The Ottawa Rules were developed in 1992 by Stiell et al. to “assist clinicians in being more selective in their use of radiography” in suspected ankle fractures. They have a sensitivity of almost 100% and should reduce the number of unnecessary radiographs by 30–40%. We aimed to determine the application of the Ottawa Rules in ankle plain radiograph requests in Accident and Emergency (A&E) and determine the number of unnecessary plain radiographs requests. We carried out a retrospective analysis of 366 ankle plain radiographs, request forms and reports, in A&E over 3 months. We implemented a reminder on the electronic requesting system to prompt clinicians to apply the Ottawa rules and analysed a further 226 scans over the next month. Unnecessary scans were calculated by determining the false negatives. i.e. requests did not fulfil Ottawa Rules and scan showed no fracture. Of the 336 original requests, 45% fulfilled the Ottawa Rules and 43% of all scans were unnecessary. Following our intervention, only 42% of requested scans fulfilled the Ottawa rules and 52% were unnecessary. We concluded that Ottawa rules are knowingly not applied in A&E. Reasons may include low cost and ease of scan, patient and clinician reassurance and perceived low risk of scanning. There are a huge number of unnecessary ankle plain radiographs and soft interventions do not impact on this. We have implemented a simplified version of the text reminder and are re-auditing the data

Introduction. The stability of the elbow joint following an acute elbow dislocation is dependent on associated injuries. The ability to identify these concomitant injuries correctly directs management and improves the chances of a successful outcome. Interpretation of plain radiographs in the presence of either a dislocation or post-reduction films with plaster in-situ is difficult. This study aimed to assess the ability of orthopaedic registrars to accurately identify associated bony injuries on initial plain radiographs using CT as the gold standard for comparison. Methods. Patients over the age of 16 years undergoing an elbow CT scan within one week of a documented elbow dislocation between 1st June 2010 and 1st June 2014 were included in the study. Three orthopaedic registrars independently reviewed both the initial dislocation and immediate post reduction plain radiographs to identify any associated bony injuries. This radiograph review was repeated by each registrar after two weeks. The incidence of associated injuries as well as the inter- and intra-observer variability was calculated. Results. 28 patients were included in the study. 54% of the patients were female and the mean age was 45 years (range 16 to 90 years). The incidence of a radial head fracture was 54%, coronoid fracture 43% and epicondyle avulsion 18% on CT. The inter-observer reliability was only shown to be fair amongst registrars and the intra-observer variability moderate. Conclusions. Computerised tomography is a useful adjunct in the assessment of associated osseous injuries following an elbow dislocation due to the presence of a high number of injuries. Plain radiographs alone have been shown to have only a fair and moderate inter and intra-observer variability respectively, therefore a low threshold to obtain further 3D imaging should be practised. Level of Evidence. IV

A painful “dreaded black line” (DBL) has been associated with progression to complete fractures in atypical femur fractures (AFF). Adjacent sclerosis, an unrecognized radiological finding, has been observed in relation to the DBL. We document its incidence, associated features, demographics and clinical progression. We reviewed plain radiographs of 109 incomplete AFFs between November 2006 and June 2021 for the presence of sclerosis adjacent to a DBL. Radiographs were reviewed for location of lesions, and presence of focal endosteal or periosteal thickening. We collected demographical data, type and duration of bisphosphonate therapy, and progression to fracture or need for prophylactic stabilization, with a 100% follow up of 72 months (8 – 184 months). 109 femurs in 86 patients were reviewed. Seventeen sclerotic DBLs were observed in 14 patients (3 bilateral), involving 15.6% of all femora and 29.8% of femora with DBLs. Location was mainly subtrochanteric (41.2%), proximal diaphyseal (35.3%) and mid-diaphyseal (23.5%), and were associated with endosteal or periosteal thickening. All patients were female, mostly Chinese (92.9%), with a mean age of 69 years. 12 patients (85.7%) had a history of alendronate therapy, and the remaining 2 patients had zoledronate and denosumab therapy respectively. Mean duration of bisphosphonate therapy was 62 months. 4 femora (23.5%) progressed to complete fractures that were surgically managed, whilst 6 femora (35.3%) required prophylactic fixation. Peri-lesional sclerosis in DBL is a new radiological finding in AFFs, predominantly found in the proximal half of the femur, at times bilateral, and are always associated with endosteal or periosteal thickening. As a high proportion of patients required surgical intervention, these lesions could suggest non-union of AFFs, similar to the sclerotic margins commonly seen in fractures with non-union. The recognition of and further research into this new feature could shed more light on the pathophysiological progression of AFFs

Applications of weightbearing computed tomography (WBCT) imaging in the foot and ankle have emerged over the past decade. However, the potential diagnostic benefits are scattered across the literature, and a concise overview is currently lacking. Therefore, we aimed to systematically review all reported diagnostic applications per anatomical region in the foot and ankle. A systematic literature search was performed in the electronic databases PubMed, EMBASE, Cochrane Library, and Web of Science. Search terms consisted of “weightbearing/standing CT and ankle, hind-, mid- or forefoot”. English language studies analyzing the diagnostic applications of WBCT were included. Studies were excluded if they simulated weightbearing CT, described normal subjects, included cadaveric samples or samples were case reports. The modified Methodological Index for Non-Randomized Studies (MINORS) was applied for quality assessment. The added value was defined as the review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines and registered in the Prospero database (CRD42019106980). A total of 48 studies (prospective N=8, retrospective N=36, cohort study N=1, diagnostic N=2, prognostic comparative study N=1) were found to be eligible for review. The following diagnostic applications were identified per anatomical area in the foot: ankle (osteoarthritis N=5, ligament injury N=6); hindfoot (deformity N=9); midfoot (Lisfranc injury N=2, flatfoot deformity N=13, osteoarthritis N=1); forefoot (hallux valgus N=12). The identified studies contained diagnostic applications that could not be used on plain radiographs. The mean MINORS equaled 10.1 on a total of 16 (range: 8 to 12). Diagnostic applications of weightbearing CT imaging are most frequently studied in hindfoot deformity, but other area's areas are on the rise. Post-processing of images was identified as the main added value compared to WBRX. However, the findings should be interpreted with caution as the average quality score was moderate. Therefore, future prospective studies are warranted to consolidate the role of WBCT in diagnostic and therapeutic algorithms

Introduction. The evaluation of treatment modalities for distal femur periprosthetic fractures (DFPF) post-total knee arthroplasty (TKA) has predominantly focused on functional and radiological outcomes in existing literature. This study aimed to comprehensively compare the functional and radiological efficacy of locking plate (LP) and retrograde intramedullary nail (IMN) treatments, while incorporating mortality rates. Method. Twenty patients (15 female, 5 male) with a minimum 24-month follow-up period, experiencing Lewis-Rorabeck type-2 DFPF after TKA were included. These patients underwent either LP (n=10) or IMN (n=10). The average follow-up duration was 48 months (range: 24–192). Treatment outcomes, including functional scores, alignment, union time, complications, and mortality rates, were assessed and compared between LP and IMN groups. Clinical examination findings pre-treatment and at final follow-up, along with two-way plain radiographs, were utilized. Statistical analyses comprised Student's t-test and Kaplan-Meier survival analysis with a 95% confidence interval. Result. At final follow-up, the LP group demonstrated a mean Knee Society score of 67.2 ± 16.1, while the IMN group exhibited a score of 72.8 ± 9.4(P = 0.58). No statistically significant differences were observed in alignment between the groups[aLDFA (anatomical lateral distal femoral angle), P = 0.31; aPDFA (anatomical posterior distal femoral angle), P = 0.73]. The mean time to union was 3.7 ± 0.8 months for LP and 3.9 ± 0.6 months for IMN (P = 0.62). Complications such as infection occurred in 1 LP patient, and non-union was observed in 2 LP patients, while no complications were noted in IMN group(P < 0.01). Mortality rates were notably lower in the IMN group compared to the LP group across various time intervals. Conclusion. Both LP and IMN treatments yielded similar functional scores, alignment, and union time for DFPF post-TKA. However, the lower incidence of complications and mortality rates associated with IMN treatment suggest its superiority in managing DFPF following TKA

Background. Recent studies have suggested that full-limb radiographs are more accurate and sensitive than short film radiographs for pre-operative measurement of the anatomical angles required to achieve optimal knee alignment in Total Knee Arthroplasty (TKA). However, there are drawbacks associated with their use including excess radiation to the pelvic organs, the need for specialised radiography equipment and increased cost. Given these drawbacks, we compared the use of MRI scans, a commonly performed pre-operative investigation, with short film knee radiographs for measurement of knee alignment. Objective. To investigate whether knee alignment measurements made on MRI scans correlate with those measured on short film knee radiographs in patients with osteoarthritic knees. Methods. We retrospectively reviewed short film knee radiographs and MRI scans of 50 patients with knee osteoarthritis. The plain radiographs had to be performed whilst weight bearing. The MRI scans were performed supine and non-weight bearing. The exclusion criteria included previous trauma to the knee, previous TKA and previous fracture of the lower limb. 4 angle measurements defined by The American Knee Society: alpha, beta, sigma and gamma were measured using each of the 2 modalities. Kolmogorov-Smirnov and two- tailed paired t-tests were used for statistical analysis of the results. Pearson correlation coefficient was used for the measure of dependence. Results. The alpha, beta, sigma and gamma angles obtained using the MR images were different to those obtained using short film weight bearing knee radiographs by −3°± 1° (p < 0.001), 1° ± 3° (p=0.002), 1° ± 3° (p=0.047) and 1° ± 4° (p=0.113) respectively. There was a weak correlation between the MRI based method and the radiographic method in measuring all 4 angles. Conclusions. Our results have shown that the angular measurements performed on MR images should be interpreted with caution as they may vary depending on the MRI slice selected for evaluation. The differences observed and the weak correlation between the 2 modalities may be due to the different scopes used for determining the femoral or tibial axes. The measurements obtained using the plain radiographs were interpreted using a single 2D projection of a 3D structure. However, the measurements of the MR images were evaluated using a 2D image of a slice through a 3D structure. In conclusion, the use of MRI scans for pre-operative planning in TKA may not be advisable at this stage as the angular measurements obtained using the MR images were poorly correlated to those obtained using plain radiographs

Introduction:. Most of the published papers on AI based diagnosis have focused on the algorithm's diagnostic performance in a ‘binary’ setting (i.e. disease vs no disease). However, no study evaluated the actual value for the clinicians of an AI based approach in diagnostic. Detection of Traumatic thoracolumbar (TL) fractures is challenging on planar radiographs, resulting in significant rates of missed diagnoses (30-60%), thus constituting a field in which a performance improvement is needed. Aim of this study is therefore to evaluate the value provided by AI generated saliency maps (SM), i.e. the maps that highlight the AI identified region of interests. Methods:. An AI model aimed at identifying TL fractures on plain radiographs was trained and tested on 567 single vertebrae images. Three expert spine surgeons established the Ground Truth (GT) using CT and MRI to confirm the presence of the fracture. From the test set, 12 cases (6 with a GT of fracture and 6 with a GT of no fracture, associated with varying levels of algorithm confidence) were selected and the corresponding SMs were generated and shown to 7 independent evaluators with different grade of experience; the evaluators were requested to: (1) identify the presence or absence of a fracture before and after the saliency map was shown; (2) grade, with a score from 1 (low) to 6 (high) the pertinency (correlation between the map and the human diagnosis), and the utility (the perceived utility in confirming or not the initial diagnosis) of the SM. Furthermore, the usefulness of the SM was evaluated through the rate of correct change in diagnosis after the maps had been shown. Finally, the obtained scores were correlated with the algorithm confidence for the specific case. Results:. Of the selected maps, 8 had an agreement between the AI diagnosis and the GT, while in 4 the diagnosis was discordant (67% accuracy). The pertinency of the map was found higher when the AI diagnosis was the same as the GT and the human diagnosis (respectively p-value = .021 and <.000). A positive and significant correlation between the AI confidence score and the perceived utility (Spearman: 27%, p-value=.0-27) was found. Furthermore, evaluator with experience < 5 year found the maps more useful than the experts (z-score=2.004; p-value=.0455). Among the 84 evaluation we found 12 diagnostic errors in respect to the GT, 6 (50%) of which were reverted after the saliency map evaluation (z statistic = 1.25 and p-value = .21). Discussion:. The perceived utility of AI generated SM correlate with the model confidence in the diagnosis. This highlights the fact that to be considered helpful, the AI must provide not only the diagnosis but also the case specific confidence. Furthermore, the perceived utility was higher among less experienced users, but overall, the SM were useful in improving the human diagnostic accuracy. Therefore, in this setting, the AI enhanced approach provides value in improving the human performance

Introduction and Objective. In recent years, along with the extending longevity of patients and the increase in their functional demands, the number of annually performed RSA and the incidence of complications are also increasing. When a complication occurs, the patient often needs multiple surgeries to restore the function of the upper limb. Revision implants are directly responsible for the critical reduction of the bone stock, especially in the shoulder. The purpose of this paper is to report the use of allograft bone to restore the bone stock of the glenoid in the treatment of an aseptic glenoid component loosening after a reverse shoulder arthroplasty (RSA). Materials and Methods. An 86-years-old man came to our attention for aseptic glenoid component loosening after RSA. Plain radiographs showed a complete dislocation of the glenoid component with 2 broken screws in the neck of glenoid. CT scans confirmed the severe reduction of the glenoid bone stock and critical bone resorption and were used for the preoperative planning. To our opinion, given the critical bone defect, the only viable option was revision surgery with restoration of bone stock. We planned to use a bone graft harvested from distal bone bank femur as component augmentation. During the revision procedure the baseplate with a long central peg was implanted “on table” on the allograft and an appropriate osteotomy was made to customize the allograft on the glenoid defect according to the CT-based preoperative planning. The Bio-component was implanted with stable screws fixation on residual scapula. We decided not to replace the humeral component since it was stable and showed no signs of mobilization. Results. The new bio-implant was stable, and the patient gained a complete functional recovery of the shoulder. The scheduled radiological assessments up to 12 months showed no signs of bone resorption or mobilization of the glenoid component. Conclusions. The use of bone allograft in revision surgery after a RSA is a versatile and effective technique to treat severe glenoid bone loss and to improve the global stability of the implant. Furthermore, it represents a viable alternative to autologous graft since it requires shorter operative times and reduces graft site complications. There are very few data available regarding the use of allografts and, although the first studies are encouraging, further investigation is needed to determine the biological capabilities of the transplant and its validity in complex revisions after RSA

Summary Statement. Pincer deformities are involved in the genesis of femoro-acetabular impingement (FAI). Radiographic patterns suggestive of pincer deformities are common among general population. Prevalence of the pincer deformities among general population may be overestimated if only plain radiographs are considered. Background. Pincer deformities (coxa profunda, protrusio acetabuli, global retroversion, isolated cranial over-coverage) have been advocated as a cause of femoro-acetabular impingement (FAI) and early hip osteoarthritis (OA). Different radiographic patterns may advocate the presence of a pincer deformity. The prevalence of these radiographic patterns among general adult population, as their role in early hip OA, is poorly defined. Methods. From a database of 40.351 pelvic radiograms and CT collected at our institution between 2005 and 2010, we selected 118 caucasian individuals (56 females, 62 males), aged between 15 and 60 years, who underwent both plain radiographs and CT of the pelvis. A series of exclusion criteria were strictly applied to achieve a sample of adult general population as more representative as possible. In particular patients with presence of any disease involving hip joint, including: advanced hip OA (grade II or III of Tonnis scale), head necrosis, fractures, heterotopic ossifications, bone and soft tissue tumors, rheumatic pathologies, classic hip dysplasia with lateral center-edge angle (L-CEA) less than 20°, clinical diagnosis of FAI or hip pain, were excluded from the present study. We also excluded patients in which open growth plates, osteopenia, hardware or evidence of prior surgery were present. Radiographs were investigated for pelvic tilt, signs of retroversion, lateral center-edge angle (L-CEA), presence of coxa profunda or protrusio acetabuli. EAV was measured on CT scans at the equatorial plane of the acetabulum passing by the 3 o'clock position, while CAV was calculated at a more cranial level corresponding to the 1 o'clock position EAV and CAV were obtained in the axial plane by measuring the angle made by a line connecting the anterior and posterior rims of the acetabulum and a line perpendicular to the line connecting the ischial spines. A new parameter, Acetabular torsion (AT), has been introduced in order to discriminate between global retroversion and isolated cranial over-coverage. AT was defined as the difference between EAV and CAV. Cam deformity was assessed by calculating the alpha angle on the femoral side; an alpha angle > 55° was considered abnormal and suggestive of cam deformity. Radiological signs of chondrolabral degeneration were noticed. Results. Mean EAV and mean CAV were higher in females, mean AA was higher in males. L-CEA, EAV and CAV increased with age. Mean AT was 8.8±6.3. AT was inversely related to CAV (r=−0.799; p<0.0005) but independent from EAV (r=−0.076; p=0.244). EAV≤10.2° was defined as the marker of global retroversion, while AT≥21.2° was defined as the marker of isolated cranial over-coverage. Overall prevalence of pincer deformities was 21.6% (> females; p=0.02). Early OA changes were related to age (p<0.0005) and AA (p<0.0005), but not to pincer deformities (p=0.96). Radiological signs of retroversion showed good or excellent negative predictability but poor positive predictability. Conclusions. Radiographic patterns of pincer deformities are common among general population. Relationship with radiological signs of chondrolabral degeneration is poor. CT allows to discriminate between global retroversion and isolated cranial over-coverage. Prevalence of the pincer deformities among general population may be overestimated if only plain radiographs are considered

Abstract. Objective. To assess the prevalence of acetabular retroversion in patients presenting with Slipped Upper Femoral Epiphysis using both validated radiological signs and CT-angle measurements. Methods. A retrospective review of all cases involving surgical management for acute SUFE presenting to the Royal Children's Hospital, Melbourne were assessed from 2012–2018. Pre-operative plain radiographs were assessed for slip angle, validated radiological signs of retroversion (post wall/crossover/ischial spine sign) and standardised post-operative CT Scans were used to assess cranial and mid-acetabular version. Results. 116 SUFEs presented in 107 patients who underwent surgical intervention; 47 females and 60 boys, with an average age of 12.7 years (range 7.5–16.6 years). Complete radiological data was available for 91 patients (99 hips) with adequate axial CT imaging of both hips. 82% patients underwent pinning in situ (PIS) with subcapital realignment surgery (SRS) performed in 18% (slip angles >75°). Contralateral prophylactic hip PIS was performed in 72 patients (87%). On the slip side, 68% of patients had 1 or more radiological signs of retroversion in the slipped hip, with 60% on the contralateral side. The mean cranial and mid-acetabular version measurements were −8°(range −30 – 8°) and 10.5°(range −10 – 25°), respectively. Conclusions. Acetabular retroversion is rare in the normal population with studies reports ranging from 0–7%. This study showed an increased prevalence of 68% in SUFE patients, which is likely to be a primary anatomical abnormality, subsequently increasing the shear forces across the proximal femoral growth plate due to superior over-coverage. The resulting CAM lesion from SUFE in combination with the pincer lesion due to retroversion can lead to premature hip impingement and degeneration. Further larger studies are required to assess if acetabular retroversion is a true risk factor, and its role in helping guide management including prophylactic pinning. Declaration of Interest. (b) declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research reported:I declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research project

Syndesmotic ankle injuries are present in one fourth of all ankle trauma and may lead to chronic syndesmotic instability as well as posttraumatic ankle osteoarthritis. The main challenge remains distinguishing them from other types of ankle trauma. Currently, the patient's injured and non-injured ankles are compared using plain radiographs to determine pathology. However, these try to quantify 3D displacement using 2D measurements techniques and it is unknown to what extent the 3D configuration of the normal ankle syndesmosis is symmetrical. We aimed to assess the 3D symmetry of the normal ankle syndesmosis between the right and left side in a non- and weightbearing CT. In this retrospective comparative cohort study, patients with a bilateral non-weightbearing CT (NWBCT; N=28; Mean age=44, SD=17.4) and weight-bearing CT (WBCT; N=33; Mean age=48 years; SD=16.3) were analyzed. Consecutive patients were included between January 2016 and December 2018 when having a bilateral non-weightbearing or weightbearing CT of the foot and ankle. Exclusion criteria were the presence of hindfoot pathology and age less than 18 years or greather than 75 years. CT images were segmented to obtain 3D models. Computer Aided Design (CAD) operations were used to fit the left ankle on top of the right ankle. The outermost point of the apex of the lateral malleolus (AML), anterior tubercle (ATF) and posterior tubercle (PTF) were computed. The difference in the coordinates attached to these anatomical landmarks of the left distal fibula in the ankle syndesmosis with respect to right were used to quantify symmetry. A Cartesian coordinate system was defined based on the tibia to obtain the direction of differences in all six degrees of freedom. Statistical analysis was performed using the Mann-Whitney U test to allow comparison between measurements from a NWBCT and WBCT. Reference values were determined for each 3D measurement in a NWBCT and WBCT based on their 2SD. The highest difference in translation could be detected in the anterior-posterior direction (Mean AP. NWBCT. = −0.01mm; 2SD=3.43/Mean AP. WBCT. =−0.1mm; 2SD=2.3) and amongst rotations in the external direction (Mean AP. NWBCT. =−0.3°; 2SD=6.7/Mean AP. WBCT. =-0,2°; 2SD=5.2). None of these differences were statistically significant in the normal ankle syndesmosis when obtained from a NWBCT compared to a WBCT (P>0.05). This study provides references values concerning the 3D symmetry of the normal ankle syndesmosis in weightbearing and non-weightbearing CT-scans. These novel data contribute relevantly to previous 2D radiographic quantifications. In clinical practice they will aid in distinguishing if a patient with a syndesmotic ankle lesion differs from normal variance in syndesmotic ankle symmetry

Summary Statement. The circle theorem is a simple and effective measurement tool for estimating acetabular version after total hip arthroplasty. Introduction. Position of the acetabular cup is a major factor in the range of motion and risk of dislocation after total hip arthroplasty. However, there is no well established technique for accurately and easily estimating acetabular cup version intraoperatively or postoperatively. The objective of this study was to evaluate a recently proposed method for measuring acetabular cup version on a single plain radiograph of the hip, which is based on one of the circle theorems in basic geometry. Patients & Methods. Radiographic version is defined as the angle between the cup face plane and a plane perpendicular to the body coronal plane. Using this definition, a metal hemispheric cup was placed in a pelvic sawbone model at a series of known angles of radiographic version (based on direct goniometer measurement). Cup inclination, pelvic tilt, and pelvic rotation were held constant for all version angles. A single antero-posterior hip radiograph was then obtained and reviewed for each version angle. The acetabular cup version was next estimated by using a compass and protractor in accordance with the circle theorem. Statistical analysis was performed utilizing Student's t-test with an alpha=0.05. Results. 20 known angles of version were evaluated: 11 anteverted angles, 7 retroverted angles, and 2 neutral angles. Mean difference between the circle theorem estimate and the true version was 0.90 degrees (range −2 to 3). There was no statistically significant difference between the circle theorem's estimates and the true version (p=0.84). Similarly, there was no significant difference between the anteverted estimates (mean difference 0.91) and the retroverted estimates (mean difference 0.86)(p=0.95). Discussion/Conclusion. Methods of measuring component position are essential for evaluating surgical technique, monitoring cup stability, and maximizing patient outcomes. Radiographic version of an acetabular cup can be estimated by using the circle theorem. This theorem can provide a quick, easy, and accurate estimate of version with the use of simple instruments (compass and protractor) and readily available plain radiographs

One-fourth of all ankle trauma involve injury to the syndesmotic ankle complex, which may lead to syndesmotic instability and/or posttraumatic ankle osteoarthritis in the long term if left untreated. The diagnosis of these injuries still poses a deceitful challenge, as MRI scans lack physiologic weightbearing and plain weightbearing radiographs are subject to beam rotation and lack 3D information. Weightbearing cone-beam CT (WBCT) overcomes these challenges by imaging both ankles during bipedal stance, but ongoingdebate remains whether these should be taken under weightbearing conditions and/or during application of external rotation stress. The aim of this study is study therefore to compare both conditions in the assessment of syndesmotic ankle injuries using WBCT imaging combined with 3D measurement techniques. In this retrospective study, 21 patients with an acute ankle injury were analyzed using a WBCT. Patients with confirmed syndesmotic ligament injury on MRI were included, while fracture associated syndesmotic injuries were excluded. WBCT imaging was performed in weightbearing and combined weightbearing-external rotation. In the latter, the patient was asked to internally rotate the shin until pain (VAS>8/10) or a maximal range of motion was encountered. 3D models were developed from the CT slices, whereafter. The following 3D measurements were calculated using a custom-made Matlab® script; Anterior tibiofibular distance (AFTD), Alpha angle, posterior Tibiofibular distance (PFTD) and Talar rotation (TR) in comparison to the contralateral non-injured ankle. The difference in neutral-stressed Alpha angle and AFTD were significant between patients with a syndesmotic ankle lesion and contralateral control (P=0.046 and P=0.039, respectively). There was no significant difference in neutral-stressed PFTD and TR angle. Combined weightbearing-external rotation during CT scanning revealed an increased AFTD in patients with syndesmotic ligament injuries. Based on this study, application of external rotation during WBCT scans could enhance the diagnostic accuracy of subtle syndesmotic instability

The Medial Patellofemoral Ligament (MPFL) is the main restraining force against lateral patellar displacement. It is often disrupted following patellar subluxation or dislocation. MPFL reconstruction is frequently performed when conservative management fails and the patient experiences recurrent patellar dislocation. Various MPFL reconstruction procedures have been described in the literature and reported outcomes are encouraging. This study analyses the radiographic outcomes following MPFL reconstruction. From January 2006 to January 2011, 76 consecutive patients (80 knees) with patellar recurrent dislocation underwent medial patellofemoral ligament reconstruction in three large teaching hospitals. Mean follow-up was 31.8 months (range, 13–72). Semitendinosus and gracilis autografts were used for the reconstruction and all procedures were carried out by the senior authors (WL, BR, CW, MB). Plain radiographs (Anteroposterior (AP), Lateral and Skyline) performed preoperatively and postoperatively were used to compare the sulcus angle, congruence angle, lateral patellofemoral angle, trochlear dysplasia (Dejour classification), trochlear boss height and patellar height (Caton-Deschamps ratio). Plain radiographs (Lateral) performed postoperatively were used to evaluate the femoral tunnel placement used for MPFL reconstruction. The sulcus angle improved from 143.2° (122.9–157.7) to 139.3° (115.7–154.6) and the congruence angle improved from 26.7° (−17.5–82.6) to 0.26° (−35.3–7.8). The lateral patellofemoral angle was 7.99° (3.2–19.2) preoperatively and 9.02° (3.2–18.2) postoperatively. The Caton-Deschamps ratio was 1.2 (1.0–1.5) preoperatively and 1.0 (0.8–1.1) postoperatively. Using the Dejour classification of trochlear dysplasia, all preoperative radiographs were considered to be grade C or D and all postoperative radiographs were considered to be grade A or B. Trochlear boss height was 5.9mm (1.8–11.6) preoperatively and 4.7mm (1.6–6.9) postoperatively. 59% of the femoral tunnels were considered to be in a good position on postoperative radiographs. This study displayed a significant improvement in postoperative radiographic parameters, demonstrating the importance of anatomic restoration when performing MPFL reconstruction

Summary. Application of RSA in supine and standing positions allows pelvic fracture stability to be measured more accurately than current techniques. RSA may enable a better understanding of these injuries. Introduction. The in vivo stability of the pelvic ring after fracture stabilisation remains unknown. Plain radiographs have a low accuracy in diagnosing loss of fracture reduction over time. Radiostereometric analysis (RSA) is an accurate imaging measurement method that has previously been applied to measure the healing of other fractures. This pilot study investigated the potential application of RSA in supine and standing positions to measure pelvic fracture stability over time and under weightbearing load. Methods. Five patients with a similar type C pelvic ring disruption who were all operated on using the same surgical technique and had RSA markers inserted at the time of surgery. All five patients had a unilateral comminuted sacral fracture lateral to the sacral foramina treated with posterior plating and pubic rami fractures stabilised by external fixation for six weeks. All patients were mobilised partial weight bearing after regaining leg control. RSA examinations at 2, 4, 12, 26 and 52 weeks included three radiographic pairs taken in supine, standing and supine positions at each time point. Two additional RSA examinations were performed the day prior and post pin removal at 6 weeks. Results. All patients ambulated before the 2 week follow-up and progressed uneventfully. At latest follow-up, there were no complications. Minimal displacements (translations less than 0.3mm and rotations less than 0.5°) were recorded between the supine exams pre and post standing at 2 weeks. Hence, the supine examination was found to be a reliable position to measure the migration of the ilium over time. No loss of reduction was identifiable on plain radiographs over time. At 52 weeks, in contrast to plain radiographic results, RSA measurements revealed that one patient had a fracture migration greater than 4mm. Such large displacements could result in sacral nerve root transection, leading to devastating consequences, such as incontinence, for patients whose sacral fractures are through or medial to the sacral foramina. In one patient, the migration recorded for the apparent uninjured posterior complex side exceeded the migration of the injured side suggesting an unrecognised bilateral injury. Comparative RSA examinations pre and post external fixator removal demonstrated that in three patients the injured hemipelvis migrated greater than 2mm after the removal of the external fixator, which may be indicative that the fixator was removed prematurely. Discussion and Conclusion. The application of RSA allows accurate measurement of pelvic fracture stability which is difficult, if not impossible, to identify and quantify with any other imaging techniques. Hence, RSA has the capacity to enable a better understanding of pelvic ring injuries and optimise their treatment

Introduction. In osteonecrosis of the femoral head (ONFH), progression of collapse is influenced by a repair reaction, especially bone resorptive activity, around the necrotic bone. Alendronate is a potent inhibitor of bone resorption by inhibiting osteoclast activity. We performed a clinical study to test if systemic alendronate treatment would prevent the development of collapse in patients with ONFH. Methods. Thirty-three hips in 22 ONFH patients with initial ARCO Stage 1 to 3 were included. Fourteen patients (20 hips) received daily administration of oral alendronate 5mg/day (alendronate group) and 8 patients (13 hips) did not receive alendronate administration (Control group). Baseline investigations included anteroposterior and lateral plain radiographs, T1-weighted magnetic resonance imaging (MRI), and biochemical markers (urinary NTX and serum BAP). Examination of the biochemical markers were repeated at 3, 6, and 12 months, and MRI imaging was repeated at 12 months. At 3 years, clinical symptoms and findings on plain radiographs were compared between the 2 groups. Advancement of ARCO stages or increase of collapse by more than 2 mm were considered as development of collapse. Results. At baseline, there were no significant differences regarding patients' age, distribution of gender, etiology, ARCO radiographic stage, and extent of necrosis between the 2 groups. In the alendronate group, there was an early decrease of osteoclast activity (NTX) and osteoblastic activity (BAP) at 3 months, with significantly larger decrease in NTX (43%) than BAP (21%) at 12 months. At 3 years, development of collapse was observed in 7 hips (54%) of the Control group, and in 3 hips (15%) of the alendronate group. Hip pain was noted in 9 hips (69%) of the Control group, and in 6 hips (30%) of the alendronate group. There was a significant difference oncollapse development and occurrence of hip pain between the two groups (p<0.05). Signal change around the necrotic region on serial MRI images during the first 1 year was observed in 54 % of the Control group, and only 11% of the alendronate group. Conclusion. Alendronate therapy decreased biochemical markers, especially osteoclast activity, after an early period from start of administration. Several clinical studies have shown promising short-term results for prevention of collapse in ONFH by administration of bisphosphonates. The present study showed a significant preventing effect of collapse development by administration of alendronate which was maintained for 3 years of treatment. Low incidence of signal change on serial MRI images may also reflect decrease of repair activity in the alendronate group. Further studies with longer follow-up, larger numbers of patients, and randomized administration of the drug among patients are required., However, alendronate administration may become one of the effective conservative treatments which might obviate the need for osteotomy or replacement surgery in some populations of ONFH patients

Hindfoot disorders are complex 3D deformities. Current literature has assessed their influence on the full leg alignment, but the superposition of the hindfoot on plain radiographs resulted in different measurement errors. Therefore, the aim of this study is to assess the hindfoot alignment on Weight-Bearing CT (WBCT) and its influence on the radiographic Hip-Knee-Ankle (HKA) angle. A retrospective analysis was performed on a study population of 109 patients (mean age of 53 years ± 14,49) with a varus or valgus hindfoot deformity. The hindfoot angle (HA) was measured on the WBCT while the HKA angle, and the anatomical tibia axis angle towards the vertical (TA. X. ) were analysed on the Full Leg radiographs. The mean HA in the valgus hindfoot group was 9,19°±7.94, in the varus hindfoot group −7,29°±6.09. The mean TA. X. was 3,32°±2.17 in the group with a valgus hindfoot and 1,89°±2.63 in the group with a varus hindfoot, which showed to be statistically different (p<0.05). The mean HKA Angle was −1,35°±2.73 in the valgus hindfoot group and 0,4°±2.89 in the varus hindfoot group, which showed to be statistically different (p<0.05). This study demonstrates a higher varus in both the HKA and TA. X. in valgus hindfoot and a higher tibia valgus in varus hindfoot. This contradicts the previous assumption that a varus hindfoot is associated with a varus knee or vice versa. In clinical practice, these findings contribute to a better understanding of deformity corrections of both the hindfoot and the knee

Medial open-wedge high tibial osteotomy has been gaining popularity in recent years, but adequate supporting material is required in the osteotomy gap for early weight-bearing and rapid union. The purpose of this study was to investigate whether the implantation of a polycaprolactone-tricalcium phosphate composite scaffold wedge would enhance healing of the osteotomy in a micro pig model. We carried out open-wedge high tibial osteotomies in 12 micro pigs aged from 12 to 16 months. A scaffold wedge was inserted into six of the osteotomies while the other six were left open. Bone healing was evaluated after three and six months using plain radiographs, CT scans, measurement of the bone mineral density and histological examination. Complete bone union was obtained at six months in both groups. There was no collapse at the osteotomy site, loss of correction or failure of fixation in either group. Staining with haematoxylin and eosin demonstrated that there was infiltration of new bone tissue into the macropores and along the periphery of the implanted scaffold in the scaffold group. The CT scans and measurement of the bone mineral density showed that at six months specimens in the scaffold group had a higher bone mineral density than in the control group, although the implantation of the polycaprolactone-tricalcium phosphate composite scaffold wedge did not enhance healing of the osteotomy

Abstract. Objectives. Knee alignment affects both the development and surgical treatment of knee osteoarthritis. Automating femorotibial angle (FTA) and hip-knee-ankle angle (HKA) measurement from radiographs could improve reliability and save time. Further, if the gold-standard HKA from full-limb radiographs could be accurately predicted from knee-only radiographs then the need for more expensive equipment and radiation exposure could be reduced. The aim of this research is to assess if deep learning methods can predict FTA and HKA angle from posteroanterior (PA) knee radiographs. Methods. Convolutional neural networks with densely connected final layers were trained to analyse PA knee radiographs from the Osteoarthritis Initiative (OAI) database with corresponding angle measurements. The FTA dataset with 6149 radiographs and HKA dataset with 2351 radiographs were split into training, validation and test datasets in a 70:15:15 ratio. Separate models were learnt for the prediction of FTA and HKA, which were trained using mean squared error as a loss function. Heat maps were used to identify the anatomical features within each image that most contributed to the predicted angles. Results. FTA could be predicted with errors less than 3° for 99.8% of images, and less than 1° for 89.5%. HKA prediction was less accurate than FTA but still high: 95.7% within 3°, and 68.0 % within 1°. Heat maps for both models were generally concentrated on the knee anatomy and could prove a valuable tool for assessing prediction reliability in clinical application. Conclusions. Deep learning techniques could enable fast, reliable and accurate predictions of both FTA and HKA from plain knee radiographs. This could lead to cost savings for healthcare providers and reduced radiation exposure for patients

Background. We herein report a case of isolated hip pain in a four year old boy. The unique aspect of this case study is the unusual history, presentation, ultrasonography, MRI and blood culture results, which lead to the diagnosis and treatment of adductor pyomyositis with a rare organism (Streptococcus Mitis) in a temperate country. The objectives of this case study is to discuss the key learning outcomes with respect to assessment and management of this case. Methods. The patient presented with a one day history of malaise, fever, left groin pain and inability to weight bear on the left leg. There was no history of any trauma, predisposing infections or recent travel. A working diagnosis of transient synovitis / septic arthritis of the hip was made on clinical examination. Results. Plain radiograph and ultrasound of the hip was normal with no effusion. Two consecutive blood cultures suggested Streptococcus Mitis bacteriaemia and MRI scan confirmed pyomyositis of the left hip adductors that was too small to drain. Streptococcus Mitis is a normal commensal organism of the oral cavity however it can lead to opportunistic infections particularly endocarditis. Echocardiogram revealed no cardiac complications, in particular no endocarditic vegetation. Patient was treated with intravenous benzylpenicillin for a week followed by oral phenoxymethylpenicillin for a week. Conclusion. Adductor pyomyositis must be considered as a differential diagnosis in a child with unusual presentation of hip pain. When an ultrasound is normal, MRI scan is warranted to confirm diagnosis. Septic screen should include blood cultures. The commonest causative organisms are the Staphylococcus family. However if Streptococcus Mitis is isolated, cardiac sources of infection resulting in septic emboli must be investigated. Repeated MRI scans are required particularly if the patient does not respond to medical management. Level of Evidence. IV