Objective. To determine the reliability, reproducibility, variability and validity of the Osteoarthritis Research Society International (OARSI) Osteoarthritis Cartilage Histopathology (OACH) system and Mankin Histopathology – Histochemical Grading System (HHGS) when applied to the characterisation of the osteoarthritic human knee. Method. Kellgren-Lawrence and Line Drawing Atlas (LDA) radiology scores clinically graded the knees of ten patients undergoing total knee arthroplasty due to osteoarthritis. The tibial plateaux were scored using the Modified Collins (MC) and Société Française d'Arthroscopie (SFA). Three observers, twice scored, using both the OACH and HHGS systems across a single complete medial and lateral tibial plateau transect taken to include the region with the most severe OA lesion. Intra and inter-observer reliability, reproducibility, variability and validity were quantified, and the correlation between the two histopathology scoring systems was calculated. Results. We identified that both histopathology scoring systems are reliable and reproducible exhibiting similar variability, when applied to characterise OA specimens sampled from a well defined patient group with knee osteoarthritis. A strong correlation between the mean OACH and HHGS scores was identified (Spearman'sρ 0.973). Conclusion. Both scoring systems provide useful measures in the characterisation of knee osteoarthritis. It is of note that an additional parameter within the OACH score over the HHGS that defines the extent of the disease, where the HHGS is a grade attributed to the most representative level of the biological aggression within the OA lesions. This study has confirmed the OACH system's utility in human knee OA and is supported by good correlation with the established Mankin HHGS

Since the 1970s Swanson implant arthroplasty has become a treatment of choice in metacarpohalangeal (MCP) joint arthroplasty in destructed MCP joints of rheumatoid patients. Sutter (Avanta) implant is also composed of silicone but the centre of rotation is more anatomical, and volar to improve extension moment. Clinical results about these implants have been similar but fracture rates of Sutter implant have been reported to be high. Reason for osteolysis is inflammation reaction to silicone particles released from prostheses due to movement of prosthesis in bone or implant fractures. Reports about osteolysis around Swanson implants present variable result. There is not grading of osteolysis in the literature before and we created a new radiographic grading for osteolysis around silicone MCP implants. Grading is based on involvement of cortical bone: Grade I: Osteolysis varying from a single clear line adjacent to the stem of the prosthesis to a larger, clear area which did not involve the bone cortex; Grade II: Osteolysis affecting the bone cortex to a maximum of one half of the thickness of the cortex; Grade III: Osteolysis affecting the cortex to more than one half of its thickness but not perforating the cortex; Grade IV: Osteolysis perforating the cortex. In this study we compare the incidence of radiographic osteolysis following insertion of 89 Swanson and 126 Sutter MCP implants in rheumatoid arthritis patients. Before surgery hands were randomised one by one to Swanson and Sutter implant groups. The mean follow-up time in the two groups of patients was 57 (40–80) and 55 (36–79) months, respectively. A total of 45 (60%) metacarpal and 40 (53%) proximal phalangeal bones showed no osteolytic changes in the Swanson group. In the Sutter group numbers were 20 (21%) and 26 (27%). In the Swanson group, there was less cortical osteolysis and there were 4 (5%) perforations of a metacarpal and no perforations of a proximal phalanx. In the Sutter group, there were 9 (9%) perforations in a metacarpal and 5 (5%) in a proximal phalanx. (p< 0.001). To create a single independent observation of osteolysis for a hand, the worst osteolysis of a metacarpal or proximal phalanx was recorded. There was only one (5%) perforation in the Swanson group, while there were 8 (30%) perforations in the Sutter group (p=0.011). In all grades of our classification, osteolysis was more frequent in the Sutter than in the Swanson group

Aims

Taper corrosion has been widely reported to be problematic for modular total hip arthroplasty implants. A simple and systematic method to evaluate taper damage with sufficient resolution is needed. We introduce a semiquantitative grading system for modular femoral tapers to characterize taper corrosion damage.

Introduction

The degree of cartilage degeneration assessed intraoperatively may not be sufficient as a criterion for patellar resurfacing in total knee arthroplasty (TKA). However, single-photon emission tomography/computed tomography (SPECT/CT) is useful for detecting osteoarthritic involvement deeper in the subchondral bone. The purpose of the study was to determine whether SPECT/CT reflected the cartilage lesion underneath the patella in patients with end-stage osteoarthritis (OA) and whether clinical outcomes after TKA without patellar resurfacing differed according to the severity of patellofemoral (PF) OA determined by visual assessment and SPECT/CT findings.

Background

We searched -in transverse ultrasound view- the value of the difference (Delta) between -proximal to the tunnel- CSA (a) and -in the tunnel's inlet- CSA (b) for separating normal from abnormal median nerves.

A system for assessment of function after major pelvic injuries is proposed. This numerical system developed from a five-year prospective study of 60 patients. Five factors were assessed and scored: pain, standing, sitting, sexual intercourse and work performance. The total score then gave a clinical grade as excellent, good, fair or poor. The scoring system allows comparison between early and late results and also between various methods of treatment.

1. A method has been described whereby the disability of hip disease, bilateral or unilateral, can be graded, and the quality of result following arthroplasty assessed, on a scale of numerical values.

2. The grade expresses the condition of the entire patient, rather than that of the hip joint alone.

3. Certain clinical criteria and physical tests have been adopted as the bases for scoring. The calculation of the patient's total score has been weighted to emphasise mobility, and to provide a more critical measure of the success of arthroplasty. Subjective tests (aside from the patient's estimate of his pain) are avoided, to provide as objective and accurate a method of assessment as possible.

Aims

Although knee osteoarthritis (OA) is diagnosed and monitored radiologically, actual full-thickness cartilage loss (FTCL) has rarely been correlated with radiological classification. This study aims to analyze which classification system correlates best with FTCL and to assess their reliability.

Aims

To investigate (1) The relationship between macroscopic grading and durability of cartilage repair following collagen-covered autologous chondrocyte implantation (ACI-C) in the knee; (2) The influence of histology on durability of cartilage repair; (3) The relationship between macroscopic appearance and histology of repair tissue.

Background

Carbon fibre (CF) instrumentation is known to be radiolucent and has a tensile strength similar to metal. A specific use could be primary or oligometastatic cancer where regular surveillance imaging and Stereotactic Radiotherapy are required.

CT images are inherently more prone to artefacts which affect Hounsfield unit (HU) measurements. Titanium (Ti) screws scatter more artefacts. Until now it has been difficult to quantify how advantageous the radiolucency of carbon fibre pedicle screws compared to titanium or metallic screws actually is.

Introduction: The American Society of Anesthesiologists (ASA) grade is supposed to accurately predict morbidity and mortality. We wanted to better inform our patients of their risk of mortality in elective operations.

Method: Analysis of data from Galen (Theatre management software) routinely gathered as part of the preoperative assessment of patients. We linked this to the Date of Death field in the Hospital Master Patient index to identify those patients who had died within 90 days of surgery, including deaths after discharge from hospital.

Results: Two thousand and thirty one patients over two years. These were elective Orthopaedic operations including knee (1074) and hip (957) replacements, both primary and revision. There were thirty one mortalities over a two year period. Sixteen mortalities for knee (1.5% of knee operations) and 15 for hip surgery (1.6% of hip operations). Respective mortality for ASA grades 1–4 are presented in table below

Discussion: Our review of the 2031 patients shows that the relative risk of mortality between ASA grades 1–4 increased from 1–8.8. We examined the notes because grade 4’s mortality was 10% and realized that 75% of ASA grades recorded by Orthopaedic surgeons and anaesthetists differed. The anaesthetists seem to down grade the ASA 4’s.

Conclusion: The relative risk of mortality is lower than that as previously described. Orthopaedic surgeons seem to assess patient better when it comes to ASA grading. The paper further discusses the implications of these conclusions.

Aims: To investigate

the influence of histology on durability of cartilage repair following collagen-covered autologous chon-drocyte implantation (ACI-C) in the knee.

Patients and methods: The modified Cincinnati scores (MCRS) of eighty-six patients were evaluated prospectively at one year and at the latest follow-up (mean follow-up = 4.7yrs. Range = 4 to 7 years). Biopsies of their cartilage repair site were stained with Haema-toxylin and Eosin and some with Safranin O and the neo-cartilage was graded as hyaline-like (n=32), mixed fibro-hyaline (n=19) and fibro-cartilagenous tissue (n=35). Macroscopic grading of the repair tissue using the international cartilage repair society grading system (ICRS) was available for fifty-six patients in this study cohort. Statistical analyses were performed to investigate the significance of histology and ICRS grading on MCRS at 1 year and at the latest follow-up.

Results: The MCRS of all three histology groups were comparable at one year evaluation (p=0.34). However, their clinical scores at the latest follow-up showed a significantly superior result for those with hyaline-like repair tissue when compared to those with mixed fibro-hyaline and fibro-cartilagenous repair (p=0.05).

There was no correlation between the ICRS grading and MCRS either at one year (p=0.12) or at the latest follow-up (p=0.16). Also, the ICRS grading of the repair tissue did not correlate with its histological type (p=0.12).

Conclusion: We conclude that any form of cartilage repair gives good clinical outcome at one year. At four years and beyond, hyaline-like repair tissue produces a more favourable clinical outcome. Macroscopic evaluation using the ICRS grading system does not reflect the clinical outcome or its durability or the histological type of repair tissue.

Antero-medial osteoarthritis of the knee displays a well recognised pattern of cartilage damage on the medial tibial plateau. Anteriorly there is a full thickness cartilage defect, with transition to a partial thickness defect, becoming full thickness in the posterior third of the plateau. The retained posterior cartilage is macroscopically normal, but no previous study has assessed its histo-logical features. This study characterises the histological changes, to examine if antero-medial OA of the knee represents a model of progressive osteoarthritic cartilage damage.

Five unicompartmental resection specimens of patients with idiopathic single compartment antero-medial osteoarthritis were assessed. The samples were stained with H& E and Saffinin-O stains and reviewed using the Mankin system, an established method for scoring osteoarthritic changes in cartilage (range 0 [normal] to 14 [grossly osteoarthritic]) Digital images of the histology were reviewed by two observers to exclude inter and intra observer error. Each specimen was assessed at 4 interval points (A,B,C,D) along the A-P axis starting from the most posterior aspect of the exposed bone to the area of macroscopically normal cartilage. Three repeat measurements were taken from the macroscopically normal region (D1,D2,D3). The scores were compared to historical age matched controls of non-osteoarthritic cartilage, where a Mankin grade of < 3 suggests normal cartilage.

From anterior to posterior the H& E staining showed a consistent decrease in structural integrity and cellularity of the cartilage, matched by a qualitative decrease in GAG content (Saffinin-O staining). Mean Mankin scores showed a progressive decrease in score; A = 14.0 (95% CI 0), B = 5.8 (95%CI 2.4), C = 4.4 (95%CI 2.5), D = 1.0 (95%CI 0.9) {p=0.04 ANOVA}. Repeated measurements at the macroscopically normal area showed the Mankin grade was maintained; D1= 1.0 (95%CI 0.9), D2 = 0.6 (95%CI 0.5), D3 = 0.6 (95%CI 0.6).

The results show that the retained posterior cartilage in antero-medial arthritis has a consistently normal Mankin grade. We suggest the defect represents a model of progressive cartilage damage from near normal (posterior) to the grossly osteoarthritic state (anterior).

A logical, objective and reproducible grading system for the pivot shift test is proposed. The rationale is based on performing the examination in varying positions of rotation of the tibia, allowing the type and degree of the different laxities to be defined and quantified. The system has been assessed against a new "unblocked" test for anterior subluxation and against radiographic measurements, operative findings and results. This grading system can be valuable in pre-operative assessment and planning and its use in postoperative evaluation would enable results from different centres and different procedures to be compared more accurately.

Quality of cementation in the early postoperative period has been proven to be an indicator of long-term survival of the total hip arthroplasty. Cementation grading described by Barrack et al is widely used but has certain limitations. It is based upon second-generation cementation technique and has unacceptably high inter- and intra-observer variability due to its subjective evaluation method.

We are introducing a new grading system of quality of femoral cementation. It is based upon the ratio of the length of radiological lucency to the total length of cement-bone interface on both antero-posterior and lateral views. Because of its objective nature, it is likely to show reproducible results.

We recruited five observers of various grades of surgical experience (trainees to consultant). Each observer graded the quality of femoral cementation on immediate postop xrays twice (gap of atleast two weeks) of 30 primary hip arthroplasties, using Barrack's grading and a new cementation index measured by dividing the ength of Radiolucency along CBI by the total Length of CBI.

Statistical analysis was performed by SPSS v17.0. Inter-observer and Intra-observer variability was determined by Intraclass Correlation Coefficient for a two way mixed model.

New cementation index showed excellent agreement for both inter and intra-observer reliability with intraclass correlation coefficient of 0.79 and 0.82 respectively. On contrary, results of inter-observer reliability for Barrack's grading were poor with value of 0.20. intra-observer reliability was found to be fair with 0.55.

As evident from this study, it is a more reliable way of assessing the quality of cementation, with excellent agreement in both inter and intra-observer categories.

Routine use of Computed Tomography (CT) to evaluate discogram morphology is time consuming, costly and incurs additional radiation hazards. In our spinal unit, discography is routinely performed without the aid of CT. Discogram morphology for different stages of disc degeneration is evaluated using the modified Adam’s grading system on images obtained on fluoroscopy. Our aims were to assess the validity of the modified Adam’s grading system of discogram morphology, by assessing its inter- and intra-observer agreement.

We reviewed the discographic images (133 intervertebral levels) of 71 patients with chronic low back pain undergoing discography as part of a preoperative assessment between 1995 and 1997. Using the modified Adam’s grading system, three independent surgeon observers of three levels of experience (Senior Fellow, Senior and Junior residents) retrospectively evaluated the morphological appearance of each disc level in a randomized and blinded manner. Each observer was supplied with descriptions and illustrations of the 5 grades1, and each level was classified accordingly. The exercise was repeated three weeks later. The respective inter- and intra-observer agreements were calculated using the kappa statistic (Fleiss 1971) and generalized kappa statistic (Landis and Koch 1977).

The inter-observer agreement was excellent (kappa = 0.77; standard error = 0.054). The intra-observer agreement for each of the three observers was also excellent (kappa = 0.8, 0.8, and 0.85 with respective standard errors = 0.046, 0.049 and 0.042).

Significance and conclusions: The inter- and intra-observer agreement and therefore the reliability of the modified Adam’s grading system is excellent. This classification is easy to apply and has a high degree of reproducibility amongst observers with different levels of spinal experience. In view of the high reproducibility, we recommend the Adam’s classification for the grading of discogram morphology. The routine use of computed tomography with the concomitant radiation exposure and additional cost would seem not to be justified.

Background

Tears of the rotator cuff are a common pathology and poorly understood. Achieving a good functional outcome for patients may be difficult, and the degree of fat infiltration into the muscle is known to be a major determining factor to surgical repair and post operative function. It is the hypothesis of this study that the degree of retraction of the common central tendon as seen on MRI corresponds to the amount of fat infiltration classified according to the Goutallier grading System.

Introduction: L5/S1 injuries can be associated with pelvic fracture but unfortunately they are often missed. Left untreated these patients may suffer disabling lower back pain. Our goal is to study the frequency of these injuries in pelvic fractures treated at this institution, thereupon to determine how many are missed and the outcome if this injury is treated conservatively. We will describe the radiological findings, anatomical features and possible surgical treatments.

Materials and Methods: A retrospective analysis was undertaken of pelvic fractures treated at this institution from 2000 onward. Outcome scores were taken from the patient records. All CT scans and x-rays were scru-tinised for a Lumbosacral Junction Injury(LJI). Numbers missed were tallied against numbers diagnosed and treated. Patient outcome measures were compared using the Matta Hip Scores. It was noted whether low back or hip pain contributed to their symptoms most.

Results: The incidence of lumbar sacral injuries associated with vertical shear pelvic fractures was 20%. Of these, 75% had not been identified as a specific lumbar-sacral injury. The remaining 25% which were identified and treated with fixation of the lumbar sacral junction had an excellent result. We have identified specific morphology patterns and propose a CT based grading system.

Discussion: We suggest that a heightened level of awareness is needed for these important injuries in pelvic trauma as their occurrence changes the management. The incidence appears to be higher than that reported by Isler and suggest our CT based classification be used to grade these injuries.

Objective: We set out to identify if the quality of femoral cementing as assessed on the first postoperative AP radiograph was significantly different when operations performed by trainees were compared with those done by consultant staff.

The Barrack scoring system was used as a tool to evaluating cementation quality in all cases.

Material and Method: 70 patients with primary hip replacement were included. 41 cases performed by consultant while 29 by training surgeons.1st post-operative hip x-rays were taken between 3–5 days postoperatively. The x-rays were numbered randomly and their digital images were graded using Barrack grades by one observer (I.R) who was blinded to the seniority of surgeon who had carried out the case.

Results: Of the total cohort of 70 patients, 35(50%) were grade A, 28(40%) grade B and 7(10%) grade C. In the consultant cases 18(44%) were grade A, 19(46%) grade B and 4(10%) were grade C. The results in for training grade surgeons were 17(58%) grade A, 9 (31%) grade B and 3(11%) grade C. There were no grade D cases in either group.

Conclusion: The quality of femoral cementing was not significantly different when the operations carried out by consultants were compared to those where a trainee was the primary surgeon (p< 0.01). These results would suggest that learning curve (Figure) from trainees to consultants was quite satisfactory. Patients undergoing operation undertaken by an adequately experienced and supervised trainee are not at increased risk for implant failure compared to the individuals where the Consultant is the primary surgeon.

Background: Resurfacing cups may produce significant clinical problems when placed at the extremes of version, including increased production of metal debris and psoas tendonitis.

Methods: We obtained the femoral and acetabular components of two unused ASR (Articular Surface Replacement) and BHR (Birmingham Hip Resurfacing) devices. The components were placed in moulds at varying degrees of inclination and anteversion in a grid to simulate pelvic landmarks and AP radiographic images were captured. The true radiological anteversion was determined by rotating the x-ray beam so that it was perpendicular to the acetabular axis and measuring the angle subtended by the cup rim and the vertical axis.

Five blinded orthopaedic registrars then used EBRA (Einzel-Bild-Roentgen-Analysis, University of Inns-bruck, Austria) software to determine the radiological anteversion from the AP films. Twenty-five ASR and twenty-five BHR images were analysed.

At the same time each observer was asked to grade the cups as “1” (< 10°) “2” (10–20°) “3” (20–30°) or “4” (> 30°) depending on the appearances of the cup vertices.

Results: Mean error for each observer was −0.7 (minimum) to 1.6° (maximum). The range of standard deviations of error for each observer was +/− 2.2 (minimum) to 3.5° (maximum). Retroverted cups were not identified in the majority of cases.

Cups graded as “1” or “4” showed high sensitivity and specificity for the true grade as determined on the lateral radiographs.

Conclusions: EBRA software can be used to calculate the anteversion of resurfacing cups to a clinically acceptable degree. The clinician must be aware of the limitations of the software most notably the difficulty in identifying a retroverted cup and errors arising from poor quality radiographs in terms of pelvic rotation. The presented clinical grading system can be used as a rapid assessment tool to identify cups at the extremes of anteversion.