Weight-bearing Anteroposterior Radiographs Research Articles

Effect of recreational physical activities on the development of knee osteoarthritis in older adults of different weights: The Framingham Study

To evaluate the long-term effect of recreational exercise on the development of knee osteoarthritis (OA) in a community-based cohort of older adults, many of whom were overweight or obese. Subjects were asked about recreational activities including walking or jogging for exercise and working up a sweat, and were asked to compare their activity levels with others. Subjects were then asked about knee pain and weight-bearing anteroposterior and lateral knee radiographs were obtained. Approximately 9 years later, subjects were reexamined for OA. Radiographs were read for OA features in both tibiofemoral and patellofemoral compartments and were scored for tibiofemoral joint space narrowing. To evaluate incident OA, we excluded knees with OA at baseline for all analyses and focused on 3 knee-specific outcomes: incident radiographic OA, symptomatic OA, and tibiofemoral joint space loss. After adjusting for age, sex, body mass index (BMI), knee injury history, and correlation between knees, we evaluated the association of each recreational activity with OA development. A total of 1,279 subjects underwent both baseline and followup examinations (mean age at baseline 53.2 years). Neither recreational walking, jogging, frequent working up a sweat, nor high activity levels relative to peers were associated with a decrease or increase in risk of OA. Joint space loss was also unaffected by activity. Persons with BMI above the median (27.7 kg/m(2) for men and 25.7 kg/m(2) for women; mean BMI >30 kg/m(2) for both) had no increases in risk of OA by different type of activity. Among middle-aged and elderly persons without knee OA, many of whom were overweight, recreational exercise neither protects against nor increases risk of knee OA.

Radiographic Narrowing of the Lateral Compartment at 10 to 18 Years After Medial Unicondylar Arthroplasty: Has the Role of Knee Alignment Been Overstated?

Methods: One hundred seven unicompartmental arthroplasties were implanted in 1985-1995 and had 10 to 18 years of radiographic follow-up. The lateral compartment joint space width was measured from weightbearing anteroposterior radiographs made during postoperative year 1 and at the most recent examination. Postoperative year 1 hip-knee-ankle angle, postoperative year 1 lateral compartment joint space width, tibial implant thickness, polyethylene shelf age, sex, weight, and age were examined as risk factors for narrowing.

Hepatocyte growth factor induction of macrophage chemoattractant protein‐1 and osteophyte‐inducing factors in osteoarthritis

In osteoarthritis (OA), hepatocyte growth factor (HGF) is supposed to play a role in cartilage repair. Because the development of osteophytes is a major characteristic of OA and thought to be part of an attempted repair process, the purpose of this study was to determine whether HGF may be involved in osteophyte formation. HGF levels in synovial fluids from 41 patients assessed by enzyme immunosorbant assay were correlated with disease severity and osteophyte formation, evaluated by anteroposterior weight-bearing radiographs. Detection of HGF, c-Met, and CD68 in cartilage and synovial tissues was assessed by immunohistochemistry. Effects of HGF on the secretion of TGF-beta1 and BMP-2 by chondrocytes, fibroblast-like synovial cells (FLS), and macrophages as well as HGF-induced secretion of MCP-1 by FLS and chondrocytes were determined by ELISA. HGF was detected in all synovial fluids and concentrations correlated highly with disease severity and osteophyte formation (p < 0.001). Immunohistochemistry revealed weak synovial staining for HGF, whereas increasing numbers of HGF expressing chondrocytes were detected depending on disease severity. In addition, an increased number of macrophages in synovial specimens was observed, which was likewise severity dependent. In a series of subsequent in vitro studies, HGF remarkable induced MCP-1 secretion by FLS in a dose-dependent manner. No effect on TGF-beta1 and BMP-2 secretion by FLS and chondrocytes was evident upon HGF stimulation, whereas secretion of these growth factors by PMA-differentiated THP-1 cells was significantly increased by HGF. The results indicate that HGF may facilitate osteophyte development by promoting MCP-1-mediated entry of monocytes/macrophages into the OA-affected joint and/or by stimulating macrophage-derived growth factors.

Differential Diagnosis of Knee Pain Commonly Encountered in Clinical Practice

The knee is a complex structure and far from being the simple hinge joint of popular belief. Knee pain would not be properly understood unless one is familiar with the anatomy and understands the role of the various structures. For patient consultation or for selecting a treatment option, it is crucial to find the central cause of symptoms and functional disabilities of the patient based on a detailed history, a focused examination and, when indicated, the selective use of appropriate imaging and laboratory studies. The history taking should be comprehensive and include the demographic characteristics, past medical history, comprehending the associated trauma, pain characteristics and quality of life. Basic physical examination should include inspection of walking pattern and the knee, evaluation of joint effusion, range of motion and the location of tenderness, and precise assessment of joint stability. Although many advanced diagnostic tools are available, plain radiographs are frequently utilized as a primary tool to evaluate conditions of the knee joint for practical and economic reasons. A weight-bearing anteroposterior radiographs should be taken for appropriate evaluation of the condition of the tibiofemoral joint, and weight-bearing radiographs in semi-flexed position is valuable to evaluate the joint space more precisely. To evaluate the patellofemoral joint, axial and lateral views should be included in the routine radiographs. In practice, physicians need to be cautious not to easily reach the conclusion that the symptoms of the knee joint can be attributed to only a few clinical findings in consulting the patients with knee pain.

Low levels of vitamin D and worsening of knee osteoarthritis: Results of two longitudinal studies

To confirm reports that 25-hydroxyvitamin D (25[OH]D) deficiency is associated with an increased risk of joint space narrowing or cartilage loss in osteoarthritis (OA). We measured 25(OH)D levels in subjects from 2 longitudinal cohort studies, the Framingham Osteoarthritis Study and the Boston Osteoarthritis of the Knee Study (BOKS). In the first, weight-bearing anteroposterior (AP) and lateral knee radiographs were obtained on subjects in 1993-1994 and again in 2002-2005 (mean interval 9 years); blood was drawn for measurement of vitamin D status in 1996-2000. In the second, subjects with symptomatic knee OA participating in a natural history study had fluoroscopically positioned semiflexed posteroanterior (PA) and lateral radiography of both knees and magnetic resonance imaging (MRI) of the more symptomatic knee performed at baseline and at 15 and 30 months. Blood was drawn at all visits, and the baseline specimen was used when available. In both studies, we defined radiographic worsening based on joint space loss in the tibiofemoral joint on either AP/PA or lateral weight-bearing views, using a semiquantitative scale (worsening defined as increase by > or =1 on a 0-3 scale). In the BOKS, we evaluated cartilage loss semiquantitatively, using the Whole-Organ Magnetic Resonance Imaging Score. In both studies, 25(OH)D levels were measured by radioimmunoassay. Analyses focused on whether vitamin D levels, defined in tertiles or as deficient (25[OH]D <20 ng/ml) versus nondeficient, predicted worsening of OA. Logistic regression analysis adjusted for age, body mass index, sex, and baseline OA level was used. The 715 subjects in the Framingham Study had a mean 25(OH)D level of 20 ng/ml at baseline, and 20.3% of the knees showed worsening, during the course of the study, with most knees having had no evidence of OA at baseline. The 277 subjects with OA in the BOKS had a mean 25(OH)D level of 20 ng/ml at baseline with 23.6% of knees showing radiographic worsening. We found no association of baseline 25(OH)D levels with radiographic worsening in either cohort, and confidence limits in the analyses of vitamin D deficiency were narrow, suggesting that results were not based on insufficient power. In fact, the risk of worsening was slightly, but not significantly, lower in persons with low levels of vitamin D than in persons with higher levels. In the BOKS, vitamin D levels were unrelated to cartilage loss seen on MRI. The findings indicate that vitamin D status is unrelated to the risk of joint space or cartilage loss in knee OA.

Die reorientierende Rearthrodese des oberen Sprunggelenks nach fehlgeschlagener Arthrodese

There are three important principles for the correction of nonunion and/or malunion of the ankle joint: (1) reorientation back to anatomic shape and to the normal biomechanical axis of the ankle and foot; (2) respect for the biology of bone by resecting all sclerotic bone and/or transplantation of autogenous bone graft; and (3) achievement of optimal biomechanical stability by using the four-screw technique, a limited-contact dynamic-compression plate or a blade plate. CT scanning is the most reliable method for detecting nonunion of the ankle joint after arthrodesis. According to Saltzman, in order to understand the pathology of malunions and nonunions and to plan their correction, weight-bearing anteroposterior radiographs with a 20 degrees internal rotation of the feet, precise lateral views, and rear views of both sides are highly recommended.

Ultrasonographic findings in knee osteoarthritis: A comparative study with clinical and radiographic assessment

To compare ultrasonographic (US) findings with clinical and radiographic assessment in knee osteoarthritis (OA). Fifty patients with primary knee OA were studied. Clinical assessment of both knees was performed by the same rheumatologist who recorded a visual analogue scale (VAS) for pain (VASP). All patients underwent a US examination of their knees by a second blinded rheumatologist. Weight-bearing anteroposterior and lateral knee radiographs were read by a third blinded rheumatologist who assessed the Kellgren and Lawrence (K-L) grade, the femorotibial (FT) space width and the presence of patello-femoral degenerative signs. Forty patients had bilateral symptomatic knee OA and 10 unilateral symptomatic OA. All knees showed radiographic FT degenerative signs. US findings in symptomatic knees were effusion (47%), protrusion of the medial meniscus (MMP) with displacement of the medial collateral ligament (MCLD) (61%) and Baker's cyst (22%). US effusion, MMP and MCLD were associated with a significantly higher VAS score for pain (P<0.05). MMP was associated with medial FT space width (P<0.05). Patients who had a difference between VAS score for pain in each knee greater than 30 (28 patients) showed significantly more unilateral effusion, MMP, MCLD and worse K-L grade in the more symptomatic knee than those with a difference lesser than 30 (22 patients). Knee effusion and MMP with MCLD are associated with pain in knee OA. In addition, MMP may contribute to the radiographic medial FT space narrowing. We propose US for assessing periarticular and intraarticular abnormalities involved in the pathophysiology of knee OA.

An Association Between Functional Second Metatarsal Length and Midfoot Arthrosis

Primary tarsometatarsal arthrosis is relatively uncommon. The etiology of osteoarthritis in the foot is poorly understood, and it is possible that mechanical or anatomic factors play a role. We compared the relative length of the metatarsals in patients with idiopathic arthrosis of the midfoot with that in a group of controls without arthrosis. We analyzed the radiographs of all patients who had had an arthrodesis of the first, second, and third tarsometatarsal joints to treat arthrosis during a three-year period at a tertiary teaching hospital. We excluded patients with a history of inflammatory arthritis, trauma, or Charcot arthropathy. Nine patients (fifteen feet), seven women and two men with an average age of 64.2 years, met the inclusion criteria. We compared them with a control group consisting of the uninjured feet of patients with an acute traumatic injury to the hindfoot and the feet of volunteers with no foot problems. We measured the first, second, and fourth metatarsal lengths and the intermetatarsal angles on weight-bearing anteroposterior radiographs. We also measured the length of the first metatarsal relative to the long axis of the second metatarsal to define the functional first metatarsal length. The ratios of metatarsal lengths and the ratios of functional lengths were used for analysis to minimize differences in foot size and differences caused by radiographic magnification. Statistical comparisons between groups were then carried out. In the study group, the length of the first metatarsal was, on the average, 77.0% of the length of the second metatarsal, whereas, in the control group, the first metatarsal length was an average of 82.0% of the second metatarsal length. The functional length of the second metatarsal was, on the average, 18.6% greater than that of the first metatarsal in the study group and only an average of 4.1% greater than that of the first metatarsal in the control group. Both differences were significant (p < 0.0004 and p < 0.0001, respectively). Patients with midfoot arthrosis had a different ratio of the first to the second metatarsal length than did a similarly aged cohort without midfoot arthrosis. The patients had a relatively short first metatarsal or a relatively long second metatarsal, or both. Midfoot arthrosis may have a mechanical etiology. Recognition of risk factors is the first step in developing prevention strategies.

AN ASSOCIATION BETWEEN FUNCTIONAL SECOND METATARSAL LENGTH AND MIDFOOT ARTHROSIS

Background: Primary tarsometatarsal arthrosis is relatively uncommon. The etiology of osteoarthritis in the foot is poorly understood, and it is possible that mechanical or anatomic factors play a role. Methods: We compared the relative length of the metatarsals in patients with idiopathic arthrosis of the midfoot with that in a group of controls without arthrosis. We analyzed the radiographs of all patients who had had an arthrodesis of the first, second, and third tarsometatarsal joints to treat arthrosis during a three-year period at a tertiary teaching hospital. We excluded patients with a history of inflammatory arthritis, trauma, or Charcot arthropathy. Nine patients (fifteen feet), seven women and two men with an average age of 64.2 years, met the inclusion criteria. We compared them with a control group consisting of the uninjured feet of patients with an acute traumatic injury to the hindfoot and the feet of volunteers with no foot problems. We measured the first, second, and fourth metatarsal lengths and the intermetatarsal angles on weight-bearing anteroposterior radiographs. We also measured the length of the first metatarsal relative to the long axis of the second metatarsal to define the functional first metatarsal length. The ratios of metatarsal lengths and the ratios of functional lengths were used for analysis to minimize differences in foot size and differences caused by radiographic magnification. Statistical comparisons between groups were then carried out. Results: In the study group, the length of the first metatarsal was, on the average, 77.0% of the length of the second metatarsal, whereas, in the control group, the first metatarsal length was an average of 82.0% of the second metatarsal length. The functional length of the second metatarsal was, on the average, 18.6% greater than that of the first metatarsal in the study group and only an average of 4.1% greater than that of the first metatarsal in the control group. Both differences were significant (p < 0.0004 and p < 0.0001, respectively). Conclusions: Patients with midfoot arthrosis had a different ratio of the first to the second metatarsal length than did a similarly aged cohort without midfoot arthrosis. The patients had a relatively short first metatarsal or a relatively long second metatarsal, or both. Midfoot arthrosis may have a mechanical etiology. Recognition of risk factors is the first step in developing prevention strategies. Level of Evidence: Prognostic Level III. See Instructions to Authors for a complete description of levels of evidence.

Association between radiographic joint space narrowing, function, pain and muscle power in severe osteoarthritis of the knee

To examine the association between radiographic classification of severe knee osteoarthritis and measurements of function, pain and power. Cross-sectional study. Specialist orthopaedic hospital. One hundred and twenty-three patients on the waiting list for elective knee arthroplasty. Weight-bearing antero-posterior radiographs scored for severity of osteoarthritis using the Kellgren and Lawrence scale. Function measured using the function subscale of the WOMAC (Western Ontario and McMaster Universities) index, timed tests of walking speed and sit-to-stand. Pain measured using the pain subscale of the WOMAC index and a visual analogue scale. Extensor strength of the lower limb measured with the leg extensor power rig. Within any radiographic grade there was considerable variation in function: WOMAC function for patients with grade 2 mean 64 (47-86), grade 3 mean 47 (12-89) grade 4 mean 45 (2-92). There was poor correlation between radiographic score function, pain or muscle power, with no statistically significant associations. A wide range of scores was also seen within patients with the same radiographic grade. Radiographic score was not found to be closely associated with function. Amongst patients with the same radiographic score there was considerable variation in function, pain and power.

Comparison between Manual and Computer-Assisted Measurements of Hallux Valgus Parameters

The aim of this study was to determine if there are intraobserver and interobserver differences in reliability when measuring hallux valgus angles (HVA), 1-2 intermetatarsal angles (IMA), and distal metatarsal articular angles (DMAA) manually compared to computer-assisted means. Our hypothesis was that the measurements taken by computer-assisted methods of these three forefoot angles would be superior in consistency and accuracy compared to manual measurements. Four examiners studied 20 weightbearing anteroposterior radiographs of patients with hallux valgus. Manual measurements were taken on photographic prints using a goniometer and a fine point pen. Computer-assisted measurements were taken on digitized images using computer software. Three sets of measurements by both of these methods were taken 1 week apart. There was no statistically significant difference between digital and manual measurements for any of the three angles measured (p .05). However, the reliability of measurements within a range of 5 degrees for both methods was 70.6% for HVA, 84% for 1-2 IMA, and 59% for DMAA. There were no significant differences in interobserver and intraobserver reliability in measuring 1-2 IMA and HVA, regardless of the method of measurement; however, there was a significant difference in interobserver reliability when measuring the DMAA either on computer or manually (p = <.05).

Expression of the CD44 variant isoform 5 in the human osteoarthritic knee joint: correlation with radiological, histomorphological, and biochemical parameters

Purpose: The purpose of this study was to correlate expression of CD44v5 in osteoarthritic synovium, cartilage, and synovial fluid with radiographical, histomorphological, and biochemical data. Methods: Cartilage and synovia specimens of 27 patients with osteoarthritis were histomorphologically assessed according to Mankin and Pelletier, respectively. Extended weight-bearing antero-posterior radiographs were evaluated according to Kellgren and Ahlback. Expression of membrane-bound CD44v5 was analyzed by immunohistochemistry and levels of soluble CD44v5 were determined by ELISA. Results: Expression of CD44v5 in cartilage and synovia was detected in 67% and 59% of the patients, respectively. Immunohistochemical findings in cartilage correlated significantly with structural cartilage changes ( p<0.001), whereas no correlation was found between expression in synovia and inflammatory synovial changes. Additionally, no relationship was evident between CD44v5 expression and radiographical data, but expression in cartilage and synovium was significantly correlated with each other ( p<0.04). Surprisingly, expression of CD44v5 in both cartilage and synovia was negatively correlated with synovial fluid levels of TNFα ( p<0.03 and p<0.02, respectively), and no association was evident with levels of IL-1β. Conclusions: The data demonstrate expression of CD44v5 in osteoarthritic cartilage and synovia, probably independent of joint inflammation. But more importantly, expression of this receptor variant in cartilage seems to be strongly related to the degree of cartilage destruction.

Knee pain reduces joint space width in conventional standing anteroposterior radiographs of osteoarthritic knees.

A suspected, but heretofore undemonstrated, limitation of the conventional weight-bearing anteroposterior (AP) knee radiograph, in which the joint is imaged in extension, for studies of progression of osteoarthritis (OA) is that changes in knee pain may affect extension, thereby altering the apparent thickness of the articular cartilage. The present study was undertaken to examine the effect of changes in knee pain of varying magnitudes on radiographic joint space width (JSW) in the weight-bearing extended and the semiflexed AP views, in which radioanatomic positioning of the knee was carefully standardized by fluoroscopy. Fifteen patients with knee OA underwent a washout of their analgesic/nonsteroidal antiinflammatory drug (NSAID) agents (duration 5 half-lives), after which standing AP and semiflexed AP knee radiographs of both knees were obtained. Examinations were repeated 1-12 weeks later (median 4.5 weeks, mean 6.0 weeks), after resumption of analgesic/NSAID therapy. Knee pain was measured with the pain subscale of the Western Ontario and McMaster Universities Osteoarthritis (WOMAC) Index (Likert scale). JSW was measured with a pair of calipers and a magnifying lens. Mixed model analyses of variance were used to test the significance of changes in pain and JSW within and between 2 groups of knees with mild-to-moderate radiographic severity of OA: (a) "flaring knees," in which the patient rated standing knee pain as severe or extreme after the washout and in which pain decreased to any degree after resumption of analgesics and/or NSAIDs (n = 12) and (b) "nonflaring knees," in which standing knee pain was absent, mild, or moderate after the washout or did not decrease after resumption of treatment (n = 15). After reinstitution of treatment, WOMAC pain scores decreased significantly in both flaring and nonflaring knees (-44%; P < 0.0001 and -18%; P < 0.01, respectively). After adjustment for the within-subject correlation between knees, mean JSW (+/-SEM) in the extended view of the flaring OA knee increased significantly from the first to second examination (0.20 +/- 0.06 mm; P = 0.005). In contrast, the change in adjusted mean JSW in the extended view of the nonflaring OA knee was negligible (-0.04 +/- 0.04 mm) and significantly smaller than that observed in flaring knees (P < 0.01). Mean JSW in the semiflexed AP view was unaffected by the severity or responsiveness of standing knee pain in flaring and nonflaring OA knees. JSW in weight-bearing extended-view radiographs of highly symptomatic OA knees can be altered significantly by changes in joint pain. In clinical trials and in epidemiologic studies of OA progression that use this radiographic technique, longitudinal variations in pain may confound changes in the apparent thickness of the articular cartilage.

Anteroposterior weight-bearing radiography of the knee with both knees in semiflexion, using new equipment

In order to obtain high reproducibility and sensitivity in the evaluation of joint space in osteoarthritic knees, we used new equipment, and established an anteroposterior weight-bearing radiograph with both knees in semiflexion taking into account our investigation of the posterior slope angle. We compared our method with the Rosenberg method, and the coefficient of variation of our method showed higher reproducibility than that of the Rosenberg method. The most essential issue is whether the bilateral leg loading radiograph can show the same sensitivity as the homolateral leg loading radiograph. We compared standing radiographs of the knee in 26° flexion with those of 26° flexion in both knees. We assessed the widths of the narrowest points of the joint spaces in the medial and lateral compartments, the condylar plateau angle, and the femorotibial angle, in 47 knees in 24 patients. The data were analyzed statistically by single regression and each correlation was of statistical significance. Our method has better reproducibility and is more comfortable for the subject than conventional methods.

Study of the joint space of the hip on supine and weight-bearing digital radiographs

AIM: To compare hip joint space on supine and weight-bearing anteroposterior digital radiographs. MATERIALS AND METHODS: Fifty anteroposterior views of the hip in 25 patients were taken in supine and weight-bearing positions on a fluoroscopic unit. Two observers in a double-blind study assessed the width of the joint space on an Easy Vision unit with an indirect method of measurement (metric index). RESULTS: Inter-observer and intra-observer variabilities of the metric index were less than 4.1%. There was no significant difference of the metric index of the hip ( P>0.05), between supine and weight-bearing positions. CONCLUSION: There is no significant difference of the width of the joint space of the hip between supine and weight-bearing anteroposterior radiographs. Measuring joint space loss in osteoarthritis of the hip with anteroposterior views should be done with radiographs of the hip in the supine position to improve image quality.

Obesity and osteoarthritis of the knee in women: results from the Matsudai Knee Osteoarthritis survey

A 14-year longitudinal study of middle-aged women was conducted to evaluate the role of obesity in the initiation and progression of idiopathic knee osteoarthritis and to investigate the effect of weight loss on its natural course. Of the 1191 women participating in the first Matsudai Knee Osteoarthritis Survey in 1979, 608 women without possible secondary osteoarthritis were re-evaluated in 1993. Data were collected by questionnaire, physical examination, and weight-bearing anteroposterior knee radiographs. The mean age of the subjects was 51.3 (range 40–65) years with mean body mass index (BMI) of 23.0 (range 16.0–34.7) at the first survey. Incident disease was defined if a grade 0 knee (a modified Kellgren and Lawrence scale) at the first survey advanced to grade 2 or higher at follow-up. Progression of the disease was defined if a grade 1 or 2 knee advanced to a higher grade at follow-up. We found that higher BMI at the first survey increased the risk of both the initiation and progression of knee osteoarthritis. Obese women (BMI≧25.0) with a decrease in body mass index of 2 units or more during the 14 years had a lower risk for radiological deterioration, although weight gain did not alter the risk significantly.

Ankle valgus and clubfeet.

Congenital equinovarus is a complex deformity that involves the ankle as well as the foot. Although equinus is the obvious and presenting ankle deformity that is typically addressed with serial manipulation, casts, and surgery, ankle valgus is a more insidious and often overlooked problem that evolves with growth. With a high prevalence (67% in this series), it may, in some cases, ameliorate the effects of residual hindfoot varus. More commonly, it may result in prominence of the medial malleolus, lateral shift of the ground reactive forces, compression of the lateral portion of the distal tibial epiphysis, fibular impingement, and excessive shoe wear. If mistaken for hindfoot valgus ("overcorrected clubfoot"), inappropriate hindfoot surgery may result. Although one may temporize with orthoses, definitive treatment options include medial malleolar epiphysiodesis or, in mature patients, supramalleolar osteotomy. We recommend a weight-bearing anteroposterior radiograph of the ankles in any patient presenting with valgus and suspected of having overcorrected congenital equinovarus, particularly if surgical intervention is being contemplated. If valgus deformity is noted in the ankle, hindfoot surgery may be contraindicated.

Defining radiographic osteoarthritis for the whole knee

To determine in the knee which individual radiographic feature or combination of features in the patellofemoral and tibiofemoral joints correlate best with a nonradiographic definition of clinical osteoarthritis in order to recommend a definition of radiographic osteoarthritis for use in studies. Using data from the Framingham Osteoarthritis Study, we tested the correlation of clinical OA, defined as frequent knee pain plus crepitus, with a variety of definitions of radiographic OA including those based on individual radiographic features, e.g. > or = grade 2 osteophyte 0-3 scale, and new definitions that included alternative combinations of features, [e.g. either > or = grade 2 osteophyte or joint space narrowing > or = grade 2 (0-3 scale) with a bone feature (such as cyst, sclerosis, or grade 1 osteophyte)]. We performed analyses looking at participants who had obtained both weight-bearing anteroposterior (AP) and lateral radiographs of both knees. In 519 participants, we found that the definitions of radiographic osteoarthritis best correlated with clinical OA were definite osteophyte > or = grade 2' (efficiency 62.4-67.1%) and an 'alternate definition' of either osteophytes > or = grade 2 or joint space narrowing > or = grade 2 with a bony feature of OA (efficiency 62.8-68.1%). A recursive partitioning analysis selected the 'alternate definition' as best. Also, we found that adding lateral views to the AP view improved the diagnostic test performance of the best performing radiographic definitions. We suggest that a knee should be characterized as having radiographic OA if there is either an osteophyte of grade 2 or greater severity (0-3 scale) present or the presence of moderate to severe joint space narrowing (> or = 2 on a 0.3 scale) with co-occurrence of a bony feature in the compartment affected.

Tendon Transfer Combined with Calcaneal Osteotomy for Treatment of Posterior Tibial Tendon Insufficiency: A Radiological Investigation

We present the radiographic results after flexor digitorum longus tendon transfer combined with a medial displacement calcaneal osteotomy for the treatment of posterior tibial tendon insufficiency. Eighteen patients with posterior tibial tendon insufficiency were reviewed from 12 to 26 months after surgery. The 15 women and 3 men had a mean age of 54 years (range, 38-72 years). The talar-first metatarsal and talonavicular coverage angles were measured before and after surgery on the anteroposterior weightbearing radiographs. The mean preoperative talar-first metatarsal and talonavicular coverage angles were 21 degrees (range, 3-45 degrees) and 34 degrees (range, 0-55 degrees), respectively. The mean postoperative values for these angles were 8.5 degrees (range, 0-35 degrees) and 21 degrees (range, -30-45 degrees), respectively. The mean talar-first metatarsal angle decreased from 21 degrees to 8.5 degrees, a mean improvement of 12.5 degrees, and the mean talonavicular coverage angle decreased from 34 degrees to 21 degrees, a mean improvement of 13 degrees. On the lateral weightbearing radiographs, the talar-first metatarsal angle and the distance from the medial cuneiform to the floor were measured before and after surgery. The mean preoperative values were -22 degrees (range, -10 to -40 degrees) and 9 mm (range, 1-19 mm), respectively. The mean postoperative values were -9 degrees (range, +5 to -25 degrees) and 16 mm (range, 10-28 mm), respectively. The mean talar-first metatarsal angle decreased from -22 to -9 degrees (a mean improvement of 13 degrees), and the distance from the medial cuneiform to the floor increased from 9 to 16 mm (a mean improvement of 7 mm). We conclude that the use of a combined medial displacement osteotomy of the calcaneus with a tendon transfer for treatment of posterior tibial tendon insufficiency may offset the inherent weakness of the flexor digitorum longus transfer by reducing the antagonistic deforming force of heel valgus.

Hallux valgus, first metatarsal pronation and collapse of the medial longitudinal arch ? a radiological correlation

In a previous study we developed a model to assess first metatarsal pronation based on the position of the inferior tuberosity of its base and showed a significant relationship between first metatarsal pronation and the intermetatarsal angle (r = 0.69, p < 0.001). The present study was undertaken to correlate first metatarsal pronation with the height of the medial longitudinal arch in an attempt to define the clinical significance of this new finding. The weight-bearing anteroposterior and lateral radiographs of the feet of 50 patients (100 feet; 36 females patients of mean age 38 years, 14 males patients of mean age 40 years) were reviewed, and in each case, the patient's age, sex, intermetatarsal angle, amount of first metatarsal pronation and medial longitudinal arch angle were recorded by independent observers. A significant relationship was demonstrated between first metatarsal pronation and the height of the medial longitudinal arch (r = 0.93, p < 0.0001). Less marked association was observed between intermetatarsal angles and first metatarsal pronation (r = 0.71, p < 0.001). Multivariate analysis of patient age, sex, intermetatarsal angle and medial longitudinal arch angle against metatarsal pronation showed that the single most dominant variable affecting metatarsal pronation was the height of the medial longitudinal arch.