Background and Objectives. Triangular fibrocartilaginous complex (TFCC) tears are common sources of ulna sided wrist pain and resultant functional disability. Diagnosis is based on history, clinical examination and radiological evidence of a TFCC central perforation or radial/ulna tear. The purpose of this study is therefore to evaluate the diagnostic accuracy of Magnetic Resonance Imaging (MRI) and Magnetic Resonance Arthrography (MRA) in the detection of TFCC injury in the adult population. Methods. Published and unpublished literature databases were systematically review independently by two researchers. Two-by-two tables were constructed to calculate the sensitivity and specificity of MRI or MRA investigations against arthroscopic outcomes. Pooled sensitivity and specificity values and summary Receiver Operating Characteristic curve (sROC) evaluations were performed. Methodological quality of each study was assessed using the QUADAS (Quality Assessment of Diagnostic Accuracy Studies) tool. Results. Twenty one studies were eligible, including 910 wrists. On meta-analysis, MRA was superior to MRI in the investigation of complete TFCC tears with a pooled sensitivity of 0.75 (95% Confidence Interval (CI): 0.70, 0.79) and specificity of 0.81 (95% CI: 0.76, 0.86), compared to MRAs 0.84 (95% CI: 0.79, 0.89), and 0.95 (95% CI: 0.92, 0.98) respectively. MRA and MRI performed at greater field strengths reported greater sensitivity and specificity findings. For 3.0 Tesla (T) MRI, the meta-analysis indicated a sensitivity of 0.86 (95% CI: 0.65, 0.97), and specificity of 1.00 (0.87, 1.00). In comparison, the pooled sensitivity for the 1.5T MRI assessment was 0.70 (95% CI: 0.64, 0.75) and specificity of 0.79 (95% CI: 0.72, 0.85). This trend was repeated for MRA where 3.0T MRA exhibited a sensitivity was 1.00 (95% CI: 0.79, 1.00) and specificity of 1.00 (95% CI: 0.82, 1.00), whilst pooled analysis 1.5T MRA demonstrated a sensitivity of 0.83 (95% CI: 0.78, 0.89) and specificity of 0.95 (95% CI: 0.91, 0.98). There was insufficient data to assess the diagnostic test accuracy of partial TFCC lesions. Conclusions. Given its acceptable diagnostic test accuracy, it is recommended that in cases where there are questions over the diagnosis and subsequent management of patients with ulna wrist pain, a MRA should be undertaken rather than MRI

The Cochrane Collaboration has produced five new reviews relevant to bone and joint surgery since the publication of the last Cochrane Corner These reviews are relevant to a wide range of musculoskeletal specialists, and include reviews in Morton’s neuroma, scoliosis, vertebral fractures, carpal tunnel syndrome, and lower limb arthroplasty.

Instability accounts for approximately 20% of revision total knee arthroplasty (TKA) operations, however, diagnostic tests remain relatively subjective. The aim of this examination was to evaluate the feasibility of using pressure mat analyses during functional tasks to identify abnormal biomechanics associated with TKA instability. Five patients (M = 4; age = 69.80±7.05 years; weight = 79.73±20.12 kg) with suspected TKA instability were examined compared to 10 healthy controls (M = 4; age = 44.6±7.52 years; weight = 70.80±14.65). Peak pressure and time parameters were measured during normal gait and two-minute bilateral stance. Side-to-side pressure distribution was calculated over 10-second intervals during the second minute. Mann-Whitney tests compared loading parameters between groups and side-to-side differences in TKA patients (significance level = p<0.05). Pressure distribution was expressed relative to bodyweight. Notable differences were seen during bilateral stance. Uneven side loading was greater – favouring the non-operated limb – in TKA patients during bilateral stance compared to controls. This was significantly different at 30s (p=0.0336) and 60s (p=0.0336). Gait analyses showed subtle pressure distribution differences in unstable TKA patients. Stance time was indifferent. TKA patients tended to exhibit longer heel contact time (0.76s vs. 0.64s and reduced weight acceptance (50.75% vs. 56.75%) on the operated limb compared to the non-operated limb. Side-to-side differences in peak toe-off forces were significantly more pronounced in TKA patients versus controls (9.25% +/− 1.5% vs. 1.67% +/−5.79%; p=0.0039). Conclusion: This feasibility work demonstrates subtle differences in limb loading mechanics during simple clinical tests in unstable TKA patients that might be invisible to the naked eye. In the long-term, pressure analyses may be a useful diagnostic tool in identifying patients that would benefit from revision surgery for TKA instability

Instability accounts for approximately 20% of all revision total knee arthroplasty (TKA), however diagnostic tests remain crude and subjective. The aim of this examination was to evaluate the feasibility of pressure mat (SB Mat, TekScan) analyses of functional tasks to differentiate instability in a clinical setting. Five patients (M = 4; age = 69.80±7.05 years; weight = 79.73±20.12 kg) with suspected TKA instability were examined compared to five healthy controls (M = 1; age = 46.80±7.85 years; weight = 71.54±16.17 kg). Peak pressure and time parameters were measured during normal gait and two-minute bilateral stance. Side-to-side pressure distribution was calculated over 10-second intervals during the second minute. Pressure distributions were expressed relative to bodyweight (%BW). T-tests compared loading parameters between groups (significance level = p<0.05). Analyses showed subtle differences in pressure distribution in unstable TKA patients versus healthy controls. Stance time during gait was indifferent. TKA patients tended to exhibit longer heel contact time (0.76 vs. 0.64 sec) and reduced weight acceptance (50.75% vs. 56.75%) on the operated versus non-operated limb. Side-to-side differences in toe-off forces were significantly more pronounced in TKA patients versus controls (9.25% vs. 3.75%; p=0.0088). Uneven loading was significantly greater – favouring the non-operated limb – in TKA patients during bilateral stance compared to controls (p<0.05). This feasibility work demonstrates subtle differences in limb loading and biomechanics during simple clinical tests in unstable TKA patients that might be undetectable to the naked eye. Pressure analyses may therefore be a useful diagnostic tool. These findings warrant further investigation

The Cochrane Collaboration has produced three new reviews relevant to bone and joint surgery since the publication of the last Cochrane Corner. These are relevant to a wide range of musculoskeletal specialists, and include reviews in lateral elbow pain, osteoarthritis of the big toe joint, and cervical spine injury in paediatric trauma patients.

Purpose of study. To explore the clinical reasoning strategies used by extended scope physiotherapists (ESPs) when assessing patients with low back pain. Background. Extended scope physiotherapists commonly work in back pain services and their training emphasises the acquisition of clinical skills and possible diagnostic tests (including MRI) to aid clinical reasoning and diagnosis. Whilst there has been some exploration of reasoning strategies of other professional groups (notably medically qualified) to date, the clinical reasoning strategies of ESP clinicians have not been reported. Methods. A qualitative study, with three focus groups, explored clinical reasoning by ESPs and non-ESPs, to compare how these clinicians assess patients' with back pain. This informed a second study, using a ‘think-aloud’ technique with 10 participants from four NHS sites, examining their reasoning strategies, immediately after completing initial consultations. Analysis was informed by a grounded theory approach. Results. Themes identified relating to clinical reasoning were prior thinking, patient interaction, gut-feeling, and formal testing. The differences in practice between ESP and non-ESP appeared to be driven by differences in accountability, safety and external influences. A key difference between the accounts of clinical reasoning provided by ESPs and non-ESPs centred on the role and appropriateness of ‘gut feeling’ in diagnostic decision making. The analysis explores the apparent tension between this instinctive contribution to reasoning and evidence-based practice. The paper explores the legitimacy of gut feeling. Conclusions. Extended scope physiotherapists appear to employ different clinical reasoning strategies to their non-ESP colleagues, highlighting the additional burden of responsibility and tension created by the use of gut feeling. No conflicts of interest. No funding obtained. This abstract has not been previously published in whole or in part; nor has it been presented previously at a national meeting

Objectives

The objective of this study was to develop a test for the rapid (within 25 minutes) intraoperative detection of bacteria from synovial fluid to diagnose periprosthetic joint infection (PJI).

Objectives

The clinical utility of routine cross sectional imaging of the abdomen and pelvis in the screening and surveillance of patients with primary soft-tissue sarcoma of the extremities for metastatic disease is controversial, based on its questionable yield paired with concerns regarding the risks of radiation exposure, cost, and morbidity resulting from false positive findings.

A retrospective series of 45 cases of chronic osteomyelitis collected over a period of 14 years was histologically classified into tuberculous osteomyelitis (25) and chronic non-granulomatous osteomyelitis (20). The tuberculous osteomyelitis group was divided into three subgroups: a) typical granulomas (13 cases); b) ill-defined granulomas (seven cases), and c) suspected granulomas (five cases). An in-house polymerase chain reaction amplifying the 245 bp nucleotide sequence, and capable of detecting 10 fg of DNA of Mycobacterium tuberculosis, was used on the DNA extracted from the paraffin blocks. The polymerase chain reaction was positive in 72% of cases (18) of tuberculous osteomyelitis, but when typical cases of tuberculous osteomyelitis with confirmed granulomas were considered (13), this increased to 84.6% (11). The chronic non-granulomatous osteomyelitis group gave positive polymerase chain reaction results in 20% of the cases (4).

Our preliminary study on tuberculous osteomyelitis shows that the polymerase chain reaction can be a very useful diagnostic tool, since a good correlation was seen between typical granulomas and polymerase chain reaction with a sensitivity of 84.6% and a specificity of 80%. In addition, our study shows that tuberculous osteomyelitis can be diagnosed in formalin-fixed paraffin-embedded tissues in the absence of typical granulomas.