Aims. The presence of facet tropism has been correlated with an elevated susceptibility to lumbar disc pathology. Our objective was to evaluate the impact of facet tropism on chronic lumbosacral discogenic pain through the analysis of clinical data and finite element modelling (FEM). Methods. Retrospective analysis was conducted on clinical data, with a specific focus on the spinal units displaying facet tropism, utilizing FEM analysis for motion simulation. We studied 318 intervertebral levels in 156 patients who had undergone provocation discography. Significant predictors of clinical findings were identified by univariate and multivariate analyses. Loading conditions were applied in FEM simulations to mimic biomechanical effects on intervertebral discs, focusing on maximal displacement and intradiscal pressures, gauged through alterations in disc morphology and physical stress. Results. A total of 144 discs were categorized as ‘positive’ and 174 discs as ‘negative’ by the results of provocation discography. The presence of defined facet tropism (OR 3.451, 95% CI 1.944 to 6.126) and higher Adams classification (OR 2.172, 95% CI 1.523 to 3.097) were important predictive parameters for discography-‘positive’ discs. FEM simulations showcased uneven stress distribution and significant disc displacement in tropism-affected discs, where loading exacerbated stress on facets with greater angles. During varied positions, notably increased stress and displacement were observed in discs with tropism compared to those with normal facet structure. Conclusion. Our findings indicate that facet tropism can contribute to disc herniation and changes in intradiscal pressure, potentially exacerbating disc degeneration due to altered force distribution and increased mechanical stress. Cite this article: Bone Joint Res 2024;13(9):452–461

Cervical spine facet tropism (CFT) defined as the facets’ joints angles difference between right and left sides of more than 7 degrees. This study aims to investigate the relationship between cervical sagittal alignment parameters and cervical spine facets’ tropism. A retrospective cross-sectional study carried out in a tertiary center where cervical spine magnetic resonance imaging (MRI) radiographs of patients in orthopedics/spine clincs were included. They had no history of spine fractures. Images’ reports were reviewed to exclude those with tumors in the c-spine. A total of 96 patients was included with 63% of them were females. The mean of age was 45.53± 12.82. C2-C7 cobb's angle (CA) and C2-C7 sagittal vertical axis (SVA) means were −2.85±10.68 and 1.51± 0.79, respectively. Facet tropism was found in 98% of the sample in at least one level on either axial or sagittal plane. Axial C 2–3 CFT and sagittal C4-5 were correlated with CA (r=0.246, P 0.043, r= −278, P 0.022), respectively. In addition, C2-C7 sagittal vertical axis (SVA) was moderately correlated with axial c2-3 FT (r= −0.330, P 0.006) Also, several significant correlations were detected in our model Cervical vertebral slopes and CFT at the related level. Nonetheless, high BMI was associated with multi-level and multiplane CFT with higher odd's ratios at the lower levels. This study shows that CFT at higher levels is correlated with increasing CA and decreasing SVA and at lower levels with decreasing CA. Obesity is a risk factor for CFT

Objectives. Understanding lumbar facet joint involvement and biomechanical changes post spinal fusion is limited. This study aimed to establish an in vitro model assessing mechanical effects of fusion on human lumbar facet joints, employing synchronized motion, pressure, and stiffness analysis. Methods and Results. Seven human lumbar spinal units (age 54 to 92, ethics 15/YH/0096) underwent fusion via a partial nucleotomy model mimicking a lateral cage approach with PMMA cement injection. Mechanical testing pre and post-fusion included measuring compressive displacement and load, local motion capture, and pressure mapping at the facet joints. pQCT imaging (82 microns isotropic) was carried out at each stage to assess the integrity of the vertebral endplates and quantify the amount of cement injected. Before fusion, relative facet joint displacement (6.5 ± 4.1 mm) at maximum load (1.1 kN) exceeded crosshead displacement (3.9 ± 1.5 mm), with loads transferred across both facet joints. After fusion, facet displacement (2.0 ± 1.2 mm) reduced compared to pre-fusion, as was the crosshead displacement (2.2 ± 0.6 mm). Post-fusion loads (71.4 ± 73.2 N) transferred were reduced compared to pre-fusion levels (194.5 ± 125.4 N). Analysis of CT images showed no endplate damage post-fusion, whilst the IVD tissue: cement volume ratio did not correlate with the post-fusion behaviour of the specimens. Conclusion. An in vitro model showed significant facet movement reduction with stand-alone interbody cage placement. This technique identifies changes in facet movement post-fusion, potentially contributing to subsequent spinal degeneration, highlighting its utility in biomechanical assessment. Conflicts of interest. None. Sources of funding. This work was funded by EPSRC, under grant EP/W015617/1

Abstract. Objectives. While spinal fusion is known to be associated with adjacent disc degeneration, little is known on the role of the facet joints in the process, and whether their altered biomechanics following fusion plays a role in further spinal degeneration. This work aimed to develop a model and method to sequentially measure the effects of spinal fusion on lumbar facet joints through synchronisation of both motion analysis, pressure mapping and mechanical analysis. Methods. Parallel measurements of mature ovine lumbar facet joints (∼8yr old, n=3) were carried out using synchronised load and displacement measurements, motion capture during loading and pressure mapping of the joint spaces during loading. Functional units were prepared and cemented in PMMA endcaps. Displacement-controlled compression measurements were carried out using a materials testing machine (3365, Instron, USA) at 1 mm/min up to 950 N with the samples in a neutral position, while motion capture of the facet joints during compression was carried out using orthogonal HD webcams (Logitech, Switzerland) to measure the displacement of key facet joint features. The pressure mapping of load transfer during displacement was carried out using a flexible pressure sensor (6900 series, Tekscan, USA). Each sample was imaged at an isotropic resolution of 82 microns using a μCT scanner (XtremeCT, Scanco, Switzerland) to quantify the curvature within the facet joints. Results. Relative facet joint displacement under load, in a neutral position, showed more displacement (2.36 ±1.68 mm) compared to the cross-head when under compression (2.06 ±1.19 mm). Motion capture indicated the relative displacement of the facet joints was more posterior with some lateral motion. For five of the six facet joints, pressure measurement was possible only on 24±7 % of the surface due to the large change in curvature. Partially measured loads through the facets was 10.5 ±1.1 N. Conclusions. The relative displacement of the lumbar facet joints compared to the crosshead displacement was consistent with previous studies of cervical facet joints, despite the differences in anatomical geometry between cervical and lumbar joints. The difficulties in accurately measuring the load transfer through the facet joints was due to the age of the tissue and the degree of curvature of the facet joints. Synchronisation of the biomechanical data will provide a setup to assess the effect of interventions such as spinal fusion, with curvature-related issues unlikely to occur in human spines. Declaration of Interest. (a) fully declare any financial or other potential conflict of interest

We carried out a study to determine the effect of facet tropism on the development of adolescent and adult herniation of the lumbar disc. We assessed 149 levels in 140 adolescents aged between 13 and 18 years and 119 levels in 111 adults aged between 40 and 49 years with herniation. The facet tropism of each patient was measured at the level of the herniated disc by CT. There was no significant difference in facet tropism between the herniated and the normal discs in both the adolescent and adult groups, except at the L4-L5 level in the adults. Facet tropism did not influence the development of herniation of the lumbar disc in either adolescents or adults

Traumatic unilateral facet dislocation of the lumbosacral junction without fracture or with non-displaced fractures of adjacent vertebrae is extremely rare. We describe a case of a young male who sustained a unilateral facet dislocation of the lumbosacral junction in a motor vehicle accident. The unusual features of this case include an unremarkable physical and neurological examination on presentation and absence of other substantial vertebral or extra-vertebral injuries

Summary. Nucleotomy almost doubles the transmitted forces on the facet joints in human lumbar spine, regardless of the amount of removed nucleus pulposus. Introduction. Low back pain involves the lumbar facet joints in 15% to 45% of the cases. The surgical intervention, nucleotomy, might also lead to painful facets with a high risk; however, its mechanism is yet to be fully understood. The aim of this study is to reveal how a small amount of nucleus removal can change the force transmission on the facets. 1.1.1.1 Methods. Nine human lumbar motion segments with a median age of 48 years (interquartile range: 8.3) were tested quasi-statically (0.2 Hz) in extension and flexion (+/−5°) under constant compression loading (700 N). Specimens were tested in vitro by a servo-hydraulic test rig (MTS, USA) equipped with an additional superstructure enabling independent actuation of axial compression, extension-flexion and anterior-posterior shear on the top of the specimen. Forces and moments were measured beneath the specimen. The test method is based on recording intact and nucleotomy performed (range of removed nucleus 0.888–1.708 g) kinematics, which were applied in sequence, at different reduction stages of the same specimen. In the last steps, the facets were the only force transmitting structures, therefore, the load cell beneath the specimen revealed the force transmission on the facets. 1.1.2 Results. The average proportion of force transmitted through the facets increased significantly due to nucleotomy for both an intact capsular ligament (caps. lig.) (p=0.008) from 8.6% (5.2) to 15.8% (6.2), and without a caps. lig. from 8.4% (2.3) to 10.3% (4.9, p = 0.008). Amount of removed nucleus did not show statistically significant correlation to the force increase on facets due to nucleotomy (p>0.19). Forces on the facets were the highest in extension: fully intact 10.7% (6.6), nucleotomy with caps. lig. 19.0% (9.6), intact without caps. lig. 9.37% (3.42), and nucleotomy without caps. lig. 12.6% (6.5). Discussion. Results show, that even a small amount of nucleus removal increase the transmitted forces on facet joints, independent of the amount of removed nucleus. Therefore, a surgeon's decision on the amount of nucleus to remove might perhaps be based on aspects other than facet loading - for example, the avoidance of reherniation. Since facet loading is highest in extension, patients after nucleotomy should perhaps limit this motion as far as possible

Introduction. Mechanical integrity of patella can be weakened by the technique of removing the articulating surface. The senior author developed the technique of maintaining subchondral bone of the lateral patellar facet in early 1980s. Though laboratory studies have demonstrated deleterious effect of excessive resection of patella on the strains in the remaining bone under load; clinical studies have not shown the importance of strong subchondral bone of lateral facet to have an effect on patellar fracture prevalence. We present the results of our patellar resection technique preserving the subchondral bone of lateral facet. Methods. 393 TKRs were performed between 1989 and 1996 using cruciate substituting modular knee with recessed femoral trochlear groove and congruent patello-femoral articulation. 45 patients with 48 knees died and 37 patients with 41 knees were lost to follow-up. Three hundred and four knees were followed for an average 10 years (range 5 -16 years). Patellar surface was resected with an oscillating saw without the use of cutting guide. The medial facet and most of the articular cartilage of the lateral facet was resected, while preserving the subchondral bone of lateral facet. An all-polyethylene implant with single peg was used in most cases. Results. There have been two fractures in the cohort with prevalence of 0.66%. Eight TKRs were revised for synovitis and osteolysis. Patellar osteolysis was found in 4 of these cases, with loosening of 3 of these patellae, and 1 patellar fracture. Two patellar implants had global radiolucencies and were considered loose. The average knee score in unrevised knees improved from 48.6 to 92.2, while functional scores improved from 50 to 81.1. Conclusion. We believe that maintaining this anatomic landmark allows for preserved patellar strength, and in association with a femoral component with a recessed trochlear groove, has resulted in our low patellar fracture rate in primary TKR and revision cases for patellar osteolysis

Introduction and Aims: The aim of this paper is to review C1-C2 facet screw use in paediatric patients and to demonstrate that the technique plays an important role in patients with underlying anatomic abnormalities, which are common in children with cervical instability. Method: A chart review was conducted of all patients managed with C1-C2 facet screws from January 1, 1996 until July 30, 2003 present in the case database. All radiographs were obtained and reviewed. Post-operative and follow-up films were assessed for acceptable screw position and evidence of fusion. Results: C1-C2 facet screws were utilised in nine patients at British Columbia’s Children’s Hospital. The youngest patient treated was five years of age with a mean age for the group of 12. The group consisted of three Down syndrome patients and six with Os Odontoidium, two of which failed previous C1-C2 fusion. Two patients presented with an acute spinal cord injury. Pre-operative CT or MR imaging was used in all patients. Screw placement was unacceptable in one case. Post-operative Halo immobilisation was used in seven patients. Post-operative complications included one wound infection and four halo pin infections requiring treatment. No patients have required surgery at a mean follow-up of four years. C1-C2 facet screws are an important adjunct in a paediatric spine practice. This technique has a great advantage in Down syndrome patients who have a high rate of pseudoarthosis because of: ligamentous laxity, non-compliance with immobilisation and a high incidence of congenital deformities such as os odontoidium and incomplete posterior arch of C1. Conclusion: C1-C2 facet screws can be safely used in young children. The screws allow for fixation in the absence of an intact posterior arch. The technique has a great advantage in Down syndrome patients who have a high rate of pseudoarthosis due to congenital deformities, ligamentous laxity and non-compliance with immobilisation

Purpose: Facet joint arthrosis is an entity that can have a key role in the etiology of low back pain, especially with hyperextension, and is a key component of surgical planning, especially when considering disc arthroplasty. Plain films and MRI are most commonly utilized as the initial imaging of choice for low back pain, but these methods may not truly allow an accurate assessment of facet arthosis. Our purpose was to observe the inter- and intraobserver reliability of utilizing CT and MRI to evaluate facet arthrosis, the inter- and intraobserver reliability of the facet grading system, and the agreement of surgeons as to when to perform disc arthroplasty after the lumbar facets are evaluated. Method: A power analysis was performed which showed we would need 6 reviewers and 43 images to have 80% power to show excellent reliability. 102 CT and the corresponding MRI images of lumbar facets were obtained from patients who were to undergo lumbar spine surgery of any type. 10 spine surgeons and 3 spine fellows reviewed the randomized images at 2 time points, 3 months apart, graded the facet arthosis as well as indicated whether they would chose to perform a disc arthroplasty based on the amount of facet arthrosis. Both interobserver and intraobserver kappa values were calculated by result comparison between observers at the two time points and between CT and MRI images from the same patient. Results: interobserver reliability for MRI was 0.21 and 0.07(fair to slight agreement), and for CT was 0.33 and 0.27(fair agreement), for the spine surgeons and spine fellows respectively. The mean intraobserver reliability for MRI was 0.36 and 0.26 (fair agreement) and for CT was 0.52 and 0.51 (moderate agreement). The kappa value for agreement of whether to perform a disc arthroplasty after grading the facet arthrosis utilizing MRI was 0.22 (fair agreement) and utilizing CT was 0.33 (fair agreement) among the senior spine surgeons. Conclusion: The existing grading system for facet arthrosis and of whether to perform a disc arthroplasty utilizing the grading system has at best only fair agreement. CT is more reliable for grading facet arthrosis

The supraspinatus tendon (SP) often ruptures. Gray established that the tendinous insertion always attaches to the highest facet of the greater tubercle of the humerus. Our osteological study of 124 shoulders in men and women between the ages of 35 and 94 years refocuses on the humeral insertion of the SP in relation to infraspinatus (IS) and teres minor (TM). We found type-I SFs (cubic) in 53 shoulders (43%) and type-II SFs (rectangular or oblong) in 21 (17%). Type-III (ellipsoid) SFs were present in 20 shoulders (16%) and type-IV (angulated or sloping) in 11 (9%). SFs were type V (with tuberosity) in 12 shoulders (10%) and type VI (pitted) in three (2%). The facet area of the SP, IP and TM varied from 49 mm, 225 mm and 36mm2. Of the three muscles, the IS facet was consistently the largest (p < 0.05) and shaped rectangularly. The SP inserted in a cubic or rectangular facet format in 75% of people. SP facet-size may relate to tendon strength, degeneration and rupture. This information may contribute to the understanding of tears of the rotator cuff

Introduction: The effect of facet tropism on the development of lumbar disc diseases has been investigated but is still controversy; moreover, there has been no study to be done on far lateral lumbar disc herniation (LDH). In the current study, the authors attempted to determine the differences of the degree of facet tropism and the degree of disc degeneration between far lateral and posterolateral LDHs. In addition, the effect of the difference of degree of facet tropism and the degree of disc degeneration on the development of far lateral LDH was investigated compared with posterolateral LDH. Methods: 38 LDHs (far lateral, n = 19; posterolateral, n = 19) who underwent posterior open discectomy or paraspinal approach were included in this study. The mean age was 52.3 years in far lateral LDH and 45.3 years in posterolateral LDH. The degrees of facet tropism and disc degeneration were measured at herniated disc level using MRI, and compared for the two different types of LDHs. Mann-Whitney U test and Spearman test were used for analysis. Results: There were significant statistical differences in the degree of facet tropism and the degree of disc degeneration. There was no significant correlation between the degree of facet tropism and the degree of disc degeneration in far lateral LDH. Discussion: The current study suggests that the differences of the degree of facet tropism and the degree of disc degeneration might be considered as the key factors to determine the development of far lateral LDH compared with posterolateral LDH

Aim: To investigate the efficacy of the Insall tube realignment procedure when used to treat osteoarthrosis of the lateral facet of the patello-femoral joint. This procedure has not been reported before for this indication. Methods: The operation is a quadricepsplasty that tilts the patella to enable it to articulate on its intact medial facet, decreasing the loading of the damaged lateral surface. An independent retrospective review was performed with clinical examinations and a score of pain and activity. The mean period of follow-up was 3.6 years with a minimum of one year. Results: There were 43 operations in 30 patients (12 males), with a mean age of 54 years. The patients graded their overall pain relief and functional change as being good to excellent in 32 knees, unchanged in four knees and worse in seven knees. The overall pre- and postoperative pain scores for sitting, walking, running and stair climbing all showed improvements. Ten patients felt some quadriceps weakness on descending stairs, but only one was clinically weak. There was an increase in the number of patients with severe pain on kneeling. Three patients with unsuspected tibio-femoral degenerative change seen at surgery all had poor results. Discussion: We recommend this relatively simple and effective operation for the surgical treatment of isolated lateral facet patello-femoral osteoarthritis

Hypertrophy of lumbar articular facets and dorsal joint capsule are well documented in degenerative instability, the molecular changes occurring in the extracellular matrix (ECM) are however unknown. The L4/L5 posterior articular complex was removed from seven individuals undergoing fusion for degenerative instability. After methanol fixation and decalcification in EDTA, specimens were cryosectioned at 12 μm and immunolabelled with monoclonal antibodies for collagen types I, II, III, V and VI; chondroitin-4 and 6 sulphates; dermatan and keratan sulphate; versican, tenascin, aggrecan and link-protein. Antibody binding was detected using the Vectastain ABC ‘Elite’ kit. Labelling patterns were compared to corresponding healthy specimens examined previously. In comparison, the degenerative capsule was more dense and hypertrophied and the enthesis more fibrocartilaginous, with immunolabelling extensive for collagen type II, chondroitin–6-sulfate, chondroitin-4-sulfate, aggrecan and link-protein. The articular surface showed extensive evidence of degeneration, while the thickened capsular entheses encircled the articular facets dorsally. Bony spurs capped with regions of cartilaginous metaplasia were prominent in this region, the ECM labelling strongly for type II collagen and chondroitin-6-sulfate. The hypertrophy of lumbar facet joints subject to instability of the functional spinal unit therefore appears to be due to proliferation of the capsular enthesis rather than the actual articular facet. In view of the physiological function of the dorsal joint capsule as a wrap-around ligament in assisting the limitation of axial rotation, the molecular changes found in degenerative instability suggest rotational instability, such as results from degenerative disc disease, to be a decisive factor in the development of spondylarthropathy. It is furthermore probable, that the pronounced sagittal joint orientation in degenerative instability is the result of reactive joint changes rather than a predisposing factor of instability

Background. Surgical resection of middle facet tarsal coalition is a well documented treatment option in symptomatic individuals that do not respond to conservative treatment. The ability to return to full recreational activity post resection may have implications on foot biomechanics and possibly degenerative changes in the subtalar and adjacent joints. Hypothesis. Open resection of middle facet tarsal coalitions should improve subtalar joint motion and biomechanical function and facilitate return to sports. Aim. The aim of this study was to assess the outcomes of open resection of middle facet tarsal coalitions (MFTCs) with particular emphasis on return to sports. Methods. Retrospective review of clinical and radiographic records of paediatric and adolescent patients who had open resection of middle facet tarsal coalitions. The ankle and hind foot were evaluated according to the American Orthopaedic Foot and Ankle Society Ankle-Hind foot Scale (AOFAS). We also quantified the return-to-activity time after tarsal coalition surgery. Results. We identified thirteen patients (Mean age; 13.7years Range; 7–21 years) with eighteen middle facet tarsal coalitions operated over a seven year period. Ten patients (12 feet) who underwent resection had an average return to recreational activity time of approximately twelve weeks and reported better exercise tolerance post resection. Conclusion. Surgical excision of middle facet tarsal coalitions has a favourable outcome with respect to return to sports

Abstract. Objective. Flexible stabilisation has been utilised to maintain spinal mobility in patients with early-stage lumbar spinal stenosis (LSS). Previous literature has not yet established any non-fusion solution as a viable treatment option for patients with severe posterior degeneration of the lumbar spine. This feasibility study evaluates the mean five-year outcomes of patients treated with the TOPS (Total Posterior Spine System) facet replacement system in the surgical management of lumbar spinal stenosis and degenerative spondylolisthesis. Methods. Ten patients (2 males, 8 females, mean age 59.6) were enrolled into a non-randomised prospective clinical study. Patients were evaluated with standing AP, lateral, flexion and extension radiographs and MRI scans, back and leg pain visual analog scale (VAS) scores, Oswestry Disability Index (ODI), Zurich Claudication Questionnaire (ZCQ) and the SF-36 questionnaires, preoperatively, 6 months, one year, two years and latest follow-up at a mean of five years postoperatively (range 55–74 months). Flexion and extension standing lumbar spine radiographs were obtained at 2 years to assess range of motion (ROM) at the stabilised segment. Results. The clinical outcome scores for the cohort improved significantly across all scoring systems. Radiographs at 2 years did not reveal any loss of position or loosening of metal work. There were two incidental durotomies and no failures at 5 years with no patient requiring revision surgery. Conclusions. The TOPS implant maintains clinical improvement and motion in the surgical management of LSS and spondylolisthesis, indicating it can be considered an option for these indications

Introduction. Anteromedial gonarthrosis is a common well described pattern of knee osteoarthritis with cartilage wear beginning in the anteromedial quadrant of the medial tibial plateau in the presence of an intact and functioning ACL. It is well known that mechanical factors such as limb alignment and meniscal integrity affect the progression of arthritis and there is some evidence that the morphology of the tibial plateau may be a risk factor in the development of this disease. The extension facet angle is the angle of the downslope of the anterior portion of the medial tibial plateau joint surface in relation to the middle portion on a sagittal view. If this is an important factor in the development of AMG there may be potential for disease modifying intervention. This study investigates if there is a significant difference in this angle as measured on MRI between a study cohort with early AMG (partial thickness cartilage damage and intact ACL) and a comparator control cohort of patients (no cartilage damage and ACL rupture). Methods. 3 Tesla MRI scans of 99 patients; 54 with partial thickness cartilage damage and 44 comparitors with no cartilage damage (acute ACL rupture) were assessed. The extension facet angle was measured (Osirix v3.6) using a validated technique on two consecutive MRI T2 sagittal slices orientated at the mid-coronal point of the medial femoral condyle. (InterClass Correlation 0.95, IntraClass Correlation 0.97, within subject variation of 1.1° and coefficient of variation 10.7%). The mean of the two extension angle values was used. The results were tabulated and analysed (R v2.9.1). Results. Of the 99 knees, 38 were female and 61 male; 44 left knees and 55 right. The mean extension facet angle for the partial thickness group was 12.7° (SD 3.35) and for the comparator group 8.7° (SD 3.09). There was a significant difference between these 2 groups (Mann Whitney U, p<0.001). Although there were significantly more men than women in the comparator group, stratification analysis showed that there was no effect of gender on the mean extension facet angle. There was no effect of age on EFA in either group. Discussion. There is a significance difference in the extension facet angle between patients with AMG with only partial thickness cartilage loss and a comparator group. This has not been shown in a study group of this size before. Since none of the subjects had full thickness cartilage loss it is unlikely that this difference is due to bone attrition changing the angle as part of the disease process but this is an important area for further study. We believe that a higher medial tibial extension facet angle alters the mechanics within the medial compartment, placing these patients at higher risk of developing AMG. This may present an opportunity for risk factor modification, for example osteotomy

Introduction: Anteromedial gonarthrosis is a common well described pattern of knee osteoarthritis with cartilage wear beginning in the anteromedial quadrant of the medial tibial plateau in the presence of an intact and functioning ACL. It is well known that mechanical factors such as limb alignment and meniscal integrity affect the progression of arthritis and there is some evidence that the morphology of the tibial plateau may be a risk factor in the development of this disease. The extension facet angle is the angle of the downslope of the anterior portion of the medial tibial plateau joint surface in relation to the middle portion on a sagittal view. If this is an important factor in the development of AMG there may be potential for disease modifying intervention. This study investigates if there is a significant difference in this angle as measured on MRI between a study cohort with early AMG (partial thickness cartilage damage and intact ACL) and a comparator control cohort of patients (no cartilage damage and ACL rupture). Methods: 3 Tesla MRI scans of 99 patients; 54 with partial thickness cartilage damage and 44 comparitors with no cartilage damage (acute ACL rupture) were assessed. The extension facet angle was measured (Osirix v3.6) using a validated technique on two consecutive MRI T2 sagittal slices orientated at the mid-coronal point of the medial femoral condyle. (InterClass Correlation 0.95, IntraClass Correlation 0.97, within subject variation of 1.1° and coefficiant of variation 10.7%). The mean of the two extension angle values was used. The results were tabulated and analysed (R v2.9.1). Results: Of the 99 knees, 38 were female and 61 male; 44 left knees and 55 right. The mean extension facet angle for the partial thickness group was 12.7° (SD 3.35) and for the comparator group 8.7° (SD 3.09). There was a significant difference between these 2 groups (Mann Whitney U, p< 0.001). Although there were significantly more men than women in the comparator group, stratification analysis showed that there was no effect of gender on the mean extension facet angle. Discussion: There is a significance difference in the extension facet angle between patients with AMG with only partial thickness cartilage loss and a comparator group. This has not been shown in a study group of this size before. Since none of the subjects had full thickness cartilage loss it is unlikely that this difference is due to bone attrition changing the angle as part of the disease process but this is an important area for further study. We believe that a higher medial tibial extension facet angle alters the mechanics within the medial compartment, placing these patients at higher risk of developing AMG. This may present an opportunity for risk factor modification, for example osteotomy

We treated 36 patients with unilateral facet dislocations or fracture-dislocations of the cervical spine at the Mayo Clinic between 1975 and 1986. Adequate records were available for 34: ten patients were treated by open reduction and posterior fusion, and 24 by nonoperative management. Of these, 19 had halo traction followed by halo-thoracic immobilisation, four had a simple cervicothoracic orthosis, and one received no active treatment. Anatomical reduction was achieved more frequently in the operative group (60% compared with 25%). Nonoperative treatment was more likely to result in cervical translation on flexion/extension lateral radiographs, and in significant symptoms. Only 36% of the patients treated by halo traction achieved anatomical alignment; in 25% halo traction failed to achieve or maintain any degree of reduction. During halo-thoracic immobilisation, half of the patients lost some degree of reduction and patient satisfaction with the appliance was low. Open reduction and internal fixation of unilateral facet injuries gave better results. 6

Peroneal spastic flatfeet without coalition or other known etiologies in adolescence remain a challenge to manage. We present eight such cases with radiological and surgical evidence of bony abnormalities in the subtalar region just anterior to the posterior facet. All patients had presented as tertiary referrals with recalcitrant pain and had undergone a trial of orthotics and physiotherapy. Diagnostic workup included a clinical and radiographic evaluation. Clinical examination consisted of gait examination, foot alignment, range of motion, torsional profile of the lower limbs and marking of symptomatic foci. All patients had standing weightbearing AP and lateral projections of the foot and ankle. CT and/or MRI scans of the foot were performed in axial coronal and saggital planes. Coalitions and other intraarticular known pathologies were ruled out. All patients had bilateral flatfeet but unilateral peroneal spasm. All patients had an accessory talar facet in front of the posterior subtalar facet. This caused lateral impingement between the facet and the calcaneum, confirmed by bone edema around the sinus tarsi. All patients had stiff subtalar joints with very limited movement under anaesthesia, indicating peroneal muscle contracture. Patients were treated with a combination of facet excision, peroneal lengthening and calcaneal lengthening to correct the flatfoot and prevent lateral impingement. We propose a mechanism of subtalar impingement between the anterior extra-articular part of the talar lateral process and the Gissane angle and believe that resection of the accessory facet without addressing the the primary driving force for impingement, which is the structural malalignment in flatfeet, would only give partial relief of symptoms. This impingement appears to occur with growth spurts in adolescents, in patients with known flatfeet