physiotherapists in triage and surveillance of patients with degenerative changes of the tibiofemoral and patellofemoral joints. The purpose of this study was to estimate the intra- and inter-observer reliability of a radiological measurement score to assess patellofemoral joint osteoarthritis, the Jones Patellofemoral Osteoarthritis Score (JPOS), with an orthopaedic physiotherapist and three grades of junior surgeons/doctors. A total of 390 skyline X-rays of the patellofemoral joint were reviewed on 2 occasions, 4 weeks apart, by an orthopaedic physiotherapist, 2 orthopaedic surgeons, and an orthopaedic doctor. Intra- and inter-observer reliability of the JPOS was calculated using a weighted kappa analysis. The results indicated that while there was good overall intra-observer agreement for this measurement score for all assessors, inter-observer reliability was generally poor between the orthopaedic physiotherapist and the orthopaedic surgeons/doctor. Our findings call into question the use of the JPOS by orthopaedic physiotherapists working in triage or orthopaedic surveillance programmes with other orthopaedic clinicians.

Inhibition of endogenous antagonists with an engineered BMP-2 variant increases BMP-2 efficacy in rat femoral defect healing

Bone morphogenetic proteins (BMP) have been used successfully by orthopedic clinicians to augment bone healing. However, these osteoinductive proteins must be applied at high concentrations to induce bone formation. The limited therapeutic efficacy may be due to the local expression of BMP antagonists such as Noggin that neutralize exogenous and endogenous BMPs. If so, inhibiting BMP antagonists may provide an attractive option to augment BMP induced bone formation. The engineered BMP-2 variant L51P is deficient in BMP receptor type I binding, but maintains its affinity for BMP receptor type II and BMP antagonists including Noggin, Chordin and Gremlin. This modification makes L51P a BMP receptor-inactive inhibitor of BMP antagonists. We implanted β-tricalcium phosphate ceramics loaded with BMP-2 and/or L51P into a critical size defect model in the rat femur to investigate whether the inhibition of BMP antagonist with L51P enhances the therapeutic efficacy of exogenous BMP-2. Our study reveals that L51P reduces the demand of exogenous BMP-2 to induce bone healing markedly, without promoting bone formation directly when applied alone.

There is only one way to predict our future: in understanding our past and in realizing our present

The future of any organisation relies on its culture, vision and strategic purpose. ESSKA was founded in Berlin in 1982 (as an official body in 1984), dedicated to Arthroscopy and Knee Surgery, which was expanded to Sports Trauma some years later and more recently to Degenerative Knee. However, the identity and the main core of the mission have never changed. Today, as always, we ‘‘...bring together orthopaedic surgeons, clinicians and scientists in Europe; ESSKA raises the level of care in the field of orthopaedic sports medicine and degenerative joint diseases to improve musculoskeletal function and quality of life of patients. To achieve its mission, ESSKA supports education and research and aims to improve cooperation among its members, national and international societies in the field of prevention, diagnosis, treatment and surgery with special emphasis on arthroscopy’’. Europe has a vast and engaging history of diversity and integration that spans 47 countries, 27 of which form the European Union and 17 the Eurozone, with more than 800 million people. This diversity means different cultures and levels of education. It also means different habits and patient needs with complex social and political relationships. The increasing longevity, sports activities and trauma in our population, and the number of people with musculoskeletal diseases requiring our help have grown exponentially in recent years. As progress in scientific development continues, society increasingly demands a good quality of life. The bar set by society increases as the years pass. Such patients need protection and help, and we must remain solid advocates of our patients. We should address this reality by working with the EU and its political decision makers in order to improve the financial resources available for prevention, medical education and differentiated medical treatment in sports trauma and degenerative knee diseases with a special focus on eastern European countries; through sponsored fellowships, courses and combined meetings, we can achieve our goal. In order to accomplish this task, we wish to affiliate all European Societies of Knee Surgery, Sports Traumatology and Arthroscopy with ESSKA. We invite their leaders to become our representatives by establishing privileged partnerships and by offering special benefits to their members. Through these initiatives, we want to stimulate the scientific exchange in Europe and to create increasingly stable relationships. Unifying our strengths, sharing identical fundamental values and at the same time respecting our individual regional or national diversities will help to position ESSKA as the European umbrella society of choice in the fields of knee surgery, sports traumatology and arthroscopy. The time is right to work together with EFORT-UEMSEBOT in orthopaedics certification and re-certification, making contributions to the treatment of sports trauma and degenerative knee. We are evaluating the advantages of creating an ESSKA Foundation in Luxembourg. Such an organisation could bring about an increase in sponsorship from industry and in extrapolating a more diverse revenue base, which is out of our scope presently. Developing a relationship with European institutions could also be profitable if they are convinced that investment in our specialty is cost effective, slowing down the progression of extremely common and potentially disabling diseases. J. Espregueira-Mendes (&) ESSKA President, Orthopaedic Department, Saude Atlântica Sports Center, Minho University, Porto, Portugal e-mail: jem@espregueira.com

Interpretation of normal foot and ankle radiographs by Accident & Emergency and Orthopaedic Clinicians

The purpose of this study was to assess the ability of clinicians dealing with foot and ankle trauma to interpret plain radiographs of the foot and ankle in standard views. A survey of 47 clinicians was conducted between November and December 2010. House officers, senior house officers (SHOs) and specialist registrars (SpRs) from the Emergency and Orthopaedic departments were recruited. Participants were supervised identifying 12 standard bones/landmarks on four images of normal foot and ankle radiographs. A significant difference was found between Emergency and Orthopaedics clinicians (p=0.01), in favour of the Orthopaedic group. Emergency SHOs correctly identified only seventy per cent of the structures assessed in this study. Orthopaedic trainees scored higher. Failure to recognize these bony landmarks may give rise to problems regarding the identification of fractures and dislocations. There is a deficiency in the knowledge and application of radiographic anatomy across Emergency clinicians, particularly evident in SHOs.

Can orthopaedic clinicians learn to read skeletal bone age? An inter- and intra observer study between specialties

Determination of skeletal age is essential for predicting eventual leg length discrepancies and predicting the accurate timing for surgical intervention in order to correct any discrepancy. To our knowledge, there has not been an interdisciplinary comparison of the degree of agreement in determining skeletal bone age. We evaluated 30 left hand/wrist radiographs (children aged 16months to 10years 6months) on two separate occasions between musculoskeletal paediatric radiologists, paediatric orthopaedic surgeons and a senior radiographer after appropriate training. All clinicians were able to reliably age patients with good intra- and interobserver agreement. We suggest that following tuition, orthopaedic surgeons are able to reliably age patients from X-rays.

Automatic Insall–Salvati ratio measurement on lateral knee x-ray images using model-guided landmark localization

The Insall–Salvati ratio (ISR) is important for detecting two common clinical signs of knee disease: patella alta and patella baja. Furthermore, large inter-operator differences in ISR measurement make an objective measurement system necessary for better clinical evaluation. In this paper, we define three specific bony landmarks for determining the ISR and then propose an x-ray image analysis system to localize these landmarks and measure the ISR. Due to inherent artifacts in x-ray images, such as unevenly distributed intensities, which make landmark localization difficult, we hence propose a registration-assisted active-shape model (RAASM) to localize these landmarks. We first construct a statistical model from a set of training images based on x-ray image intensity and patella shape. Since a knee x-ray image contains specific anatomical structures, we then design an algorithm, based on edge tracing, for patella feature extraction in order to automatically align the model to the patella image. We can estimate the landmark locations as well as the ISR after registration-assisted model fitting. Our proposed method successfully overcomes drawbacks caused by x-ray image artifacts. Experimental results show great agreement between the ISRs measured by the proposed method and by orthopedic clinicians.

Cumulative effects of hypercholesterolemia on tendon biomechanics in a mouse model

High cholesterol represents a significant healthcare problem. Clinical studies have linked hypercholesterolemia to Achilles tendon xanthomas and rotator cuff tears, and research in other systems indicates detrimental effects of high cholesterol; however, understanding of its impact on tendon properties and healing is limited. We hypothesized that tendons from aging hypercholesterolemic (APOE) mice would exhibit inferior baseline and healing mechanical properties compared to controls, while younger, but mature mice would be no different. Surprisingly, tensile testing of patellar tendons from 14-week-old APOE mice receiving a unilateral full-thickness central defect resulted in normalized (injured:sham) cross-sectional areas closer to baseline (p = 0.02) compared to controls. Uninjured data from 10-month-old APOE mice showed a decrease in elastic modulus (p = 0.02), indicating a detrimental effect of hypercholesterolemia on tendon properties in this model. These results could benefit patients through knowledge that high cholesterol could increase the likelihood of tendon tears. Furthermore, knowledge that tendon tears are indicative of high cholesterol could provide orthopedic clinicians with an additional preventive treatment opportunity for patients with undiagnosed hypercholesterolemia.

Upper extremity deep vein thrombosis in orthopaedic and trauma surgery: a systematic review

Upper extremity deep venous thrombosis (DVT) is considered a rare phenomenon. Little is known as to what factors may contribute to the development of upper extremity DVT following trauma or elective orthopaedic surgery. The incidence of pulmonary embolism (PE) related to upper extremity thrombosis is reported as 12 to 36%, where up to 16% of cases are fatal. The purpose of this paper was to systematically review the literature to assess all cases of upper extremity DVT presented in the literature in order to determine epidemiology and outcome. A review of EMBASE, Medline, CINAHL and AMED from their inception to November 2009, sources of grey literature and a pertinent hand search of specialist orthopaedic journals was undertaken. A total of 38 cases of upper extremity DVT and 19 cases with PE were identified from 20 publications. The incidence of upper extremity DVT and PE was greatest in cases following shoulder surgery. There did not appear to be any greater risk in patients with diabetes or obesity. In total, one patient died after a PE following shoulder surgery. Although a relatively uncommon complication, the literature suggests that upper extremity DVT can lead to PE, which should be considered by orthopaedic clinicians in patients following upper extremity surgery or trauma.

Physical examination of the foot and ankle by orthopaedic and accident and emergency clinicians

Physical examination of the foot and ankle by orthopaedic and accident and emergency clinicians

Bone Graft Substitute Plug Failure With Giant Cell Reaction in the Treatment of Osteochondral Lesions of the Distal Femur: A Report of 2 Cases With Operative Revision

Although the treatment of symptomatic osteochondral lesions remains the focus of many orthopaedic clinicians, controversy remains regarding treatment choices and indications. Recently, the use of synthetic bone graft substitute composite plugs has been described to treat bone void lesions. We report 2 cases in which bone graft substitute plugs were used to graft bone defects in the knee and subsequently failed, requiring revision surgery. At revision arthroscopy, failure of incorporation was noted with foreign-body giant cells on histologic evaluation. Our technique for site debridement, revision bone grafting, and osteochondral resurfacing is presented.

Differential diagnosis and conservative treatment for piriformis syndrome: a review of the literature

ABSTRACTThis article provides an overview of the current literature concerning the differential diagnoses and conservative treatment options for piriformis syndrome. Orthopaedic clinicians must be able to properly evaluate, diagnose and treat patients with a wide variety of neuromusculoskeletal cond

Physical examination of the foot and ankle by orthopaedic and accident and emergency clinicians

Our aim was to test the knowledge of clinicians in the Orthopaedic clinic and in the Emergency department of the surface anatomical landmarks that should be examined routinely in the assessment of foot and ankle injuries. A survey of 109 clinicians was conducted. Each participant was asked to palpate six important surface landmarks. Two participants failed to identify even a single landmark. Of 109 assessed only 27% correctly identified all six landmarks. The mean number of landmarks correctly identified by each clinician was 4.1 with a standard deviation of 1.5 and range of 0–6. The knowledge of surface anatomy overall by junior Orthopaedic and Emergency clinicians was found to be very poor. Clinicians are becoming more reliant on potentially unnecessary and expensive imaging investigations. They have neglected the basic art of physical examination based on a sound knowledge of human anatomy. At present, the authors believe that the anatomical teaching that should begin in undergraduate medicine is inadequate.

Harnessing stakeholder perspectives to improve the care of osteoporosis after a fracture

This study used in-depth interviews and focus groups to evaluate osteoporosis care after a fracture. Patients (eligible women aged 67 who sustained a clinical fracture(s)), clinicians, and staff stated that an outreach program facilitated osteoporosis care management, but more-tailored education and support and increased participation of orthopedic specialists appear necessary. Osteoporosis treatment reduces fracture risk, but screening and treatment are underutilized, even after a fracture has occurred. This study evaluated key stakeholder perspectives about the care of osteoporosis after a fracture. Participants were from a nonprofit health maintenance organization in the United States: eligible women members aged 67 or older who sustained a clinical fracture(s) (n = 10), quality and other health care managers (n = 20), primary care providers (n = 9), and orthopedic clinicians and staff (n = 28); total n = 67. In-depth interviews and focus groups elicited participant perspectives on an outreach program to patients and clinicians and other facilitators and barriers to care. Interviews and focus group sessions were transcribed and content-analyzed. Patients, clinicians, and staff stated that outreach facilitated osteoporosis care management, but important patient barriers remained. Patient knowledge gaps and fatalism were common. Providers stated that management needed to begin earlier, and longer-term patient support was necessary to address adherence. Orthopedic clinicians and staff expressed lack of confidence in their osteoporosis management but willingness to encourage treatment. Although an outreach program assisted with the management of osteoporosis after a fracture, more-tailored education and support and increased participation of orthopedic specialists appear necessary to maximize osteoporosis management.

The treatment of skeletal Class III growing patient using MTA(Modified Tandem Appliance)

In growing patients with Class III malocclusion and midfacial deficiency, the treatment protocol calls for orthopedic maxillary protraction and clinicians choose the facemask therapy generally. But facemask is not esthetic or comfortable to patients because it should be worn extraorally. Consequently it is difficult to obtain patients cooperation, and this often influences the treatment effects negatively. MTA (modified tandem appliance), that is a small intraoral appliance, is carried conveniently and esthetic relatively. So it seemed more patient-friendly than a facemask. While the treatment effect of this is similar to that of a facemask. This report presents skeletal Class III malocclusion two cases treated by MTA with good results.