True Lateral Radiographs Research Articles

Longterm outcome of 886 posterior malleolar fractures: A systematic review of the literature

The objective of the present study was to review the current data on the long-term outcomes of posterior malleolar fractures, with special emphasis on the role of the type of treatment, surgical approach, and reduction and internal fixation. The search was limited to skeletally mature patients. Major databases were searched from 1978 to 2014 to identify studies relating to functional outcome, subjective outcome, and radiographic evaluation at least 2 years after either surgical or conservative treatment of posterior malleolar fractures. Of 68 initially relevant studies, 19 met our inclusion criteria. A total of 886 fractures were identified in 885 patients. The mean sample size-weighted follow-up period was 3.7 years. Comparable results are achieved when comparing open reduction and internal fixation to conservative treatment for posterior malleolar fractures. Current consensus suggests posterior malleolar fragments comprising of >25% of the distal tibial plafond as seen on a true lateral radiograph and fragments with more than 2mm dislocation require open reduction and internal fixation of the fragment. The current consensus on treatment of posterior malleolar fractures is neither supported nor disapproved by the available evidence.

Anatomic anterior cruciate ligament reconstruction: reducing anterior tibial subluxation.

To measure and compare the amount of anterior tibial subluxation (ATS) after anatomic ACL reconstruction for both acute and chronic ACL-deficient patients. Fifty-two patients were clinically and radiographically evaluated after primary, unilateral, anatomic ACL reconstruction. Post-operative true lateral radiographs were obtained of both knees with the patient in supine position and knees in full passive extension with heels on a standardized bolster. ATS was measured on the radiographs by two independent and blinded observers. ATS was calculated as the side-to-side difference in tibial position relative to the femur. An independent t test was used to compare ATS between those undergoing anatomic reconstruction for an acute versus chronic ACL injury. Chronic ACL deficiency was defined as more than 12weeks from injury to surgery. Patients averaged 26.4±11.5years (mean±SD) of age, 43.6% were female, and 48.1% suffered an injury of the left knee. There were 30 and 22 patients in the acute and chronic groups, respectively. The median duration from injury to reconstruction for the acute group was 5 versus 31weeks for the chronic group. After anatomic ACL reconstruction, the mean ATS was 1.0±2.1mm. There was no statistical difference in ATS between the acute and chronic groups (1.2±2.0 vs. 0.6±2.3mm, n.s.). Assessment of inter-tester reliability for radiographic evaluation of ATS revealed an excellent intraclass correlation coefficient of 0.894. Anatomic ACL reconstruction reduces ATS with a mean difference of 1.0mm from the healthy contralateral limb. This study did not find a statistical difference in ATS between patients after anatomic ACL reconstruction in the acute or chronic phase. These observations suggest that anatomic ACL reconstruction, performed in either the acute or the chronic phase, approaches the normal AP relationship of the tibiofemoral joint. IV.

Prevalence of and Risk Factors for Dislocation Arthropathy

Background: Glenohumeral osteoarthritis is a well-documented, long-term complication of open stabilization procedures. However, there is a lack of knowledge about long-term radiographic outcome after arthroscopic Bankart procedures. Hypothesis: Glenohumeral osteoarthritis will develop less frequently in arthroscopic Bankart repair compared with open repairs reported in the literature. Study Design: Case series; Level of evidence, 4. Methods: The inclusion criteria for this study were (1) all-arthroscopic Bankart repair for a (2) symptomatic anteroinferior shoulder instability and (3) a minimum follow-up of 10 years. True anteroposterior and lateral radiographs were obtained to evaluate the prevalence and grade of osteoarthritis according to the Samilson classification. Patients were assessed by the Constant score and examined for passive external rotation deficits. Results: Of 165 shoulders that fulfilled the inclusion criteria, 100 were available for evaluation. The median Constant score at an average ± SD 156.2 ± 18.5 months after Bankart repair was 94 (range, 46-100). Twenty-one shoulders (21%) sustained a recurrent dislocation. Overall, 31% of shoulders showed no evidence of glenohumeral osteoarthritis; 41% showed mild, 16% moderate, and 12% severe degenerative changes. Osteoarthritis did not correlate with Constant score results (P = .427). The grade of osteoarthritis was significantly associated with the number of preoperative dislocations (P = .016), age at initial dislocation (P = .005) and at surgery (P = .002), and the number of anchors used (P = .001), whereas time from initial dislocation to surgery (P = .854) and external rotation deficit at 0° and 90° of abduction (P = .104 and .348, respectively) showed no significant correlation. Recurrent dislocation did not affect the presence or grade of osteoarthritis (P = .796 and .665, respectively). Conclusion: At an average 13 years after arthroscopic Bankart repair, osteoarthritic changes are a common finding and, overall, are comparable with reports in the literature regarding open procedures as well as nonoperative treatment. The extent of trauma sustained during preoperative dislocations and the age of the patient seem to be more relevant for long-term dislocation arthropathy than the kind of treatment. Accordingly, the study hypothesis must be rejected. Avoiding preoperative dislocations is more important for the prevention of osteoarthritis than short-term treatment. The number of anchors used was found to be a predictor for long-term development of osteoarthritis.

Fluoroscopic Determination of the Tibial Insertion of the Posterior Cruciate Ligament in the Sagittal Plane

Background: Currently, placement of the tibial tunnel for arthroscopic transtibial posterior cruciate ligament (PCL) reconstruction relies on a limited arthroscopic view of the native insertion or the use of intraoperative imaging. No widely accepted method exists for intraoperative determination of PCL tibial tunnel placement, and current descriptions are cumbersome. Purpose: To identify the center of the PCL’s anatomic tibial insertion site as a percentage of the PCL facet length on a lateral radiograph of the knee so that it may be reliably located in the sagittal plane during surgical reconstruction. Study Design: Descriptive laboratory study. Methods: Twenty fresh-frozen cadaveric knees were dissected and the tibial insertions of the PCL were digitized with an optical tracing system. The digitized PCL footprints were mapped onto 3-dimensional computed tomography–acquired tibial models, and their center points were determined. A K-wire was then inserted into the center of the PCL’s tibial insertion under direct visualization, a direct lateral radiograph was obtained, and the center point was measured. The center locations for both methods were defined as a percentage of PCL facet length from anterior and proximal to posterior and distal, and intraobserver and interobserver reliability was tested with 4 different observers. Results: The average location of the PCL center on the 3-dimensional bone model method was 71.7% ± 5.6% along the PCL facet from anterior/proximal to posterior/distal. In the lateral radiographic method, the center of the PCL was at an average of 69.7% ± 4.9% of the facet length. There was no significant difference between the percentage measurements of the 2 methods (P = .13). Interobserver reliability (κ = 0.57) and intraobserver reliability (κ = 0.71) were moderate to strong. Conclusion: Locating the center of the tibial PCL insertion with fluoroscopy at a point that is 70% of the PCL tibial facet length on a true lateral radiograph is a reliable method for locating the PCL tibial insertion. Clinical Relevance: The method described in this study enables clinicians to identify the tibial location of the PCL insertion, which must be accurately determined during PCL reconstruction.

Influence of Posterior Condylar Offset on Maximal Flexion and Outcome Scales Following TKA in Asian Patients

Background: Infection complicates traditional joint reconstruction prostheses in up to 7% of cases, witBackground: Alteration in femoral posterior condylar offset (PCO) after total knee arthroplasty (TKA) has been reported to influence maximal flexion angle after TKA. However, there are contradictory reports about its influence on clinical outcome, and the effects of PCO alterations may vary with implant type.Question / purposes: The purpose of this study was to determine whether PCO alterations affect maximal flexion after TKA and other functional outcomes, and whether the effects of PCO alterations differ by implant type.Patients and Methods: Fifty consecutive cases of TKAs in each of four implant types, namely, fixed bearing (FB) cruciate retaining (CR) or posterior stabilized (PS), mobile bearing (MB) CR or PS were included in the study. Patients were evaluated for maximal flexion and clinical outcome scales. The PCO alteration was measured using pre- and postoperative true lateral knee radiographs. Correlations between PCO alterations and functional outcomes including maximal flexion were compared among the four implant types. Results: No significant correlation was found between PCO alterations and maximal flexion achieved in any of the four implant groups (Correlation Coefficient [CC]=-0.03, 0.14, -0.14, 0.04; p> 0.05). The mean maximal postoperative flexion was greater in PS implants than in CR implants (p <0.05). In MB-CR implanted knees, a greater PCO alteration was correlated with worse anterior knee pain score as measured by the PF scoring system (CC=-0.44, p=0.003) and worse WOMAC pain score (CC=-0.41, p=0.007). Conclusions: Our findings indicate that PCO alterations have no effect on maximal postoperative flexion after TKA regardless of the implant type. Whether the implant is of PS or CR type is a better predictor of the final flexion achieved. However, increased PCO is correlated with worse pain score in MB-CR implants. Level of Evidence: Level III, Retrospective comparative study

Irreducible dislocation of the great toe interphalangeal joint secondary to an incarcerated sesamoid.

Irreducible dorsal dislocation of the interphalangeal (IP) joint of the great toe is rare. We report a case of a 29-year-old gentleman who presented to the Orthopaedic Surgery Specialist Outpatient Clinic with an irreducible IP joint of the great toe that had been untreated for 4 weeks. The mechanism of injury is believed to be a combination of axial loading with a hyperdorsiflexion force when the patient fell foot first into a drain. As the patient did not report severe symptoms and a true lateral radiograph was not ordered, the dislocation was missed initially at the emergency department. The patient had continued to run and play field hockey prior to visiting us. Incarceration of the sesamoid became a block to manipulation and reduction at the specialist outpatient clinic 3 weeks later. The patient was treated with open surgical exploration, resection of the interposed sesamoid, and Kirschner-wire fixation of the IP joint followed by occupational therapy for mobilization exercises. The operative course was uneventful. At 6 months after surgery, the patient could walk, run, and return to sports.

Cephalometric evaluation of a sample of Iraqi adults with normal occlusion using tetragon analysis

Background: This study aimed to determine the cephalometric values of tetragon analysis on a sample of Iraqi adults with normal occlusion. Material and methods: Forty digital true lateral cephalometric radiographs belong to 20 males and 20 females having normal dental relation were analyzed using AutoCAD program 2009. Descriptive statistics and sample comparison with Fastlicht norms were obtained. Results: The results showed that maxillary and mandibular incisors were more proclined and the maxillary/mandibular planes angle was lower in Iraqi sample than Caucasian sample. Conclusion: It's recommended to use result from this study when using tetragon analysis for Iraqis to get more accurate result.

The relation among ramal width and length with some cervical and cranio-facial measurements in different skeletal classes

Background: The purpose of this study was to assess the relation among the ramal length and width with various cervical and cranio-facial measurements for a sample of Iraqi adults with different skeletal classes. Materials and method: The sample composed of 71 Iraqi adults (36 females and 35 males) with an age ranged between 17-30 years and had different skeletal mal-relations using SNA, SNB and ANB to differentiate between them and assorting them into CL.I, CL.II and CL.III mal-relation. Each individual was subjected to clinical examination and digital true lateral cephalometric radiograph that had been analyzed using AutoCAD 2007 software computer program to determine sixteen linear and ten angular measurements. Descriptive statistics were obtained and independent samples t-test was performed to evaluate the gender differences in different classes. ANOVA test as used to compare the measurements among the skeletal classes in each gender, while Pearson’s correlation coefficient test was used to determine the relations among ramal length and width with other measurements in all classes. Results and Conclusions: All of the linear measurements were significantly higher in males than females. On the other hand, the angular measurements showed non-significant gender difference except for SN-PP angle in class II group. ANOVA test showed statistically significant difference in upper gonial angle, Y-axis angle and the mandibular length. Ramal length and width correlated significantly with PFH, SN-MP angle and Co-Gn.

Radiographic Identification of the Anterior and Posterior Root Attachments of the Medial and Lateral Menisci

Background: Anatomic root placement is necessary to restore native meniscal function during meniscal root repair. Radiographic guidelines for anatomic root placement are essential to improve the accuracy and consistency of anatomic root repair and to optimize outcomes after surgery. Purpose: To define quantitative radiographic guidelines for identification of the anterior and posterior root attachments of the medial and lateral menisci on anteroposterior (AP) and lateral radiographic views. Study Design: Descriptive laboratory study. Methods: The anterior and posterior roots of the medial and lateral menisci were identified in 12 human cadaveric specimens (average age, 51.3 years; age range, 39-65 years) and labeled using 2-mm radiopaque spheres. True AP and lateral radiographs were obtained, and 2 raters independently measured blinded radiographs in relation to pertinent landmarks and radiographic reference lines. Results: On AP radiographs, the anteromedial and posteromedial roots were, on average, 31.9 ± 5.0 mm and 36.3 ± 3.5 mm lateral to the edge of the medial tibial plateau, respectively. The anterolateral and posterolateral roots were, on average, 37.9 ± 5.2 mm and 39.3 ± 3.8 mm medial to the edge of the lateral tibial plateau, respectively. On lateral radiographs, the anteromedial and anterolateral roots were, on average, 4.8 ± 3.7 mm and 20.5 ± 4.3 mm posterior to the anterior margin of the tibial plateau, respectively. The posteromedial and posterolateral roots were, on average, 18.0 ± 2.8 mm and 19.8 ± 3.5 mm anterior to the posterior margin of the tibial plateau, respectively. The intrarater and interrater intraclass correlation coefficients (ICCs) were >0.958, demonstrating excellent reliability. Conclusion: The meniscal root attachment sites were quantitatively and reproducibly defined with respect to anatomic landmarks and superimposed radiographic reference lines. The high ICCs indicate that the measured radiographic relationships are a consistent means for evaluating meniscal root positions. Clinical Relevance: This study demonstrated consistent and reproducible radiographic guidelines for the location of the meniscal roots. These measurements may be used to assess root positions on intraoperative fluoroscopy and postoperative radiographs.

Quantification Of Trochlea Dysplasia Via Computed Tomography: Assessment Of Morphology Difference Between Control And Chronic Patellofemoral Instability Patients

Objectives:Trochlear dysplasia is an important risk factor for the development of recurrent patella instability. Owing to its complex 3-Dimensional morphology, the need for a true lateral radiograph, and poor inter-observer reliability, the Dejour classification system of dysplasia may not be the most optimal measure for quantification. The purpose of this study is to report a novel technique to define and quantify the trochlea volume and length using an axial computed tomography. This technique was applied to a series of patients surgically treated for recurrent patellofemoral instability and the measurements compared to a control group.Methods:From 2007 to 2013, 99 control patients (136 knees) were identified from trauma CT scans obtained during admission at our Level I trauma hospital. Patients older than 35y/o or with fractures in the distal femur were excluded. Axial cuts at 1.25 mm were used to measure trochlea volume; defined to be from the physeal scar to the final axial image in which the sulcus could be visualized (Figure 1). Trochlear groove distance was measured from a midline sagittal reformatted image perpendicular to the posterior margin of the femoral condyles. The inter-observer reliability was assessed with independent measurements from attending orthopedist, MSK radiologist and two senior residents. Dysplasia patient cohort was a series of 35 patients (70knees) who were surgically treated for recurrent instability, by AAS or CME, from 2007-2013 and a diagnosis of dysplasia based on lateral knee radiograph. CT tracking studies are obtained from bilateral knees as a normal part of our pre-operative assessment. Institutional IRB approval was obtained for data retrieval.Results:Control cohort average age 25 +/- 4 years, 68 M:31F, without documented history of patella instability on chart review. Dysplastic cohort average age 24 +/- 5 years, 2 M:33F, all 35 patients had bilateral knees scanned. Statistically significant differences were noted in comparing the trochlea volume (3.75 +/- 0.97 cm3 vs. 2.0+/- 0.56 cm3) and the trochlea length (34.8 +/- 4.9 mm vs. 31.7 +/- 4.2 mm) between control and dysplastic cohorts respectively. Comparing female only patients demonstrated difference in trochlea volume (2.89 +/- 0.57 cm3 vs. 2.0+/- 0.36 cm3), but not trochlea length (31.7 +/- 2.5 mm vs. 31.7 +/- 2.7 mm). No difference in trochlea volume or length b/w symptomatic knee to asymptomatic contralateral knees in patients with recurrent instability (2.31 cm3 vs. 2.24 cm3) and (30.0 mm vs. 30.5 mm). Inter-observer reliability was assess measuring trochlea volume: ICC for Right Trochlea: 0.98, ICC Left Trochlea: 0.97.Conclusion:This novel technique clearly defines and quantifies the trochlea morphology into volume and length values with high ICC values. Applying this technique demonstrates a significant difference in both trochlea volume and length between a control group and patients treated for recurrent patellofemoral instability.

Measurement of tibial tuberosity-trochlear groove distance: evaluation of inter- and intraobserver correlation dependent on the severity of trochlear dysplasia.

Excessive tibial tuberosity-trochlear groove distance (TT-TG) is considered as one of the major risk factors in patellofemoral instability (PFI). TT-TG characterises the lateralisation of the tibial tuberosity and the medialisation of the trochlear groove in the case of trochlear dysplasia. The aim of this study was to assess the inter- and intraobserver reliability of the measurement of TT-TG dependent on the grade of trochlear dysplasia. Magnetic resonance imaging (MRI) scans of 99 consecutive knee joints were analysed retrospectively. Hereof, 61 knee joints presented with a history of PFI and 38 had no symptoms of PFI. After synopsis of the axial MRI scans with true lateral radiographs of the knee, the 61 knees presenting with PFI were assessed in terms of trochlear dysplasia. The knees were distributed according to the four-type classification system described by Dejour. Regarding interobserver correlation for the measurements of TT-TG in trochlear dysplasia, we found r=0.89 (type A), r=0.90 (type B), r=0.74 (type C) and 0.62 (type D) for Pearson's correlation coefficient. Regarding intraobserver correlation, we calculated r=0.89 (type A), r=0.91 (type B), r=0.77 (type C) and r=0.71 (type D), respectively. Pearson's correlation coefficient for the measurement of TT-TG in normal knees resulted in r=0.87 for interobserver correlation and r=0.90 for intraobserver correlation. Decreasing inter- and intraobserver correlation for the measurement of TT-TG with increasing severity of trochlear dysplasia was detected. In our opinion, the measurement of TT-TG is of significance in low-grade trochlear dysplasia. The final decision to perform a distal realignment procedure based on a pathological TT-TG in the presence of high-grade trochlear dysplasia should be reassessed properly. Retrospective study, Level II.

Using fibula as a reference can be beneficial for the tibial component alignment after total knee arthroplasty, a retrospective study

One of the important factors in a successful arthroplasty is component alignment. The primary objective of this study was to determine whether the fibular shaft reference technique is beneficial for the tibial component position on the postoperative plain radiograph after total knee arthroplasty. A total of 42 patients between 2009 and 2011 were analysed retrospectively. The surgeon prepared the tibia using an extramedullary cutting guide and set the posterior tibial slope with respect to the fibular reference rod. In the postoperative radiographic measurements, a true anteroposterior and lateral radiograph of the lower leg covering the whole length of the tibia was used. Five patients were excluded as they did not meet the inclusion criteria, four patients were excluded due to improper radiographs and the study group was reduced to 33 patients and 35 knees. The mean preoperative tibiofibular angle was 2.1° ± 0.8°. The mean postoperative tibial sagittal angle measurements were 83.3° ± 1.4° (81°-86°). 33 (94 %) Knees gained the desired tibial sagittal angle within the desired alignment (5° ± 3°). The mean postoperative tibial coronal angle was 89.3° ± 1.5°. The tibial component coronal angle of two knees was more than 3 alignment from the neutral mechanical axis. The major clinical relevance of the technique described in the present study is cost-effectiveness, and it does not require any extra time or surgical equipment. This method can be used as an alternative choice for bulky extremities which is a cause of malalignment of the components. Retrospective case series, Level IV.

A Technique of Predicting Radiographic Joint Line and Posterior Femoral Condylar Offset of the Knee

Purpose. To describe a reliable method of predicting native joint line and posterior condylar offset (PCO) using true lateral digital radiographs of the distal femur. Methods. PCO was measured relative to a line drawn parallel to the posterior cortex of the distal femur and the joint line was measured from the posterior condylar flare to the articular surface. A ratio was then calculated for these measurements relative to the width of the femur at the level of the flare. Two independent observers measured PCO and joint line ratio for 105 radiographs of the different knees and one repeated these measurements after one week. Results. There was a significant correlation between the width of the femoral diaphysis at the level of the posterior condylar flare with joint line (P = 0.008) and PCO (P = 0.003). Joint line and PCO could be predicted within 4 mm and 2 mm, respectively, using the identified ratio between the width of the femoral diaphysis at the level of the posterior condylar flare with measured joint line and PCO. The inter- (P < 0.001) and intra- (P < 0.001) observer reliability for these ratios were high. Conclusion. These ratios could be used to predict the native joint line and PCO.

Femoral Radiographic Landmarks for Popliteus Tendon Reconstruction and Repair

Background: Although the popliteus muscle-tendon complex is one of the most important structures in controlling posterolateral rotatory stability of the knee, not much literature has been reported concerning the use of femoral radiographic landmarks of the popliteus tendon in repair and reconstruction. Hypothesis: By using standardized radiographic techniques, the femoral insertion of the popliteus tendon could be more precisely determined by the Blumensaat line than by the extension line of the posterior cortex. Study Design: Descriptive laboratory study. Methods: Ten fresh-frozen human knees were dissected, and the popliteus tendon was exposed. After identification of the femoral insertion site of the popliteus tendon, the insertion’s center was indicated with a radiographic marker. True lateral radiographs of the distal femur were taken, and the digital radiographic images were analyzed by 2 independent observers. Results: The femoral insertion site of the popliteus tendon was found to be a mean 47.5% ± 5.2% across the width of the femoral condyle, 60.7% ± 7.8% along the perpendicular bisector of the Blumensaat line, 0.3 ± 1.7 mm posterior to the extension line of the posterior femoral cortex, and 20.5 ± 3.8 mm distal to the perpendicular line at the Blumensaat point. The variance from the mean point by using the Blumensaat line as a reference was significantly smaller than by using the extension line of the posterior cortex (mean, 2.6 vs 3.6 mm; P = .044). Conclusion: A reproducible anatomic and radiographic reference point for the femoral insertion of the popliteus tendon can be determined using standardized radiographic techniques and can be more precisely determined by the Blumensaat line compared with the extension line of the posterior femoral cortex. Clinical Relevance: This radiographic information provides an adjunctive tool for preoperative, intraoperative, and postoperative assessments of surgical repair and reconstruction of the popliteus tendon.

Radiographic Landmarks for Locating the Femoral Origin of the Superficial Medial Collateral Ligament

Background: Little has been written about the use of radiographic landmarks for locating the origin of the superficial medial collateral ligament (sMCL). A standardized radiographic landmark for the sMCL origin using intraoperative fluoroscopic imaging may be of value in aiding the surgeon in accurate femoral tunnel placement in the setting of extensive soft tissue disruption and bony attrition. Purpose: To determine a reproducible radiographic landmark that will assist in correct femoral tunnel placement in sMCL repair and reconstruction. Study Design: Descriptive laboratory study. Methods: Ten fresh-frozen unmatched human cadaveric knees were dissected, and the origin of the sMCL was exposed. A 2-mm metallic marker was then placed at the center of the femoral origin of the sMCL. True lateral fluoroscopically assisted digital radiographs were obtained of the knee with the posterior and distal femoral condyles overlapping in a standardized fashion. With the use of computer software, reference lines were drawn on the images, creating 4 quadrants. Two independent examiners performed quantitative measurements of the sMCL origin in relation to this axis and to the Blumensaat line. Results: Mean measurements showed the sMCL origin to be closely related to the intersection point of the Blumensaat line and a line drawn distally from the posterior femoral cortex on a true lateral radiograph. The sMCL origin was found at a mean point 1.6 ± 4.3 mm posterior and 4.9 ± 2.1 mm proximal to the intersection of a line paralleling the posterior femoral cortex and a line drawn perpendicular to the posterior femoral cortical line, where it intersects the Blumensaat line. In 5 of 10 specimens, the center of the sMCL origin fell precisely on the Blumensaat line. The remaining specimens had sMCL origins anterior to the Blumensaat line. The femoral origin of the sMCL was found in the proximal and posterior quadrants in 8 of 10 specimens. Conclusion: With a relatively small amount of deviation, the sMCL origin can be consistently identified on a true lateral radiograph of the knee using reproducible reference lines on fluoroscopic imaging. Clinical Relevance: Accurate identification of the femoral origin of the sMCL can be accomplished by intraoperative fluoroscopic imaging. This information may be of significant benefit in repairing acute injuries and in reconstructive procedures complicated by bony attrition and soft tissue loss.

Impact of patellar height on unicompartment knee arthroplasty: does patella baja lead to an inferior outcome?

BackgroundThough a number of series with long-term results have been published, there is still a paucity of literature on the role of patellar height after unicompartment knee arthroplasty (UKA). The present study was conducted with a hypothesis that patella baja may lead to a poor outcome at follow-up.Materials and methodsA retrospective review of 134 knees was performed and patellar height calculated before and after UKA by Blackburne-Peel index (BPI) and the Insall-Salvati ratio (ISR) on true lateral radiographs of the patients in 30° of flexion taken pre-operatively and at 1 year, 2 years and final follow-up (minimum 5 years). Statistical analysis was performed to evaluate the outcomes.ResultsThere was a decrease in ISR in 14.18 % and in BPI in 19.4 % at final follow-up. There was a significant decrease in BPI values while the decrease was not significant for ISR. After eliminating the pre-operative patella baja, 7.3 % developed post-operative patella baja, according to ISR, while 11.5 % developed patella baja as per BPI. At final follow-up there was a statistically significant decrease in stair climbing scores in patients with patella baja when compared to patients with normal ISR.ConclusionPatients with a decrease in patellar height as per ISR have a decrease in stair climbing score at mid-term follow-up while the overall KSS, and pain scores are not affected by a change in patellar height and neither is there a significant progress in patellofemoral osteoarthritis among patients with patella baja compared to normal patella.

The value of lateral cephalometric image in sex identification

Determination of sex and estimation of stature from the skeleton is vital to medicolegal investigations. Skull is composed of hard tissue and is the best preserved part of skeleton after death, hence, in many cases it is the only available part for forensic examination. Lateral cephalogram is ideal for the skull examination as it gives details of various anatomical points in a single radiograph. This study was undertaken to evaluate the accuracy of digital cephalometric system as quick, easy and reproducible supplement tool in sex determination in Iraqi samples in different age range using certain linear and angular craniofacial measurements in predicting sex. Materials and Method The sample consisted of 113of true lateral cephalometric radiographs for adults with age range from 22-43 years old (51 males, 62 females), using certain linear and angular craniofacial measurements with the aid of computer program AutoCAD 2007 Results: The eleven parameters measured for males and females when compared are statistically significantly different. All cranio-cephalometric measurements gave overall predictive accuracy of sex determination by discriminant analysis (86.7%). The stepwise selection method gave overall predictive accuracy of sex determination by discriminant analysis (85.8%). Age showed no statistical difference among the studied age range except for the distance from Mastoid to Frankfort plane. Conclusion: The lateral cephalometric measurements of craniofacial bones are useful to support sex determination of Iraqi population in forensic radiographic medicine. Keyword: Sex determination, lateral cephalgram, discriminant analysis, craniofacial measurements. (J Bagh Coll Dentistry 2013; 25(2):54-58).

Does Radiographic Beam Angle Affect the Radiocapitellar Ratio Measurement of Subluxation in the Elbow?

Radial head alignment is the key to determine elbow reduction after treatment of subluxations or Monteggia fractures. The radiocapitellar ratio (RCR) quantifies the degree of subluxation, by evaluating radial head alignment with the capitellum of the humerus; this ratio is reproducible when measured on true lateral radiographs of nonsubluxated elbows. However, the impact of beam angulation on RCR measurement is unknown. Our hypotheses were that the RCR of the nonsubluxated elbow would remain in the normal range as the beam angle changed and that the RCR variability would increase for the subluxated elbow with small deviations in the beam angle. Radiographs were taken of six healthy cadaveric extremities using beam angles ranging from -20° to 20° along the inferosuperior axis and from -20° to 20° along the dorsoventral axis. The same views then were taken of the six arms with anterior radiocapitellum subluxation followed by posterior radiocapitellum subluxation. RCRs were measured by one observer. As a reference value, the RCR was measured in the 0° to 0° position and the difference between each RCR in a nonreference position was subtracted from each RCR reference to obtain the delta-RCR. An ANOVA was performed to assess the main and interactive effects on the RCR measured in each C-arm position compared with the RCR measured on a true lateral radiograph. The RCR remained in the normal range even as the beam angle of the C-arm varied between -20° and 20°. The position of the beam did not affect the RCR in anteriorly subluxated elbows (p = 0.777), whereas RCR variation increased especially in the presence of posterior radial head subluxation when the C-arm position was 10° or more out of plane (p = 0.006). The inferosuperior malposition of the C-arm had a greater impact on quantification of radial head alignment measurement. Despite that, the RCR measurement is reliable in reduced and subluxated elbows on lateral radiographs with a C-arm position deviation of as much as 20°. Identification of a subluxated elbow could be made on any lateral radiograph with a beam angulation deviation of as much as 20°. This suggests that the RCR is a useful diagnostic tool for clinical and research purposes, although for subluxated elbows, it is important to pay careful attention to the inferosuperior position of the C-arm.

The Importance of Tibial Tunnel Placement in Anatomic Double-Bundle Anterior Cruciate Ligament Reconstruction

The purposes of this study were to measure the anterior edge of the tibial tunnel after anatomic anterior cruciate ligament (ACL) reconstruction on lateral radiographs and to determine whether the difference in tibial tunnel placement affects postoperative outcomes. For 60 patients who underwent anatomic double-bundle ACL reconstruction with semitendinosus tendon, we evaluated the side-to-side difference in anterior tibial translation on stress radiographs, as well as rotational stability by the pivot-shift test, 2 years after surgery. Loss of extension (LOE) was evaluated on lateral radiographs of both knees in full extension, and graft integrity was assessed during second-look arthroscopy 1 to 2 years after surgery. On true lateral radiographs, we measured the anterior placement percentage of the tibial tunnel using the method described by Amis and Jakob. The cutoff value was set at 25% of the mean value of the anterior edge of the ACL that Amis and Jakob reported, and patients were divided into 2 groups (27 in the anterior group and 33 in the posterior group). Postoperative clinical results were compared between the groups. The mean anterior placement percentage was 26.0% ± 4.1%. The postoperative mean side-to-side difference was 1.4 ± 2.7 mm for the anterior group and 3.0 ± 2.7 mm for the posterior group, a significant difference (P < .05). The positive ratio of the pivot-shift test was not significantly different between groups (P > .05). Mean LOE in the anterior and posterior groups was 0.9° ± 3.0° and -0.8° ± 4.0°, respectively; the difference was not significant (P > .05). Five of 27 knees in the anterior group and 5 of 33 knees in the posterior group had superficial graft laceration or elongation, which was not significantly different (P > .05). Anterior placement of the tibial tunnel in anatomic double-bundle ACL reconstruction leads to better anterior knee stability than posterior placement does. Anterior tibial tunnel placement inside the footprint did not increase the incidence of LOE and graft failure. Level IV, therapeutic case series.

Preoperative Prediction for Length of Patellar Tendon in Anterior Cruciate Ligament Reconstruction Using Bone-Patellar Tendon-Bone Autograft

Preoperative prediction of patellar tendon length is important during anterior cruciate ligament (ACL) reconstruction using bone-patellar tendon-bone (BPTB) autograft. Three methods of imaging analysis to predict patellar tendon length were compared in this study. One hundred and twenty-three patients who underwent ACL reconstruction using BPTB autograft by single surgeon during October 2002 through April 2011 were included. We measured the patellar tendon length from true and oblique lateral simple radiographs (classified according to degree of rotation) and magnetic resonance image (MRI). These values were compared with actual length measured during operation and assessed accuracy by calculating the coefficient of determination. The mean length of patellar tendon measured during operation and by true lateral and oblique lateral radiographs and MRI were 42.4±0.45 mm (range, 32.0–54.0 mm), 41.7±0.61 mm (range, 24.2–55.3 mm), 40.7±0.57 mm (range, 24.8–51.5 mm), and 41.7±0.52 mm (range, 28.7– 56.0 mm), respectively. The correlation of patellar tendon length was the most strong between actual length and value from true lateral radiograph (coefficient of determination, r=0.660) according to simple linear regression analysis. R values were 0.361 and 0.332 for oblique lateral radiograph and MRI compared to actual value, respectively. In conclusion, Patellar tendon length measured on true lateral radiograph was the best method to coincide with actual patellar tendon length among various preoperative prediction methods.