Similar to the radiological findings in rapidly destructive arthrosis of the hip joint (RDA), subchondral insufficiency fracture of the femoral head (SIF) can result in progressive femoral head collapse of unknown etiology. We thus examined the osteoclast activity in hip joint fluid in SIF with progressive collapse in comparison to that in RDA. Twenty-nine hip joint fluid samples were obtained intraoperatively with whole femoral heads from 12 SIF patients and 17 RDA patients. SIF cases were classified into subgroups based on the presence of ≥2mm collapse on preoperative radiographs: SIF with progressive collapse (n=5) and SIF without progressive collapse (n=7). The levels of tartrate-resistant acid phosphatase (TRACP)-5b, interleukin-8, vascular endothelial growth factor (VEGF), and matrix metalloproteinase (MMP)-9 were measured. Numbers of multinuclear giant cells at the subchondral region were assessed histopathologically using mid-coronal slices of each femoral head specimen. Median levels of all markers and median numbers of multinuclear giant cells in SIF with progressive collapse were significantly higher than those in SIF without progressive collapse, while there were no significant differences in SIF with progressive collapse versus RDA. Regression analysis showed that the number of multinuclear giant cells correlated positively with the level of TRACP-5b in joint fluid. This study suggests an association of increased osteoclast activity with the existing condition of progressive collapse in SIF, which was quite similar to the findings in RDA. Therefore, high activation of osteoclast cell may reflect the condition of progressive collapse in SIF as well as RDA

Summary. The ankle X-ray has moderate diagnostic power to identify syndesmotic instability, showing large sensitivity ranges between observers. Classification systems and radiographic measurements showed moderate to high interobserver agreement, with extended classifications performing worse. Introduction. There is no consensus regarding the diagnosis and treatment of ankle fractures with respect to syndesmotic injury. The diagnosis of syndesmotic injury is currently based on intraoperative findings. Surgical indication is mainly made by ankle X-ray assessment, by several classification systems and radiographic measurements. Misdiagnosis of the injury results in suboptimal treatment, which may lead to chronic complaints, like instability and osteoarthritis. This study investigates the diagnostic power and interobserver agreement of three classification methods and radiographic measures, currently used to assess X-ankles and to identify syndesmotic injury. Patients and Methods. Twenty patients (43.2 ± 15.3yrs) with an ankle fracture, indicated for surgery, were prospectively included. All patients received a preoperative ankle X-ray, which was assessed by several observers: two orthopaedic surgeons, one trauma surgeon and two radiologists. The ankle X-ray was assessed on syndesmotic injury/stability and presence of fractures (fibula, medial/tertius malleolus). Three classification systems were used: Weber, AO-Müller (short-version n=3 options; extended-version n=27 options), Lauge-Hansen (short-version n=5 options; extended-version n=17 options) and two radiographic measurements were done: tibiofibular overlap (TFO) and ratio medial clearspace/superior clear space (MCS/SCS). All observers were instructed about the assessments before the measurements. During surgery, a proper intraoperative description of the syndesmosis was noted. Agreement (%), Intraclass Correlation Coefficients (ICC) and Kappa were calculated to determine interobserver agreement. Kappa statistic was interpreted according to Landis and Koch. To test the diagnostic power of ankle X-rays to identify syndesmotic instability, sensitivity and specificity were calculated with intraoperative findings serving as golden standard. Results. Six of 20 ankles showed syndesmotic instability intraoperatively. An overall sensitivity of 43% (specificity: 78) was found for X-rays in identifying syndesmotic instability, showing a wide range in sensitivity between observers (17–83%), with radiologists performing better (range 50–83%) than surgeons (range: 17–33%). Overall, substantial to perfect interobserver agreement (range 70–100%) was found for all short classification systems, showing an average kappa ≥0.60. The agreement reduced for more extended classification systems. E.g. observer agreement for the AO-Muller classification with 3, 9 and 27 options was respectively 85% (kappa 0.66), 68% (kappa 0.57) and 55% (kappa 0.51). One observer deviated slightly from others in all classification assessments. Removing this observer resulted in excellent agreement for all classification systems (>90%). Radiographic measurements showed moderate to high interobserver agreement, with TFO performing best (avg. ICC 0.88). Discussion/Conclusion. In ankle fractures, a preoperative X-ray has low sensitivity in detecting syndesmotic instability, showing large sensitivity ranges between observers. Further study is needed to investigate the contribution of classification systems in determining the best treatment method for syndesmotic injury. Ankle X-ray assessment using the three classification systems and radiographic measures was consistent among observers. Disagreement between observers can be attributed to intrinsic differences among the systems (e.g. stepwise classification vs. single assessment). No preference for one specific classification was found, as all showed comparable interobserver agreement. However classification systems with few options are recommended, as the observer agreement reduced with more extending classifications

The role of digital radiography has evolved in recent years. In many hospitals, radiographs have been completely digitised and moved to Picture Archiving and Communications System (PACS). Pre-operative templating for arthroplasty has been a major problem as a result. We investigate the accuracy of Orthoview™ software in templating for hip and knee arthroplasty. A retrospective review of 20 Stryker-Exter hip and 20 Biomet-Vanguard knee arthroplasties was conducted. Anonymised preoperative radiographs were reviewed by experienced orthopaedic surgeons. Templated component sizes were compared with actual implanted component sizes. All radiographs were digitised on Kodak Carestream PACS. Five surgeons were asked to separately review the radiographs to avoid intra-observer error. In templating for hip arthroplasty, Orthoview™ was 80% accurate in predicting the femoral stem size within one size of the actual component used. It predicted the offset with 100% accuracy. In 90% of patients, the actual head implant was within one size of the templated head. The system was able to predict the acetabular component size in only 30%. In knee arthroplasty, Orthoview™ was 80% accurate within one size of the actual component used for the femur and 90% for the tibia. Orthoview™ enables the flexibility of digitised films to be used for pre-operative templating. It is reasonably accurate in prediction of femoral sizing in both hip and knee arthroplasty and tibial size in knee arthroplasty. It is considerably less useful for acetabular sizing. Surgeons should keep this variability in mind until more accurate systems are available

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

In recent years the majority of X-ray departments have moved to a digital format of recording and archiving radiographs. These digital images (as with previous ‘films’) have a built in magnification factor (variable with each patient), which, may cause errors in templating for joint replacement surgery. Placing a marker of known size at the same level as the joint in question allows calculation of the magnification. This may help to restore hip offset in total hip replacement. To establish the magnification factor for digital radiographs taken in our unit. To assess the usefulness of marker images in accurate preoperative templating. Preoperative marker radiographs were identified retrospectively. The apparent size of the marker was measured on digital image. This value was used to calculate the magnification of the image. The scaled X-ray was up loaded to a digital templating software programme. This software uses a ‘scaling tool’ to calculate the magnification of the image. The hip joint templating tool was the used to calculate the offset of the proximal femur, this was performed with the calculated magnification and also an assumed magnification of 120%. The recommended offset of Exeter V40 stem was noted for both values. Images were identified for 40 patients with markers. The average magnification was 122% for both PACS and Orthoview with a range 113% – 129% and a standard deviation of 4%. The median value for magnification was 120%. The average change in offset between calculated and estimated magnification was 1.275mm with a maximum change of 3mm. In two cases this difference resulted in a change in the recommended offset (5%). The use of marker radiographs is widely described. In this small series the magnification is the same as previously reported in other studies. The difference in offset between calculated and estimated magnification was relatively small and caused a change in the recommended offset in only two patients. Variation in the use of the templating tool in our software can produce a much greater change in offset. Marker radiographs will only be useful as part of a standardised method of pre-operative templating