Abstract. Objective. A common orthopaedic pain found in a wide spectrum of individuals, from young and active to the elderly is anterior knee pain (AKP). It is a multifactorial disorder which is thought to occur through muscular imbalance, overuse, trauma, and structural malalignment. Over time, this can result in cartilage damage and subsequent chondral lesions. Whilst the current gold standard for chondral lesion detection is MRI, it is not a highly sensitive tool, with around 20% of lesions thought to be mis-diagnosed by MRI. Single-photon emission computerised tomography with conventional computer tomography (SPECT/CT) is an emerging technology, which may hold clinical value for the detection of chondral lesions. SPECT/CT may provide valuable diagnostic information for AKP patients who demonstrate absence of structural change on other imaging modalities. This review systematically assessed the value of SPECT/CT as an imaging modality for knee pain, and its ability to diagnose chondral lesions for patients who present with knee pain. Methods. Using PRISMA guidelines, a systematic search was carried out in PubMed, Science Direct, and Web of Knowledge, CINAHL, AMED, Ovid Emcare and Embase. Inclusion criteria consisted of any English language article focusing on the diagnostic value of SPECT/CT for knee chondral lesions and knee pain. Furthermore, animal or cadaver studies, comparator technique other than SPECT/CT or patients with a pathology other than knee chondral lesions were excluded from the study. Relevant articles underwent QUADAS-2 bias assessment. Results. 11,982 manuscripts were identified, and the titles were screened for relevance. Seven studies were selected as being appropriate and were subjected to QUADAS-2 assessment. All 7 articles scored low for bias. Two papers deemed that the ICRS score of chondral lesions at intraoperative assessment correlated with SPECT/CT tracer uptake. Two studies concluded that MRI significantly correlated with SPECT/CT tracer uptake, with some instances whereby SPECT/CT identified more chondral lesions than MRI. Two papers compared bone scintigraphy (BS) to SPECT/CT and concluded that SPECT/CT was not only able to identify more chondral lesions than BS, but also localise and characterise the lesions. Conclusion. Evidence implies that SPECT/CT may be a useful imaging modality for the detection and localisation of cartilage lesions, particularly in discrepant cases whereby there is an absence of lesions on other imaging modalities, or a lack of correspondence with patients’ symptoms. More studies would be of value to confirm the conclusions of this review. 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

To report the case of an asymptomatic simultaneous bilateral neck of femur fracture following vitamin D deficiency which was missed, misdiagnosed and treated for coexisting severe bilateral osteoarthritis knee. A male aged 62 years presented with severe osteoarthritis of both knee joints confining him to bed about eight weeks prior to presentation. The patient did not have any complaints pertaining to his hip joints/axial skeleton. Examination of the hip joints revealed only crepitus with absence of straight leg rising. Radiological survey showed bilateral displaced fracture neck of femur. He had elevated serum alkaline phosphatase; 119IU/L(N:39–117IU/L), decreased Serum 25 (OH) Vit D level;6.03ng/ml(N:7.6–75ng/ml), decreased spot urinary calcium;78mg/day(N:100–300mg/day) with normal serum calcium, phosphorus and highly raised parathormone levels;142.51pg/ml(N:12–72pg/ml). Tc-99 Bone scan showed increased radiotracer uptake in both the hip joints and knee joints. Bone Mineral Density was in favour of osteoporosis. Biopsy fromthe heads of both femurs also revealed osteoporosis. Bilateral staged total hip arthroplasty was done and he was put on Vitamin D replacement therapy. Patient was on regular monthly follow-up for intial one year and three monthly follow-up thereafter. At present with three year follow-up patient is community ambulant with a walking frame. Despite medical advice patient had denied total knee arthroplasty for osteoarthritis of his knee joints. Asymptomatic simultaneous bilateral neck of femur fracture is a rare injury and poses a diagnostic challenge to the treating orthopaedic surgeon with its bizarre clinical picture. Similar presentation of metabolic bone disease can be easily missed without a proper screening, keeping in mind a high index of suspicion for the above disorders. Besides proper clinical examination of both hip and knee joint should be performed in patients presenting with bilateral knee pain. A good functional outcome may be achieved with prompt surgical intervention and medical treatment

Fragility fractures are an increasing cause of morbidity and mortality in the elderly population. Their association with reduced bone mineral density (BMD) is well documented. It is a reasonable assumption that hip fracture severity is linked to the magnitude of bone loss, (the lower the BMD, the more severe the fracture), however it is not known whether this correlation exists. Our aim therefore was to investigate the relationship between BMD and hip fracture severity. We reviewed 142 patients, 96 females and 46 males, mean age 74 years (49-92), who had sustained a hip fracture following a simple ground level fall. All had subsequently undergone DEXA bone scanning of the contralateral hip and lumbar spine. Fractures were classified as intra-capsular, extra-capsular or subtrochanteric, then sub-classified using the Garden, Jensen and Seinsheimer classifications respectively. They were grouped into simple (stable) or comminuted (unstable) fracture patterns. Risk factors for osteoporosis were recorded. A low hip BMD (<2.5) was associated with an increased risk of extra-capsular fracture (p=0.025). However, no association with fracture type (extra vs. intra-capsular, p>0.05) was identified with the following variables; age, gender, BMI <25, smoking, and excess alcohol intake. We did not find any statistically significant associations between fracture severity and the nine principle variables tested for: age; gender; smoking; BMI < 25; alcohol excess and low hip or lumbar BMD T or Z score <-2.5. Although the association between BMD and risk of fragility fractures is well documented, the results of this study would suggest that severity of hip fractures does not follow this correlation. Therefore, no assumption can be made about BMD of the proximal femur based on the severity of fracture observed on plain radiographs alone

Osteoid osteoma is a classically described benign bone tumour. Traditionally, the surgical treatment of choice was excision, but this can have significant morbidity. In recent years, percutaneous Radiofrequency Ablation (RFA) has grown in popularity as an alternative treatment. This study reports the outcomes using this technique in our regional bone tumour unit. Between May 2003 and October 2007, 14 patients (female, n=4; male, n = 10) aged 15 - 32yrs (mean age, 20.4yrs) underwent CT guided radiofrequency ablation treatment. These patients had typical radiograph, CT, MRI or isotope bone scan features of osteoid osteoma and had significant pain symptoms. The protocol for ablation in our institute is heating the tip of the electrode to 90°C for 6 minutes. All patients were subsequently offered follow up in the out-patient clinic. Outcomes were taken from the Scottish Bone Tumour Registry database. 11 patients (78.6%) patients had complete resolution of symptoms after one RF treatment. 3 (21.4%) cases were unsuccessful but 1 of these was due to technical failure. All 3 of the above patients had complete relief of symptoms after one further RF treatment. 1 (7.1%) patient initially had complete relief of symptoms, but suffered a recurrence after 9 months. This patient also had a second curative treatment. Follow up ranged from 3 – 18 months (mean 10 months). Percutaneous RFA for osteoid osteoma is an attractive treatment due to its efficacy and low morbidity. Our results showed a primary success rate of 78%, a secondary success rate of 100% (after one additional procedure) and a recurrence rate of 7.1%. These are comparable to previous reported series. We believe our results add to the growing literature supporting radiofrequency ablation as the treatment of choice for osteoid osteoma

Discitis in childhood is rare. It can be difficult to diagnose, particularly in the younger child, often leading to a delay in initiation of appropriate treatment. It is not known whether it represents an infective or an inflammatory process. Our aim was to review all cases treated at a regional children's hospital since the introduction of the departmental database. A retrospective review (64,058 cases), for the period 1990-2008 was performed. 12 cases were identified (3 male/9 female), with a biphasic age distribution; eight [mean 22 months old (12-32)] and four [mean 12 years old (11-13)]. Mean time to diagnosis from onset was 22 days, (5-49). Symptoms varied with age, no one less than 28 months complained of back pain, while all over 28 months did, to a varying degree. All the younger children presented primarily with a gait abnormality. 92% (11/12) were apyrexial on admission. WBC and CRP were normal in 83% (10/12). Venous blood cultures were negative in 89% (8/9). Only ESR was mildly raised, mean 30 (10-65). Radiographs showed loss of intervertebral disc height in 91% (10/11), earliest by 10 days following onset symptoms, mean 28 days. A technetium bone scan was performed in 42% (5/12) and an MRI of the lumbar spine, in 58% (7/12). All were positive for discitis. All occurred in the lumbar spine, 50% at L3/4. Antibiotics were used in 11/12 (92%), flucloxacillin alone in the majority 9/11. One had non-steroidal medication alone. No form of brace was used. Mean follow-up was 13.3 months (2-36). In all, symptoms had resolved by mean 6.5 weeks (2-12). No recurrence was noted. The common features of childhood discitis are presented; knowledge of these may aid the physician to come to a more rapid diagnosis of this uncommon paediatric condition

There is little information about the effects of extracorporeal shock-wave about application the effects (ESWA) of on normal bone physiology. We have therefore investigated the effects of ESWA on intact distal rabbit femora in vivo. The animals received 1500 shock-wave pulses each of different energy flux densities (EFD) on either the left or right femur or remained untreated. The effects were studied by bone scintigraphy, MRI and histopathological examination. Ten days after ESWA (0.5 mJ/mm. 2. and 0.9 mJ/mm. 2. EFD), local blood flow and bone metabolism were decreased, but were increased 28 days after ESWA (0.9 mJ/mm. 2. ). One day after ESWA with 0.9 mJ/mm. 2. EFD but not with 0.5 mJ/mm. 2. , there were signs of soft-tissue oedema, epiperiosteal fluid and bone-marrow oedema on MRI. In addition, deposits of haemosiderin were found epiperiosteally and within the marrow cavity ten days after ESWA. We conclude that ESWA with both 0.5 mJ/mm. 2. and 0.9 mJ/mm. 2. EFD affected the normal bone physiology in the distal rabbit femur. Considerable damaging side-effects were observed with 0.9 mJ/mm. 2. EFD on periosteal soft tissue and tissue within the bone-marrow cavity

The treatment of chronic osteomyelitis often includes surgical debridement and filling the resultant void with antibiotic-loaded polymethylmethacrylate cement, bone grafts or bone substitutes. Recently, the use of bioactive glass to treat bone defects in infections has been reported in a limited series of patients. However, no direct comparison between this biomaterial and antibiotic-loaded bone substitute has been performed.

In this retrospective study, we compared the safety and efficacy of surgical debridement and local application of the bioactive glass S53P4 in a series of 27 patients affected by chronic osteomyelitis of the long bones (Group A) with two other series, treated respectively with an antibiotic-loaded hydroxyapatite and calcium sulphate compound (Group B; n = 27) or a mixture of tricalcium phosphate and an antibiotic-loaded demineralised bone matrix (Group C; n = 22). Systemic antibiotics were also used in all groups.

After comparable periods of follow-up, the control of infection was similar in the three groups. In particular, 25 out of 27 (92.6%) patients of Group A, 24 out of 27 (88.9%) in Group B and 19 out of 22 (86.3%) in Group C showed no infection recurrence at means of 21.8 (12 to 36), 22.1 (12 to 36) and 21.5 (12 to 36) months follow-up, respectively, while Group A showed a reduced wound complication rate.

Our results show that patients treated with a bioactive glass without local antibiotics achieved similar eradication of infection and less drainage than those treated with two different antibiotic-loaded calcium-based bone substitutes.

Cite this article: Bone Joint J 2014; 96-B:845–50.

Objectives

An experimental piglet model induces avascular necrosis (AVN) and deformation of the femoral head but its secondary effects on the developing acetabulum have not been studied. The aim of this study was to assess the development of secondary acetabular deformation following femoral head ischemia.

There is no diagnostic, non-invasive method for the early detection of loosening after total hip arthroplasty. In a pilot study, we have analysed two serum markers of bone remodelling, procollagen I C-terminal extension peptide (PICP) and cross-linked N-terminal telopeptide (NTx), as well as the diagnostic performance of NTx for the assessment of osteolysis. We recruited 21 patients with loosening (group I), 18 with a well-fixed prosthesis (group II) and 17 at the time of primary arthroplasty for osteoarthritis (OA) (group III). Internal normal reference ranges were obtained from 30 healthy subjects (group IV).

The serum PICP level was found to be significantly lower in patients with OA and those with loosening, when compared with those with stable implants, while the NTx level was significantly increased only in the group with loosening, suggesting that collagen degradation depended on the altered bone turnover induced by the implant. This hypothesis was reinforced by the finding that the values in the pre-surgery patients and stable subjects were comparable with the reference range of younger healthy subjects.

A high specificity and positive predictive value for NTx provided good diagnostic evidence of agreement between the test and the clinical and radiological evaluations. The NTx level could be used to indicate stability of the implant. However, further prospective, larger studies are necessary.