Aims

To establish cut-off values for lateral pubofemoral distance (PFD) measurements for detecting hip dysplasia in early (four days) and standard care (six weeks) screening for developmental dysplasia of the hip (DDH).

Modular dual mobility (DM) articulations are increasingly utilized during total hip arthroplasty (THA). However, concerns remain regarding the metal liner modularity. This study aims to correlate metal artifact reduction sequence (MARS) magnetic resonance imaging (MRI) abnormalities with serum metal ion levels in patients with DM articulations. All patients with an asymptomatic, primary THA and DM articulation with >2-year follow-up underwent MARS-MRI of the operative hip. Each patient had serum cobalt, chromium, and titanium levels drawn. Patient satisfaction, Oxford Hip Score, and Forgotten Joint Score-12 (FJS-12) were collected. Each MARS-MRI was independently reviewed by fellowship-trained musculoskeletal radiologists blinded to serum ion levels. Forty-five patients (50 hips) with a modular DM articulation were included with average follow-up of 3.7±1.2 years. Two patients (4.4%) had abnormal periprosthetic fluid collections on MARS-MRI with cobalt levels >3.0 μg/L. Four patients (8.9%) had MARS-MRI findings consistent with greater trochanteric bursitis, all with cobalt levels < 1.0 μg/L. A seventh patient had a periprosthetic fluid collection with normal ion levels. Of the 38 patients without MARS-MRI abnormalities, 37 (97.4%) had cobalt levels <1.0 μg/L, while one (2.6%) had a cobalt level of 1.4 μg/L. One patient (2.2%) had a chromium level >3.0 μg/L and a periprosthetic fluid collection. Of the 41 patients with titanium levels, five (12.2%) had titanium levels >5.0 μg/L without associated MARS-MRI abnormalities. Periprosthetic fluid collections associated with elevated serum cobalt levels in patients with asymptomatic dual mobility articulations occur infrequently (4.4%), but further assessment of these patients is necessary. Level of Evidence: Level IV

The diagnosis of infection following shoulder arthroplasty is notoriously difficult. The prevalence of prosthetic shoulder infection after arthroplasty ranges from 3.9 – 15.4% and the most common infective organism is Cutibacterium acnes. Current preoperative diagnostic tests fail to provide a reliable means of diagnosis including WBC, ESR, CRP and joint aspiration. Fluoroscopic-guided percutaneous synovial biopsy (PSB) has previously been reported in the context of a pilot study and demonstrated promising results. The purpose of this study was to determine the diagnostic accuracy of percutaneous synovial biopsy compared with open culture results (gold standard). This was a multicenter prospective cohort study involving four sites and 98 patients who underwent revision shoulder arthroplasty. The cohort was 60% female with a mean age was 65 years (range 36-83 years). Enrollment occurred between June 2014 and November 2021. Pre-operative fluoroscopy-guided synovial biopsies were carried out by musculoskeletal radiologists prior to revision surgery. A minimum of five synovial capsular tissue biopsies were obtained from five separate regions in the shoulder. Revision shoulder arthroplasty was performed by fellowship-trained shoulder surgeons. Intraoperative tissue samples were taken from five regions of the joint capsule during revision surgery. Of 98 patients who underwent revision surgery, 71 patients underwent both the synovial biopsy and open biopsy at time of revision surgery. Nineteen percent had positive infection based on PSB, and 22% had confirmed culture positive infections based on intra-operative tissue sampling. The diagnostic accuracy of PSB compared with open biopsy results were as follows: sensitivity 0.37 (95%CI 0.13-0.61), specificity 0.81 (95%CI 0.7-0.91), positive predictive value 0.37 (95%CI 0.13 – 0.61), negative predictive value 0.81 (95%CI 0.70-0.91), positive likelihood ratio 1.98 and negative likelihood ratio 0.77. A patient with a positive pre-operative PSB undergoing revision surgery had an 37% probability of having true positive infection. A patient with a negative pre-operative PSB has an 81% chance of being infection-free. PSB appears to be of value mainly in ruling out the presence of peri-prosthetic infection. However, poor likelihood ratios suggest that other ancillary tests are required in the pre-operative workup of the potentially infected patient

Abstract. Introduction. There are several imaging-based measurements for patello-femoral height. Available methods rely predominantly on sagittal images. The latter can be misleading with sagittal oblique slices and when the patella is tilted and/or chronically subluxed. In this study we describe a simple method of patellar height measurement using axial MRI overlap. Materials and methods. A retrospective observational analysis of 97 knees from 251 patients was conducted. Cases were selected following the exclusion of scans with fractures, massive effusion, patello-femoral pathology. Axial patello-trochlear overlap (APTO) was measured on the axial MRI images as follows: (1) Patellar length (P): expressed as the number of axial images showing patellar articular surface (2) Trochlear overlap (T): the number of axial images showing overlap between patellar articular surface and articular surface of lateral trochlea. APTO is the ratio T/P. All measurements were carried out independently and on two separate occasions by 6 raters. As a control conventional patello-trochlear index were measured for all patients by a senior musculoskeletal radiologist. Results. The mean APTO value was 36.7 (range 14.2 to 66.6; SD 11.4). There was a positive correlation with patello-trochlear index (Pearson correlation coefficient: 0.76, P < 0.001). Intra-observer reliability was good (ICC: 0.66 95 CI 0.54, 0.76, P < 0.001). Inter-observer reliability was fair (ICC: 0.51, 95 CI 0.41, 0.6, P < 0.001). Conclusion. In the present proof of concept study APTO was a reliable measurement of patellar height and correlated with patella-trochlear indices. The method described can prove valuable in overcoming issues with sagittal image measurements

Background. MRI is the preferred modality for the diagnosis of ankle joint pathology. Musculoskeletal radiologists aim to determine and report both chondral and/or osseous stability/instability of each lesion. The aim of this study was to specifically analyse the reliability of MRI reported findings in predicting the stability of OCL's in symptomatic patients. Methods. A single centre, single surgeon consecutive series of patients who had undergone an ankle arthroscopy procedure preceded by an MRI scan for symptomatic ankle pathology were included in this retrospective clinical study. All MRI scans were reported by a musculoskeletal radiologist. MRI reports and arthroscopic findings were extracted and analysed. Arthroscopy findings were taken as the gold standard. Results. Between April 2012 and July 2016, 48 patients who fulfilled the above criteria were included. There were 27 male and 21 female patients, the average age was 43.4 (SD 14.1). The average time interval between MRI scan and arthroscopy was 9 months (2–49 months), 28 patients (58.3%) had a right sided pathology. There was a significant negative relationship between OCL's reported as stable on MRI to arthroscopic findings, r=−.31, p=0.03. Of the 21 patients who had OCL's reported as stable on the MRI scan, all had unstable lesions on arthroscopic evaluation (100%). One patient had an unstable OCL reported on the MRI scan and it was also found unstable arthroscopically. In 27 patients, where there was no mention of the stability of the reported OCL on the MRI, 22 patients (81.5%) had unstable lesions and 5 patients (18.5%) had stable lesions on intra-operative arthroscopic findings. Conclusion. This study demonstrates that MRI has a poor predictive value for the stability of OCL's of the ankle. Therefore we recommend that in the symptomatic patient an arthroscopy is indicated irrespective of MRI findings. Evidence. retrospective case review, level IV

Introduction: Lesser metatarsophalangeal joint (MTPJ) instability is a common cause of forefoot pain. Instability is probably caused by tears of the plantar plate and collateral ligaments. We prospectively compared MRI and ultrasound with and without arthrography in the assessment of patients with MTPJ instability. Materials and Methods: MTPJ instability was diagnosed by the draw test. Nineteen patients underwent imaging with consent. One musculoskeletal radiologist performed MRI arthrography and a different musculoskeletal radiologist performed ultrasonography supplemented with arthrography. Each radiologist reported his own study, blinded to the results of the other modality. Where possible, the radiological diagnosis was evaluated at surgery. Results: MRI identified four full thickness plantar plate tears. In five studies no contrast was seen in the MTP joint and in 10 contrast was contained within the joint. Ultrasound identified six full thickness plantar plate tears as hypoechoic zones that extended through the whole thickness of the plate. Eleven studies showed partial thickness tears. Two studies showed thinning of the plate. Ultrasound arthrography identified seven full thickness tears by extravasation of injected fluid into the flexor tendon sheath. Eleven studies showed partial thickness tears and one was normal. Ultrasound and ultrasound arthrography agreed in 14/19 patients. MRI agreed with ultrasound on 3 of 6 full thickness tears and with ultrasound arthrography in 4 of 6 full thickness tears. MRI gave additional information about the articular surfaces in four patients. Surgical comparison was available in 11/19 patients. Ultrasound with and without arthrography correctly predicted four partial thickness tears. Ultrasound arthrography correctly predicted 6/7 full thickness tears, MRI 3/7 and ultrasound 3/7. Discussion: Ultrasound with arthrography appears the best modality to distinguish between partial and full-thickness tears. It is cheaper, simpler and can be performed in the outpatient setting. Larger studies with surgical confirmation are required to assess its value more precisely

Myxofibrosarcoma (MFS) is the second most common subtype of soft tissue sarcoma (STS) and is associated with a high rate of local recurrence after resection. These tumours frequently present with peri-lesional edema, termed “tumour tails” on staging MRI scans [1]. Tumour tails(TT) may contain satellite neoplastic cells or can represent benign reactive edema. There are no clear radiological features to distinguish malignant from reactive peri-lesional edema which limits accurate surgical planning, resulting in either high rates of inadvertently positive resection margins and local recurrences or overly-aggressive resections which negatively impact function and increase morbidity [2]. The objective of this pilot study was to prospectively study a cohort of MFS patients with TTs in an attempt to identify radiological features that predict which type of edema is malignant and requires resection together with the main tumour mass. Patients diagnosed with MFS on biopsy at an orthopaedic oncology referral centre between January 1-December 31 2018 who also had TTs on staging MRI scans were prospectively recruited for the study. Tumours were treated with wide surgical excision, including the TTs, and (neo)adjuvant radiotherapy as per institutional protocol. Staging MRI scans were reviewed in a blinded fashion by two musculoskeletal radiologists to distinguish malignant from reactive TTs. The main tumour mass underwent standard histological evaluation while the regions encompassing the TTs were photographed and sectioned into grids. Each tissue section was examined histologically for the presence of satellite neoplastic cells based on morphological criteria. Radiological and histological findings were compared. Six patients met the inclusion criteria and underwent analysis. All tumours were located in the extremities and were deep to fascia. Mean age at presentation was 67 years (range 51 – 85), with a male:female ratio of 4:2. All patients received radiotherapy (50 Gy), either pre- (n=4) or post-operatively (n=2) based on multidisciplinary tumor board discussion or enrolment in a prospective clinical trial. Radiologically, TTs were labelled as malignant in four patients (66.7%) and as benign TTs in two others. The tails were recognised to be malignant due to the differing signal characteristics to reactive edema on mixed MRI sequences. The radiological evaluation correlated exactly with histological analysis, as satellite neoplastic cells were identified microscopically in the same four cases in which the TTs were designated to be malignant by MRI (specificity&sensitivity=100%). Surgical resection margins were microscopically positive in 50% of cases in the TTs themselves, and 75% of cases in which TTs were designated as malignant on staging MRI. “The malignant nature of peri-lesional edema in MFS, also known as the TT, was accurately predicted in this small pilot study based on specific radiological features which correlated exactly with histologic identification of isolated tumor cells. These findings validate development of a larger prospective study to recruit additional patients with tumor tails beyond just MFS, in order to more robustly study the correlation between the MRI appearance and histological distribution of satellite sarcoma cells in peri-lesional edema in STS. We are already recruiting to this expanded radiological-histological investigation including evaluation of additional novel MRI sequences

Purpose: The Instability Severity Index Score (ISIS) is a 6-item questionnaire that has been reported to predict failure of arthroscopic Bankart repair among patients treated for recurrent anterior glenohumeral instability. Two of the ISIS items pertain to radiographic features (presence of a Hill-Sachs lesion, loss of glenoid contour). These, however have yet to be validated. The goal of this study was to examine the inter – and intra-rater agreement and corresponding reliability of the radiographic aspects of the ISIS. Method: Fifty-two plain, randomly selected, true antero-posterior radiographs in 45° gleno-humeral external rotation were evaluated by five assessors (three upper extremity orthopaedic surgeons, one senior orthopaedic resident and one musculoskeletal radiologist). Radiographs were retrieved for patients with documented recurrent shoulder instability requiring surgical stabilization and placed in a blinded Microsoft Powerpoint presentation for evaluation. Assessors were asked to determine the presence/absence of a Hill-Sachs lesion and if a loss of glenoid contour was present. Radiographs were evaluated in random order on two occasions, separated by a one-week time interval. Intra – and inter-rater reliability was assessed using percentage of agreement and kappa statistics. Results: For session one, the number of Hill-Sachs lesions observed among raters ranged from 11 to 32. This resulted in inter-rater agreement ranging from 48% to 78% (k = 0.07 to 0.42), indicating poor to fair reliability. Cases with loss of glenoid contour ranged from seven to 14 with inter-rater agreement of 66% and 90% (k = 0.01 to 0.61), suggesting poor to moderate reliability. Session two led to modest increases in inter-rater agreement. The number of Hill-Sachs lesions observed ranged from four to 30 (agreement of 48% to 84%; k = 0.11 to 0.60) indicating fair to moderate reliability and the number of cases with loss of glenoid contour ranged from three to 14 (agreement of 66% to 94%; k = – 0.04 to 0.69), ranging from poor to moderate reliability. With respect to intra-rater reliability, agreement ranged from 71% to 94% (k = 0.41 to 0.86) for Hill-Sachs lesions, indicating fair to good reliability and 76% to 94% (k= 0.20 to 0.74) for loss of glenoid contour, ranging from fair to good reliability. Intra-rater agreement and corresponding kappa values were highest among the upper extremity surgeons and the musculoskeletal radiologist, particularly for loss of glenoid contour (85% to 94%; k = 0.56 to 0.74) suggesting there is moderate to good reliability in this measurement. Conclusion: Our results indicate that the intra-rater reliability of the ISIS radiographic features was highest among upper extremity specialists and the musculoskeletal radiologist, suggesting that the ISIS may have utility in an experienced clinician’s individual practice. As the inter-rater reliability appears low, particularly for Hill-Sachs lesions, its wide-spread use across surgeons should be examined in further research

Introduction. Injections are used to treat a wide variety of pathologies. Our aim was to evaluate the efficacy and safety of foot and ankle injections in our clinic. Materials and methods. We performed a retrospective review of notes and a telephone questionnaire audit into the clinical outcome of all patients who underwent an injection of the foot or ankle in a year. All procedures were performed in an out-patient setting by a consultant musculoskeletal radiologist using either ultrasound or X-ray guidance, with a minimum of two year follow-up. According to the pathology treated, the type of injection included depomedrone, hyaluronic acid and high volume saline injections. Results. Overall 410/446 (92%) patients reported a significant improvement in symptoms and 227 (62%) reported complete resolution of their pain, with 127 (28%) remaining asymptomatic at two year follow-up. The mode time of recurrence of pain was three months. 59 (13%) underwent a further injection and 102 (23%) underwent operative intervention within the follow-up period. There were no reported infections. Complications occurred in two percent of patients, including steroid flare, pain and plantar plate ruptures. Conclusion. Injections are a safe and effective option for treating a variety of foot and ankle conditions and reduce the need for surgery. They are particularly effective for the treatment of ankle soft tissue impingement. They appear ineffective in providing significant improvement in pain for longer than three months in conditions such as plantar fasciitis and hallux rigidus

Introduction. The highest incidence of recurrent shoulder instability is in young patients, surgical repair can reduce recurrent instability and improve shoulder function. This has led to an increasing rate of stabilisation and use of MRI to identify associated injuries in first time dislocations. MRA has the benefit of distending the joint and is becoming increasingly used. The aim of this study is to establish the sensitivity and specificity of MRA in the investigation of patients with traumatic anterior shoulder dislocations. Methods. A retrospective analysis of patients undergoing both magnetic resonance arthrography and arthroscopy after a traumatic anterior shoulder dislocation between January 2011 and 2014. Images were interpreted by eight musculoskeletal radiologists and arthroscopic findings were obtained from surgical notes and used as a reference. The sensitivity, specificity and positive predictive value for the different injuries were calculated. Results. 60 patients were reviewed; 88% were male, mean age was 28 years (range 18 to 50) and 27% were primary dislocations. The overall sensitivity and specificity of MRA to all associated injuries was 0.9 (CI 0.83–0.95) and 0.94 (CI 0.9–0.96) retrospectively. The lowest sensitivity was seen in osseous Bankart 0.8 (CI 0.44–0.96) and SLAP lesions 0.5 (CI 0.14–0.86). Conclusion. MRA has a high sensitivity when used to identify associated injuries in shoulder dislocation although in 8 patients (13%) arthroscopy identified an additional injury. The overall agreement between MRA and arthroscopic findings was good but identification of GHL and rotator cuff injuries was poor. Level of Evidence. IV. Conflict of Interests. The authors confirm that they have no relevant financial disclosures or conflicts of interest. Ethical approval was not sought as this was a systematic review

Purpose and background:. MRI findings associated with spondyloarthritis (SpA) can be difficult to distinguish from the more prevalent findings of degeneration. Despite this, the two groups of MRI-findings are often evaluated in separate studies and in different study populations, which may reduce their applicability in daily clinical practice. The purpose of this study was to estimate the prevalence of degenerative and SpA related MRI-findings in the spine and sacroiliac joints (SIJ) in patients with persistent LBP. Methods:. Patients with persistent LBP (n=1037, median age 33 [IQR 27–37], 54% women) referred to an outpatient, secondary care and non-surgical department were included in the study. MRI of the whole spine and the SIJ was performed and degenerative and SpA-related MRI-findings were evaluated by experienced musculoskeletal radiologists. Results:. The prevalence of disc degeneration, disc contour changes, and Modic changes were 87%(±1.1), 82%(±1.2) and 48%(±1.6). All degenerative spinal findings were most frequent in men and patients aged 30–40 years. Spinal SpA-related MRI-findings were rare. In the SIJ, 28%(±1.4) had at least one MRI finding, with bone marrow oedema (BMO) being the most common (21%(±1.3)). SIJ erosions were most prevalent in patients aged 18–29 years and BMO in patients aged 30–40 years. SIJ sclerosis and fatty marrow deposition were most common in women. Post hoc analysis showed that SIJ BMO, sclerosis and erosions were most frequent in women indicating pregnancy-related LBP. Conclusion:. The high prevalence of SIJ MRI findings associated with age, gender, and pregnancy-related LBP need further investigation of their clinical importance in patients with persistent LBP

The final alignment of Patient Specific Instrumentation (PSI) TKA relies on the accuracy and the correct placement of the 3-D moulds, precision of saw cuts, soft tissue balancing and cementing technique. We aimed to compare the predicted alignment between PSI and Articulated Surface Mounted (ASM) computer navigation. Eight consecutive patients underwent knee replacement using MRI based PSI (Zimmer) with planning of 0º femoral and tibial mechanical alignment. After placing the conventional cutting blocks over the pins (placed according to PSI), the predicted alignment of cuts was verified with ASM navigation. PSI technique was used regardless of navigation values and alignment was compared. Good correlation was found for tibial cuts (maximum variation: coronal plane – 1º, sagittal plane – 2º) and femoral cuts in the sagittal plane (maximum variation 2º). However, in two patients the coronal plane variation in femur was > 2º (3º and 4º respectively). Navigation predicted combined final alignment of 5º valgus and 4º valgus in these patients. However, long leg standing x-rays revealed neutral and 1º valgus alignment in those two patients respectively, matching closely with PSI prediction. Final alignment in long-leg standing x-rays were independently reported by a musculoskeletal radiologist. Six knees were in neutral mechanical alignment (including the 2 navigation predicted outliers). The remaining 2 knees had a maximum deviation of 2 degrees from neutral. We conclude that there was overall good correlation between PSI and navigation. Even in cases where navigation predicted more than 3º combined varus/valgus alignment, PSI prediction was more accurate on long leg views

Hamstring tendons are commonly used for Anterior Cruciate Ligament (ACL) reconstruction. In our series of 100 consecutive Hamstring ACL reconstructions, a four-strand graft was less than 7.0 mm in 5 patients. The aim of this study was to develop a screening test to assess the size of the hamstring tendon and so aid in the pre operative planning and patient counselling especially if hamstring size was deemed to be inadequate. A retrospective study of 100 consecutive hamstring ACL reconstructions analysed the correlation of the tendon size to height, weight and body mass index. A prospective double blind study was also set up involving independent observations by a musculoskeletal radiologist and the lead Orthopaedic surgeon. Result. There was no correlation between the anthropometric measures and hamstring size in the retrospective study. A total of 27 limbs were assessed sonographically, in 26 patients. Spearman's rank correlation coefficient was found to Pearson's r = 0.0786; p = 0.715. Conclusion. Pre-operative anthropometric measures and Ultrasound could not be used as a screening test to detect inadequate hamstrings in the clinical setting

Introduction. Uncertainties in the management of patients with MOM hip implants continue to be a problem for all surgeons. Guidelines vary and do not fully define or quantify thresholds. We aimed to assess the differences in decision-making amongst an international community of six specialist orthopaedic institutions. Methods. Five international tertiary referral orthopaedic units (one UK, two USA, and two European) were invited to participate. Each unit organised an MDT panel consisting of 2 or more hip surgeons and a musculoskeletal radiologist. All units discussed the same 10 patients. A full clinical dataset was provided including blood test and all imaging. Differences in the interpretation of findings, management decision and rationale for decisions were compared between institutions. Results. Asymptomatic patients with metal ions below 7ppb and intra-articular synovitis were collectively treated with monitoring and repeat ion measurement. Symptomatic patients with similar findings were recommended revision surgery by all units. Raised metal ions and a cystic pseudotumour on imaging that is palpable clinically was also consistently recommended revision surgery. Moderate symptoms (OHS 30), 2B pseudotumour, and moderate metal ions (cobalt 5.5ppb) were seen as an indication for revision in 5 units, however the reverse is seen if the patient had several co-morbidities. Further to this, rising blood metal ions (6 to 7.5ppb) was recommended surgery by 4 units, and watchful waiting in 2 units. Rising blood metal ion levels (6ppb to 10ppb) and a small fluid collection on MRI in asymptomatic patients was recommended clinical review and repeat metal ions by 3 units, repeat MRI by 1 unit and revision for suboptimal implant position by the remaining 2 units. Conclusion. Moderate symptoms, blood metal ions and cystic pseudotumours led to inconsistent agreement between institutions. Coordinated international guidance and MDT panel discussions are recommended to improve consensus in decision-making

Introduction. Most of the algorithm available today to balance varus knee is based on a surgeon's hands-on experience without full understanding of pathological anatomy of varus knee. The high-resolution MRI allows us to recognize the anatomical details of the posteromedial corner and the changes of the soft tissue associated with the osteoarthritis and varus deformity. We have in this study, reviewed 60 cases of severe varus knee scheduled for TKR and compared it to normal MRI and those MRI were evaluated and read by a musculoskeletal radiologist. We have documented clearly the changes that happens in soft tissue, leading to tight medial compartment. We will also show multiple short intra-operative video confirming that MRI findings. Material & method. We have retrospectively reviewed the MRI on 60 patients with advanced osteoarthritis varus knee. We also reviewed 20 MRI for a normal knee matched for age. We evaluated the posteromedial complex and MCL in sagittal PD-weighted VISTA to check the alignment of the MCL and posteromedial complex and the associate MCL bowing and deformity that could happen in osteoarthritis knee. We have measured the thickness of the posteromedial complex and the posterior medial bowing of the superficial MCL and the involvement of the posterior oblique ligament in those patients. To measure the posterior bowing of the MCL, a line was drawn through the posterior aspect of both menisci and we measured the distance between the posterior edge of MCL to that line in actual image. To measure the thickness of the posteromedial complex, we measured it at two areas in the posterior medial corner posteriorly at the level of the medial meniscus. Measuring the medial bowing of the MCL was done by a line drawn through the medial edge of the femoral condyle and the tibial condyle at the level of the medial meniscus to the inner aspect of the MCL. The normal distance between the posterior aspects of the MCL to the posterior meniscus line was approximately measured 2 cm. in average. Results. We were able to recognize and measure the medial deviation of MCL in all arthritic knees due to the deformity and the effect of the medial margin osteophyte and medial extrusion of the meniscus. Thickening of posteromedial complex was recognized in the majority of the cases with prominent thickening seen in 50/60 knees with average thickness measuring approximately 1.2 cm due to the synovial thickening, adhesions, granulation tissue, degenerated medial meniscus, and involvement of the posterior oblique ligament and the capsular branch of the semimembranosus tendon, as well as the oblique popliteal ligament. The involvement of posterior oblique ligament were seen in majority of the cases. In 55 cases we have showed a heterogeneous appearance of the ligament and loss of normal signal within the postero medial complex and we have documented that the oblique ligament will cause the posterior bowing of the MCL. The medial bowing of the MCL is also correlated to the severity of the varus deformity with an average distance to the normal medial line of the medial meniscus measuring approximately 1.1 cm. Discussion. Our study shows that the changes affecting the superficial MCL is likely to be secondary to the obvious changes involving the posteromedial complex and to the marginal osteophyte as well as the extrusion of the medial meniscus. Also, we have confirmed that there are deforming structures such as the oblique ligament with adhesion and thickening with all the posterior medial complex. Those changes clearly caused the posterior bowing to the superficial MCL without an actual shortening of the ligament. The scarring tissue in the posteromedial corner and the adhesion is acting as a soft phyte tensioning and deforming the ligament and the posterior capsule. The oblique ligament act as a deforming forces forcing the superficial MCL to bow posteriorly. The lengths of the superficial MCL stayed the same. Conclusion. The conventional wisdom of releasing the distal attachment of the superficial medial MCL to balance knee has to be a challenge based on our MRI finding. Releasing the superficial MCL can sometimes lead to a major instability of the knee requiring a more constrained implant. Our MRI assessment clearly showed that the Superficial MCL is deformed because of posterior bowing and medial bowing and considerable thickening of the posteromedial corner, as well as the accompanying osteophyte. We believe that clearing the superficial MCL and excising those thickened scar tissue in the posterior medial corner will enable us to balance the knee without creating instability Conclusion: The conventional wisdom of releasing the distal attachment of the superficial medial MCL to balance knee has to be a challenge based on our MRI finding. Releasing the superficial MCL can sometimes lead to a major instability of the knee requiring a more constrained implant. Our MRI assessment clearly showed that the Superficial MCL is deformed because of posterior bowing and medial bowing and considerable thickening of the posteromedial corner, as well as the accompanying osteophyte. We believe that clearing the superficial MCL and excising those thickened scar tissue in the posterior medial corner will enable us to balance the knee without creating instability

The orientation of the acetabular component in metal-on-metal hip resurfacing arthroplasty affects wear rate and hence failure. Correct assessment of acetabular orientation is key in assessing the painful hip resurfacing. This study aimed to establish if interpretation of pelvic radiographs with TraumaCad software can provide a reliable alternative to computed tomography (CT) in measuring the acetabular inclination and version. TraumaCad was used to measure the acetabular orientation on AP pelvis radiographs of 14 painful hip resurfacings. Four orthopaedic surgeons performed each measurement twice. These were compared with measurements taken from CT reformats performed by an experienced musculoskeletal radiologist. The correlation between TraumaCad and CT was calculated, as was the intra- and inter-observer reliability of TraumaCad. There is strong correlation between the two techniques for the measurement of inclination and version (p<0.001). Intra- and inter-observer reliability of TraumaCad measurements are good (p<0.001). Mean absolute error for measurement of inclination was 2.1°. TraumaCad underestimated version compared to CT in 93% of cases, by 12.6 degrees on average. When assessing acetabular orientation in hip resurfacing, the orthopaedic surgeon may use TraumaCad in the knowledge that it correlates well with CT and has good intra- and inter-observer reliability but underestimates version by 12° on average. This underestimation may be contributed to by the natural divergence of the X-ray beam, the short arc of the ellipse left exposed by the large diameter head, and the non-hemispherical resurfacing cup

Introduction:. The treatment of acute rupture of the tendo-achilles remains controversial. There is good evidence to suggest that outcomes are the same for both operative and non-operative treatment when a functional rehabilitation program is utilised. However, debate continues as to whether the radiological gap-size between the proximal and distal remnants of the tendon has an influence on the suitability for non-operative management. Methods:. All adult patients who attended the emergency department with a clinically suspected tendo-achilles rupture were place in a plantarflexed cast, and underwent MRI scanning to confirm the diagnosis. They were then counselled on the risks and benefits of operative versus non-operative treatment. Patients opting for non-operative treatment were asked to take part in the study and treated using a functional rehabilitation programme. Gap sizes were determined using a standardised protocol by a single musculoskeletal radiologist blinded to the clinical outcomes. Results:. A total of 69 patients have been recruited into the study, 40 have complete their one year review. There were two re-ruptures. The average age was 42.4 years (range 19–70). The average gap size recorded by MRI was 40.4mm (range 6–110). The average ATRS score was 80 (range 17–100) and the single limb heel raise percentage of contralateral side was 64.8% (range 4–115). The Spearman rank correlation coefficient comparing gap size and ATRS score was 0.272 (p=0.045) and for gap size and strength was 0.158 (p=0.165). Conclusion:. This study shows a weak positive correlation between MRI measured gap size of the ruptured tendo-achilles and the Achilles tendon Total Rupture Score at one year. No correlation could be demonstrated between gap size and strength at one year. These results suggest that the MRI measured gap size is unimportant in predicting outcome and hence suitability for non-operative treatment of tendo-achilles rupture using functional rehabilitation

Introduction:. Instability and synovitis of the lesser metatarsalphalangeal (MTP) joints is a significant cause of forefoot pain. Plantar plate imaging traditionally has been through MRI and fluoroscopic arthrography. We have described ultrasound arthrography as a less resource-intensive technique without radiation exposure. We report the correlation between ultrasound arthographic and surgical findings. Methods:. Patients with lesser MTP joint instability and pain underwent ultrasound arthrography by a consultant musculoskeletal radiologist. The main finding was the presence of a full or partial tear of the plantar plate. In some patients the location of the tear along with its size in the long and short axis was also reported. Authors who were not involved in the imaging or surgery reviewed the operation notes of patients who underwent surgery to identify. Whether a partial or full thickness tear was identified. Size and location of the tear. The accuracy of ultrasound arthrography was calculated using surgical findings as the standard. Results:. 53 patients with 55 joints underwent ultrasound arthrography, and of these 34 went on to have surgery. 23 patients had adequate documentation of surgical and ultrasound findings. Surgery confirmed plantar plate tears in 21 patients (91.3%) with 9 full thickness tears and 7 partial thickness tears confirmed both operatively and with ultrasound (in 5 patients the operation note did not specify completeness of tear). In 2 patients, in whom ultrasound demonstrated a partial thickness tear, no tear was found at surgery. The sensitivity of ultrasound arthrography for plantar plate tears is 100%, specificity is 0% (although based on few patients), and positive predictive value of 91.3%. Conclusion:. Ultrasound arthrography has a high sensitivity, but low specificity for plantar plate tears, comparable with ultrasound in previous studies. It allows differentiation of partial and full thickness tears which may be important for treatment

Introduction. In the evaluation of patients with pre-arthritic hip disorders, making the correct diagnosis and identifying the underlying bone pathology is of upmost importance to achieve optimal patient outcomes. 3-dimensional imaging adds information for proper preoperative planning. CT scans have become the gold standard for this, but with the associated risk of radiation exposure to this generally younger patient cohort. Purpose. To determine if 3D-MR reconstructions of the hip can be used to accurately demonstrate femoral and acetabular morphology in the setting of femoroacetabular impingement (FAI) and development dysplasia of the hip (DDH) that is comparable to CT imaging. Materials and Methods. We performed a retrospective review of 14 consecutive patients with a diagnosis of FAI or DDH that underwent both CT and MRI scans of the same hip with 3D reconstructions. 2 fellowship trained musculoskeletal radiologists reviewed all scans, and a fellowship trained hip preservation surgeon separately reviewed scans for relevant surgical parameters. All were blinded to the patients' clinical history. The 3D reconstructions were evaluated by radiologists for the presence of a CAM lesion and acetabular retroversion, while the hip preservation surgeon also evaluated CAM extent using a clock face convention of a right hip, location of femoral head blood supply, and morphological anterior inferior iliac spine (AIIS) variant. The findings on the 3D CT reconstructions were considered the reference standard. Results. Of 14 patients, there were 9 females and 5 males with a mean age 32 (range 15–42). There was no difference in the ability of MRI to detect the presence of a CAM lesion (100% agreement between 3D-MR and 3D-CT, p=1), AIIS morphology (p=1, mode=type 1 variant), or acetabular retroversion (85.7%, p=0.5). 3D-MR had a sensitivity and specificity of 100 in detecting a CAM lesion relative to 3D-CT. Four CT studies were inadequate to adequately evaluate for presence of a CAM. Five CT studies were inadequate to evaluate for location of the femoral head vessels, while MRI was able to determine location in those patients. In the 10 remaining patients for presence of CAM, and nine patients for femoral head vessel location, there was no statistically significant difference between 3D-MR and 3D-CT in determining the location of CAM lesion on a clock face (p=0.8, mean MRI = 12:54, mean CT: 12:51, SD = 66 mins MR, 81 mins CT) or in determining vessel location (p=0.4, MR mean 11:23, CT mean 11:36, SD 33 mins for both). Conclusion. 3D MRI reconstructions are as accurate as 3D CT reconstructions in evaluating osseous morphology of the hip, and may be superior to CT in determining other certain clinically relevant hip parameters. 3D-MR was equally useful in determining the presence and extent of a CAM lesion, acetabular retroversion, and AIIS morphologic variant, and more useful than 3D CT in determining location of the femoral head vessels. In evaluating FAI or hip dysplasia, a 3D-MR study is sufficient to evaluate both soft tissue and osseous anatomy, sparing the need for a 3D CT scan and its associated radiation exposure and cost

The TruFit® plug is a cylindrical scaffold designed to bridge defects in articular cartilages. It is a porous structure with interconnected pores, which gives it the capability of providing a framework for the ingrowth new tissue and remodelling to articular cartilage and bone. The aim of this study was to assess the radiological incorporation of TruFit® Plugs using MRI. Between December 2007 & August 2009, 22 patients underwent treatment of a chondral or osteochondral lesion using one or more TruFit Plugs. At a minimum of 2 years, 10 patients (12 lesions) were MRI scanned and assessed with a modified MOCART Scoring system by an independent Consultant Musculoskeletal Radiologist. 8 patients were no longer contactable and 4 patients declined MRI as their knee was asymptomatic. 8 of 12 lesions showed congruent articular cartilage cover with a surface of a similar thickness and signal to the surrounding cartilage and reconstitution of the subchondral bone plate. 2 lesions had a thicker congruent articular surface with a similar signal to the surrounding articular cartilage without restoration of the subchondral bone plate. 2 lesions showed no graft incorporation at all and were filled with granulation tissue. Full incorporation of the bony portion of the plug had occurred in only 3 lesions with partial incorporation in 7 lesions. The remaining portion of these 7 lesions looked cystic on MRI. The MRI appearances of the TruFit® Plug at 2 years are encouraging with the majority (83%) showing good restoration of the articular surface with tissue of similar thickness, congruity and signal as the surrounding articular cartilage. However complete incorporation of the TruFit® Plug is rare and cystic change is common. The significance of this cystic change is not clear