Preoperative Radiographic Staging Research Articles

Total knee arthroplasty without patella resurfacing leads to worse results in patients with patellafemoral osteoarthritis Iwano Stages 3-4: a study based on arthroplasty registry data.

To determine whether the preoperative degree of degeneration of the patellofemoral joint really affects the outcome of total knee arthroplasty (TKA) surgery without patella resurfacing and thus to establish a parameter that might serve as a guiding factor to decide whether or not to perform retropatellar resurfacing. It was hypothesized that patients with preoperative mild patellofemoral osteoarthritis (Iwano Stages 0-2) would significantly differ from patients with preoperative severe patellofemoral osteoarthritis (Iwano Stages 3-4) in terms of patient-reported outcome (Hypothesis 1) and revision rates/survival (Hypothesis 2) after TKA without patella resurfacing. Application of a retrospective-comparative design on the basis of Arthroplasty Registry data that included patients with primary TKA without patella resurfacing. Patients were allocated to the following groups based on preoperative radiographic stage of patellofemoral joint degeneration: (a) mild patellofemoral osteoarthritis (Iwano Stage ≤ 2) and (b) severe patellofemoral osteoarthritis (Iwano Stages 3-4). The Western Ontario and MacMaster Universities Osteoarthritis Index (WOMAC) score was assessed preoperative and 1 year postoperative (0: best, 100 worst). In addition, implant survival was calculated from the Arthroplasty Registry data. In 1209 primary TKA without patella resurfacing, postoperative WOMAC total and WOMAC subscores did not differ significantly between groups, but potentially suffered from type 2 error. Three-year survival was 97.4% and 92.5% in patients with preoperative mild and severe patellofemoral osteoarthritis, respectively (p = 0.002). Five-year survival was 95.8% vs. 91.4% (p = 0.033) and 10-year survival was 93.3% vs. 88.6% (p = 0.033), respectively. From the study findings, it is concluded that patients with preoperative severe patellofemoral osteoarthritis have significantly higher risks for reoperation than do those with preoperative mild patellofemoral osteoarthritis-when treated with TKA without patella resurfacing. Hence, it is recommended that patella resurfacing be applied in patients with severe Iwano Stage 3 or 4 patellofemoral osteoarthritis during TKA. III, Retrospective comparative.

Radiographic staging practices of newly diagnosed colorectal cancer vary according to medical specialty

Since 2008, multiple guidelines have endorsed incorporation of chest CT in the radiographic staging assessment of newly diagnosed colorectal cancer (CRC). Radiographic staging practices performed after CRC is detected have not been studied. To evaluate radiographic staging practices for newly diagnosed CRC between gastroenterologists versus non-gastroenterologists. Observational cohort study. Single, tertiary-care referral center. Patients newly diagnosed with a T1 or higher stage CRC at time of colonoscopy between 2008 and 2013. Radiographic staging. Radiographic preoperative staging examinations ordered by gastroenterologists in comparison to those ordered by non-gastroenterology specialists. This study included 277 patients with CRC newly diagnosed by colonoscopy. There were 141 total ordering physicians (68 gastroenterologists and 73 non-gastroenterologists). The majority of preoperative radiographic staging was performed by gastroenterologists (59.2% of patients, n = 164). Colorectal surgeons managed staging in 28.7% of patients (n = 47). Gastroenterologists were more likely to omit a staging chest CT than were non-gastroenterologists (64.6% vs 46.9%; P < .001). Physician practice setting, rectal location of tumor, and advanced endoscopic appearance of tumors were predictors of chest CT inclusion. Single center, moderate sample size of both providers and patients. Gastroenterologists more frequently ordered the initial radiographic staging studies in newly diagnosed CRC patients. However, gastroenterologists were less likely to include chest CT in the initial staging of CRC despite current guideline recommendations to do so. If confirmed with further studies, educational efforts to improve compliance and standardization may be needed.

Die valgisierende Tibiakopfpendelosteotomie

91 high tibial valgus barrel-vault osteotomies were subject of a follow-up study from 10 to 19 years (phi 11.9) after the osteotomy. 20 of the patients rate themselves as excellent, 29 as good, 22 as poor and 22 as failed. Adipositas was a factor that mainly worsened the results. Furthermore a postoperative flexion deformity and preoperative joint-space-narrowing were negative conditions, too. A slight overcorrection, more than the physiological valgus proved to be advantageous. The results were not influenced by age, sex and preoperative radiographic stage and range of motion. In summary the osteotomy has been shown to be a successful measure to prolong the period until final destruction of the knee joint will happen.

Preoperative Radiographic Staging for Ureteral Injuries is Not Warranted in Patients Undergoing Celiotomy for Trauma

Preoperative radiographic staging of the urinary tract has been shown to be inaccurate with regard to the ureter. The purpose of this study was to assess the need for radiographic staging of the injured patient for the diagnosis of ureteral injury before operative exploration. We conducted a retrospective review of all patients who sustained injury of the ureter as the result of external trauma over an 8 Y2-year period at an urban and suburban Level I trauma center. All patients were injured through penetrating mechanisms and underwent laparotomy. Only three patients had preoperative radiographic staging of the urinary tract. No ureteral injuries were missed. We conclude that surgical exploration of the ureter is sufficiently accurate to obviate the need for preoperative radiographic staging of the ureters in patients who have sustained penetrating injury and warrant laparotomy.

Minimum 10-Year Results of Sugioka??s Osteotomy for Femoral Head Osteonecrosis

Sugioka's transtrochanteric rotational osteotomy was performed on 14 hips (12 patients) before 1987 for avascular necrosis of the femoral head involving a large part of the weight-bearing area. Three hips required a secondary total hip arthroplasty within 5 years after the osteotomy. The remaining 11 hips were examined at a mean of 13.2 years after surgery (range, 10-17.7 years). The clinical and radiologic results were related to the preoperative radiographic stage of the disease. In the hips with less than 2 mm of collapse, highly satisfactory results were maintained more than 15 years after surgery, with minimal development of degenerative changes. In hips with 2 mm or more of collapse or with acetabular changes, the results tended to deteriorate gradually during the long course of observation but were fairly acceptable. This study shows the osteotomy can enable hip joints to survive and function well for more than 10 years with proper patient selection and operative procedure.

Survivorship analysis of hips treated with core decompression for nontraumatic osteonecrosis of the femoral head.

We reviewed the long-term results of core decompression for the treatment of nontraumatic osteonecrosis of the femoral head, performed in thirty-four patients (fifty-four hips) between January 1, 1981, and June 30, 1995. Twenty patients (59 percent) had bilateral involvement. The mean age of the patients at the time of presentation was thirty-eight years (range, twenty-two to eighty-three years). The presumed risk factors were use of corticosteroids (thirty-seven hips), excessive intake of alcohol (eight hips), and use of adrenocorticotropic hormone for the treatment of multiple sclerosis (two hips); the remaining seven hips had idiopathic osteonecrosis. According to a modification of the classification system of Ficat and Arlet in combination with the system of Steinberg et al., thirteen hips were stage I (normal radiographs) preoperatively; seven, stage IIA sclerotic; sixteen, stage IIA cystic or sclerocystic; ten, stage IIB (transitional stage, with a crescent sign); and eight, stage III (collapse). The mean duration of follow-up after the core decompression was 120 months (range, twenty-four to 196 months). The result was considered successful if the patient was asymptomatic, with no progression of the disease, and unsuccessful if there was radiographic failure (progression to stage III [collapse]) or clinical failure (the need for a subsequent operation), or both. The Kaplan-Meier product-limit method was used to estimate clinical and radiographic survival. Overall, twenty-six hips (48 percent) had a satisfactory clinical result and twenty (37 percent) survived according to radiographic criteria. Radiographic or clinical failure, or both, were seen in four of the thirteen stage-I hips, none of the seven stage-IIA sclerotic hips, thirteen of the sixteen stage-IIA cystic or sclerocystic hips, nine of the ten stage-IIB hips, and all eight stage-III hips. On the basis of the Cox proportional-hazards regression model, significant predictors of overall failure included an advanced preoperative radiographic stage (p < 0.0001), a shorter duration of symptoms (p < 0.05), and use of corticosteroids (p < 0.05). No association was found between age, gender, excessive intake of alcohol, or renal transplantation and the overall outcome. Two patients (two hips; 4 percent) had a postoperative complication. One patient had a fracture of the femoral neck, and the other had a hematoma. Our findings suggest that core decompression is a safe and effective procedure for the treatment of stage-I or stage-IIA sclerotic disease. These data also demonstrate the importance of differentiating between stage-IIA sclerotic disease and stage-IIA cystic or sclerocystic disease. We believe that core decompression has a limited role in the operative management of patients who have evidence of cystic changes in the femoral head on plain radiographs.

Maladie de Kienböck traitée par ostéotomie de raccourcissement du radius Analyse des résultats à propos de treize cas

A series of 13 cases of Kienbock's disease, treated by shortening of the radius, operated between 1975 and 1995, is presented. This series consisted of 7 males and 6 females with a mean age of 27.5 years (range: 17 to 37 years). The dominant hand was affected in 12 cases. 6 men and 5 women performed heavy work. The mean period between the first symptoms and the operation was 18 months (range: 3 months to 6 years). In 10 cases, pain was severe and limited activities; in 3 cases, pain was moderate with partial limitation of activity. 8 cases had a mobility greater than 75% compared to the healthy side. 5 cases had a mobility of approximately 50%. None of the cases had a mobility less than 25%. Strength was not measured preoperatively with the JAMAR dynamometer. The standard radiographic assessment included an AP palm-plate film (raised palm) and a true profile on a small board. This radiographic assessment established, for each case: the Decoulx and Lichtmann classification, the radioulnar index, the angle of the radial slope and the lunate fossa, collapse of the carpus according to Youm and McMurtry. There were two stage 1, three stage 2, eight stage 3 (six stage 3A, and two stage 3B) and no stage 4. The radioulnar index was negative in 10 cases, zero in 1 case, and positive in 2 cases. The mean angle of the radial slope was 23 degrees, the mean angle of the lunate fossa was 10.8 degrees, the mean height of the carpus was 0.476. The incision was anterior in 7 cases, and posterolateral in 6 cases. The mean shortening was 5 mm (range: 4 to 6 mm). Patients were reviewed with a mean follow-up of 5 years (range: 10 months to 12 years). The analysis according to Michon's criteria revealed 3 excellent results, 9 good results, 1 moderate result and no poor results. All patients were able to resume their previous occupation. Five no longer had any pain, 6 had moderate and rare pain, 2 patients presented pain limiting activity. 10 patients presented a mobility greater than 75% compared to the healthy side. In 2 cases, the mobility was greater than 50%. In 9 cases, the strength was greater than 75% compared to the healthy side, and in 4 cases, it was greater than 50%. Radiological assessment, all stages combined, showed 4 improvements, 7 stabilizations, 2 deteriorations. There was no correlation between the height of the carpus (which varied only very slightly postoperatively) and the clinical or radiological course. In this series of 13 patients; shortening osteotomy gave results on all stages of the disease. There was no correlation between the clinical and radiological course of the lunate, and the following factors: age, preoperative radiographic stage, instability of the carpus, position of the plate. On the basis of the results of our series, it appears important to increase the angle of the lunate fossa and to obtain an angulation greater than 12 degrees 5 and to maintain a negative radioulnar index. The 2 cases of radiological deteriorations corresponded to a positive postoperative radioulnar index, while the index remained negative in the 4 cases of improvement; all cases in which the angulation of the lunate fossa was greater than 12 degrees stabilized or improved radiologically, regardless of the preoperative stage. Despite contradictory theories, we believe, in the light of our series, that an angulation of the lunate fossa greater than 12 degrees and that a negative radioulnar index appear to be decisive criteria in the course of Kienböck's disease treated by shortening of the radius.

Staging of Soft Tissue Sarcomas of the Extremities

The management of soft tissue sarcomas of the extremities has undergone recent change with the advent of multimodality therapies and limb-sparing procedures. A better understanding of prognostic variables has led to staging systems that are predictive of locoregional and distant treatment failures. Advances in preoperative radiographic staging have aided the surgeon to better plan the surgical approach at the time of resection. These malignancies truly require a multidisciplinary approach for best overall patient management.

RENAL GUNSHOT WOUNDS

Over the past 14 years, 2079 patients have been seen at our institution with renal trauma. Of these, 84 sustained gunshot wounds (81 unilateral, 3 bilateral; a total of 87 renal units). We evaluated this group to characterize the nature of their injuries and establish a methodology for renal salvage and reconstruction. Preoperative radiographic staging was performed with excretory urography (IVP) or computed tomographic (CT) scanning. The injuries were classified into five categories: 16 contusions (18.4%), 12 minor lacerations (13.8%), 44 major lacerations (50.5%), six vascular injuries (6.9%), and nine combination laceration and vascular injury (10.3%). Most patients had multiple organ injuries, with 79 requiring associated surgical procedures (94%). The mean injury Severity Score (ISS) was 26.7 (range, 4-59). Based on radiographic and clinical staging criteria, 69 renal injuries were surgically explored (79.3%), and 12 patients underwent nephrectomy (13.8%). Forty-six renal units were reconstructed (66.6%) by various methods, including renorrhaphy, omental pedical flaps, mesh or peritoneal patch grafts, partial nephrectomy, and vascular repair. Overall, 75 renal units were salvaged (86.2%). Early renal vascular control was achieved in all patients who underwent renal exploration. Follow-up functional studies were done in 24 (28.5%): none had delayed nephrectomy or postinjury hypertension. Overall, 79 patients survived (94%); however, mortality was not related to renal injury. These findings suggest that aggressive radiographic staging coupled with early vascular control and careful selection of reconstructive techniques can ensure a high renal salvage rate in patients with renal gunshot injuries.

The bipolar endoprosthesis in avascular necrosis of the femoral head

The authors reviewed the clinical and radiographic results of 31 bipolar hip arthroplasties performed for avascular necrosis in 24 patients. The average patient age at the time of operation was 43 years, and the average follow-up period was 4.6 years. Using a modified Hospital for Special Surgery hip rating system, the results were excellent in eight hips, good in seven, fair in eight, and poor in eight. Eight hips had residual pain despite a satisfactory rating. Four hips have required revision. There was a correlation between the patient's age and preoperative radiographic stage and the clinical result. Abduction-adduction weight-bearing radiographs showed that only 33% of the hips had significant inner-bearing motion. Superior acetabular cartilage narrowing or migration of the acetabular component was seen in 14 hips. Femoral component subsidence occurred in seven hips.

The meaning of radiolucencies in parosteal osteosarcoma.

Parosteal osteosarcoma with either intralesional radiolucencies or extralesional clefts within the tumor was identified in eighteen patients. In each patient, both high-quality radiographs and whole macrosections of the lesions were available for correlative study of the radiolucencies. The intralesional radiolucencies were characterized as either deep or peripheral. Study of the macrosections showed that most of the peripheral lucent areas were comprised of low-grade malignant cartilaginous or fibrous tissue that was mixed with fat and bone trabeculae. The majority (67 per cent) of the high-grade dedifferentiated areas of tumor, however, corresponded to the deep radiolucencies. We think that the presence of a deep radiolucent area on a computed tomographic scan or other preoperative radiographic staging studies must create suspicion that a high-grade (grade-II) dedifferentiated region exists within an otherwise low-grade parosteal osteosarcoma.

The Solitary Pulmonary Nodule and Staging of Lung Cancer

More favorable survival rates are encountered when a bronchogenic carcinoma is identified and resected at the asymptomatic, small, circumscribed, nodular stage. The only two reliable radiologic criteria for benignity are the long-term absence of growth and certain characteristic patterns of calcification. With the advent of computed tomography, the preoperative radiographic staging of non-small cell bronchogenic carcinoma can accurately select those patients for potential surgical care.

Intra-articular Radiation Synovectomy

Fifty-three knees in 44 patients with severe, chronic rheumatoid arthritis (RA) were treated by the instillation of an intra-articular radionuclide (dysprosium-165; 165Dy) coupled with a large, relatively inert carrier (ferric hydroxide macroaggregate). The extremely low leakage rates found in earlier animal experiments were confirmed in the human, with a mean leakage rate of 0.3% of the injected dose. This leakage corresponds to a total body dose of 0.4 rad and a liver dose of 2.5 rad, equivalent to a lumbosacral series of diagnostic radiographs. Eighty percent of the treated knees showed improvement, which was maintained as long as one year after treatment. There was a direct correlation between the preoperative radiographic stage and the response to treatment, with patients in Stages I and II more likely to have a good or excellent response at one year. There was also good correlation between clinical improvement and improvement in technetium-99m (99mTc)-pertechnetate flow scintigraphy. Chemical synovectomy by the instillation of appropriate radionuclides can be recommended as an effective means of reducing inflammation, effusion, and pain in patients with RA. The duration of favorable results cannot be predicted, but the results to date suggest that longevity should be comparable with that of surgical synovectomy. Like surgical synovectomy, radiation synovectomy is most effective in the early stages of the disease process, before there is extensive destruction of cartilage and bone.