Background. Establishing the diagnosis in a child presenting with an atraumatic limp can be difficult. Clinical prediction algorithms have been devised to distinguish septic arthritis (SA) from transient synovitis (TS). Within Europe measurement of the Erythrocyte Sedimentation Rate (ESR) has largely been replaced with assessment of C-Reactive Protein (CRP) as an acute phase protein. We produce a prediction algorithm to determine the significance of CRP in distinguishing between TS and SA. Method. All children with a presentation of ‘atraumatic limp’ and a proven effusion on hip ultrasound between 2004 and 2009 were included. Patient demographics, details of the clinical presentation and laboratory investigations were documented to identify a response to each of the four variables (Weight bearing status, WCC >12,000 cells/m3, CRP >20mg/L and Temperature >38.5°C). SA was defined based upon culture and microscopy of the operative findings. Results. 311 hips were included within the study. Of these 282 were considered to have transient synovitis. 29 patients met criteria to be classified as SA based upon laboratory assessment of the synovial fluid. The introduction of CRP eliminated the need for a four variable model as the use of two variables (CRP and weight bearing status) had similar efficacy. Treating individuals who were non-weight-bearing and a CRP >20mg/L as SA correctly classified 94.8% individuals, with a sensitivity of 75.9%, specificity of 96.8%, positive predictive value of 71.0%, and negative predictive value of 97.5%. CRP was a significant independent predictor of septic arthritis. Conclusions. CRP was a strong independent risk factor of septic arthritis, and its inclusion within a regression model simplifies the diagnostic algorithm. Nevertheless, this and other models are generally more reliable in excluding SA, than confirming SA, and therefore a clinician's acumen remains important in identifying SA in those individuals with a single abnormal variable

The opposable thumb is one of the defining characteristics of human anatomy and is involved in most activities of daily life. Lack of optimal thumb motion results in pain, weakness, and decrease in quality of life. First carpometacarpal (CMC1) osteoarthritis (OA) is one of the most common sites of OA. Current clinical diagnosis and monitoring of CMC1 OA disease are primarily aided by X-ray radiography; however, many studies have reported discrepancies between radiographic evidence of CMC1 OA and patient-related outcomes of pain and disability. Radiographs lack soft-tissue contrast and are insufficient for the detection of early characteristics of OA such as synovitis, which play a key role in CMC OA disease progression. Magnetic resonance imaging (MRI) and two-dimensional ultrasound (2D-US) are alternative options that are excellent for imaging soft tissue pathology. However, MRI has high operating costs and long wait-times, while 2D-US is highly operator dependent and provides 2D images of 3D anatomical structures. Three-dimensional ultrasound imaging may be an option to address the clinical need for a rapid and safe point of care imaging device. The purpose of this research project is to validate the use of mechanically translated 3D-US in CMC OA patients to assess the measurement capabilities of the device in a clinically diverse population in comparison to MRI. Four CMC1-OA patients were scanned using the 3D-US device, which was attached to a Canon Aplio i700 US machine with a 14L5 linear transducer with a 10MHz operating frequency and 58mm. Complimentary MR images were acquired using a 3.0 T MRI system and LT 3D coronal photon dense cube fat suppression sequence was used. The volume of the synovium was segmented from both 3D-US and MR images by two raters and the measured volumes were compared to find volume percent differences. Paired sample t-test were used to determine any statistically significant differences between the volumetric measurements observed by the raters and in the measurements found using MRI vs. 3D-US. Interclass Correlation Coefficients were used to determine inter- and intra-rater reliability. The mean volume percent difference observed between the two raters for the 3D-US and MRI acquired synovial volumes was 1.77% and 4.76%, respectively. The smallest percent difference in volume found between raters was 0.91% and was from an MR image. A paired sample t-test demonstrated that there was no significant difference between the volumetric values observed between MRI and 3D-US. ICC values of 0.99 and 0.98 for 3D-US and MRI respectively, indicate that there was excellent inter-rater reliability between the two raters. A novel application of a 3D-US acquisition device was evaluated using a CMC OA patient population to determine its clinical feasibility and measurement capabilities in comparison to MRI. As this device is compatible with any commercially available ultrasound machine, it increases its accessibility and ease of use, while proving a method for overcoming some of the limitations associated with radiography, MRI, and 2DUS. 3DUS has the potential to provide clinicians with a tool to quantitatively measure and monitor OA progression at the patient's bedside

Introduction:. The earliest evidence of particle-induced response is found in the synovium, leading to osteolytic defect. The degree of synovitis can be quantified by magnetic resonance imaging (MRI). This is the first long-term, prospective, matched-pair study using MRI to analyze wear-induced synovitis and osteolysis between rotating-platform posterior-stabilized (RP-PS), fixed-bearing metal-back (FB-MB), and all-polyethylene tibial (APT) designs in active patients with identical femoral components and polyethylene. Methods:. From September 1999 to October 2001, a matched-pair analysis of 24 TKAs (18 patients, 3 groups: 8 RP-PS, 8 FB-MB, and 8 APT) was performed. TKAs were matched for age, sex, body mass index (BMI), and University of California Los Angeles (UCLA) activity scores. All patients underwent MRI using MAVRIC (multi-acquisition variable-resonance image combination) knee protocol designed to reduce metal susceptibility artifact. Images were evaluated for volumetric measure of synovitis and/or osteolysis and presence of fibrous membrane formation at the cement-bone interface. Results:. The mean age was 64 ± 5 years (59–72). The mean follow-up was 11.6 ± 0.7 years (10–13). The mean UCLA score at the time of surgery was 8.5 ± 2.6 (5–10). Reactive synovitis was observed in 6 RP-PS (75%), all 8 FB-MB (100%), and 6 APT (75%) knees. There was a significant difference between the volumetric synovitis in RP-PS (4046 mm3 ± 4502 mm3), and FB-MB knees (24498 mm3 ± 22248 mm3), p < 0.001. Osteolysis with bone loss more than 4 mm was seen in 3 FB-MB, 2 APT, but in none of the RP-PS knees. There was no statistical difference for osteolysis between the three designs. Conclusion:. Based of this study, it appears that particle induced synovitis is evident in all 3 types of bearing surfaces, however, it is significantly less in the RP-PS group. This is in contradiction to the report of retrieval studies

A patient in his thirties developed synovitis with grade 4 chondrolysis and a stiff knee with a fixed flexion deformity between three and six years following PLC and PCL reconstruction using LARS (Ligament Augmentation and Reconstruction System, Corin). There was histologic evidence of foreign body reaction, the knee was painful, swollen and stiff. We did not use any further LARS ligaments for soft tissue reconstructions of the kneein our practice. We commenced a recall programme for all 83 patients patients who underwent a soft tissue knee reconstruction using LARS. Of those contacted, 41 replied (49%) and 16 patients had symptoms (19%) and were investigated further with XRay, MRI and arthroscopy as indicated. We discovered a total of five patients had histologically proven synovitis with foreign body reactions (6%), three of whom had life-changing symptomatic pain, swelling and stiffness with degenerate changes (3.6%). These patients had undergone various reconstructions, including a) PLC only, b) ACL and PCL, c) PCL and PLC and d) ACL, PCL and PLC. A further single case of massive bone cyst formation was noted, following PCL reconstruction using LARS (1.2%)

Introduction. Persistent pain after medial unicompartmental knee arthroplasty (UKA) is a prevailing reason for revision to total knee arthroplasty (TKA). Many of these pathologies can be addressed arthroscopically. The purpose of this study is to examine the outcomes of patients who undergo an arthroscopy for any reason after medial UKA. Methods. A query of our practice registry revealed 58 patients who had undergone medial UKA between October 2003 and June 2015 with subsequent arthroscopy. Mean interval from UKA to arthroscopy was 22 months (range, 1–101 months). Indications for arthroscopy were acute anterior cruciate ligament tear (1), arthrofibrosis (7), synovitis (12), recurrent hemarthrosis (2), lateral compartment degeneration including isolated lateral meniscus tears (11), and loose cement fragments (25). Results. Mean follow-up after arthroscopy was 37 months (range, 1–134 months). Twelve patients have been revised from UKA to TKA. Relative risk of revision after arthroscopy for lateral compartment degeneration was 4.27 (6 of 11; 55%; p=0.002) and for retrieval of loose cement fragments was 0.05 (0 of 25; 0%; p=0.03). Relative risk for revision after arthroscopy for anterior cruciate ligament tear, arthrofibrosis, synovitis, or recurrent hemarthrosis did not meet clinical significance secondary to the low number of patients in these categories. Conclusions. The results of this study suggest that arthroscopic retrieval of cement fragments does not compromise UKA longevity. However, arthroscopy for lateral compartment degradation after UKA predicts a high risk of revision to TKA regardless of its relative radiographic insignificance

Purpose of the Study:. Spontaneous intraarticular haemorrhages are the most frequent bleeding episodes encountered in the haemophiliac population, causing pain, joint deformity and arthropathy. Chronic haemophiliac arthropathy is characterised by persistent joint swelling, proliferative synovitis, and damage to or loss of articular cartilage. Elimination of the synovitis is the key to prevention of recurrent intraarticular haemorrhages and joint damage. The purpose of the study was to investigate the indications for, and outcome of, radioactive synoviorthesis for haemophiliac arthropathy. Methods:. A retrospective study was done to assess the results of 12 intra-articular injections of radioactive Yttrium-90 colloid, performed in 10 patients from November 1993 to December 2006. Patients were referred by the Haematology Unit if they had a target joint, as defined as >2 bleeds into the same joint in the preceding 6 months. Follow up was conducted at 6 monthly intervals, assessing clinical and radiological outcomes. The radiological involvement of the target joint, the pre- and post-treatment range of movement, presence of synovitis and bleeding events were compared from presentation to that at follow up. Range of movement of each target joint was assessed and compared to that at follow-up. Results:. The average age at time of injection was 10.6 years (range 6–15). The duration of follow-up was 35 months (range 6 to 60 months). The involved joints had an average of 2 bleeds each in the 6 months preceding the injection (24 events). Following Yttrium injection only 1 out of 12 joints had a bleed in the subsequent 6 months (1 event). Synovitis of the target joint resolved in 11 of 12 joints. Nine target joints (75%) showed a favourable improvement in range of movement. Those with a favourable radiological score had a better clinical outcome, but even those with a poor score showed improvement. Conclusion:. In this study, intra-articular injection of radioactive Yttrium-90 colloid was shown to:. –. Significantly reduce bleeding events in a Haemophiliac cohort. –. Resolve synovitis in 11 out of 12 joints with haemophiliac arthropathy. –. Improve range of movement in the majority of patients. –. This was best in those with a better radiological appearance at presentation. –. Those with a poorer radiological grade also showed some improvement suggesting that while results are less certain, patients may still benefit from the intervention

This case series highlights the use of the Ganz approach (trochanteric slide approach) and surgical dislocation for excision of fibrous dysplasia of the femoral neck, pigmented villonodular synovitis and synovial chondromatosis of the hip. The first patient was a 16-year-old girl, who presented with pain in her hip, having fallen whilst playing football. Investigations revealed a fibrous dysplasia, which was successfully excised returning her to an active lifestyle. The second patient was a 27-year-old lady, who presented having suffered left hip pain for four years. She was diagnosed with a pigmented villonodular synovitis, which was excised and the patient was able to return to the gym. The third patient was a 41-year-old lady, who presented after experiencing right hip pain both at night and at rest for a year, without any trauma. She was diagnosed with synovial chondromatosis and returned to all activities of daily living. The Ganz approach allows safe dislocation of the hip joint without the risk of osteonecrosis of the femoral head. We demonstrate that it is possible to obtain excellent exposure of the femoral neck, head and acetabulum to surgically treat these three tumours of the hip. The surgeon can thus be reassured that complete excision of the tumour has occurred. This series can recommend the Ganz approach with trochanteric slide and full surgical dislocation of the hip to excise pigmented villonodular synovitis, synovial chondromatosis and fibrous dysplasia of the hip

Aberrant infrapatellar fat metabolism is a notable feature provoking inflammation and fibrosis in the progression of osteoarthritis (OA). Irisin, a secretory subunit of fibronectin type III domain containing 5 (FNDC5) regulate adipose morphogenesis, energy expenditure, skeletal muscle, and bone metabolism. This study aims to characterize the biological roles of Irisin signaling in an infrapatellar fat formation and OA development. Injured articular specimens were harvested from 19 patients with end-stage knee OA and 11 patients with the femoral neck fracture. Knee joints in mice that overexpressed Irisin were subjected to intra-articular injection of collagenase to provoke OA. Expressions of Irisin, adipokines, and MMPs probed with RT-quantitative PCR. Infrapatellar adiposity, articular cartilage damage, and synovial integrity verified with histomorphometry and immunohistochemistry. Infrapatellar adipose and synovial tissues instead of articular cartilage exhibited Irisin immunostaining. Human OA specimens showed 40% decline in Irisin expression than the non-OA group. In vitro, the gain of Irisin function enabled synovial fibroblasts but not chondrocytes to display minor responses to the IL-1β provocation of MMP3 and MMP9 expression. Of note, Irisin signaling reduced adipogenic gene expression and adipocyte formation of mesenchymal progenitor cells. In collagenase-mediated OA knee pathogenesis, forced FNDC5 expression in articular compromised the collagenase-induced infrapatellar adipose hypertrophy, synovial hypercellularity, and membrane hyperplasia. These adipose-regulatory actions warded off the affected knees from cartilage destruction and gait aberrance. Likewise, intra-articular injection of Irisin recombinant protein mitigated the development of infrapatellar adiposity and synovitis slowing down the progression of cartilage erosion and walking profile irregularity. Affected joints and adipocytes responded to the Irisin recombinant protein treatment by reducing the expressions of cartilage-deleterious adipokines IL-6, leptin, and adiponectin through regulating PPAR&gamma, function. Irisin dysfunction is relevant to the existence of end-stage knee OA. Irisin signaling protects from excessive adipogenesis of mesenchymal precursor cells and diminished inflammation and cartilage catabolism actions aggravated by adipocytes and synovial cells. This study sheds emerging new light on the Irisin signaling stabilization of infrapatellar adipose homeostasis and the perspective of the therapeutic potential of Irisin recombinant protein for deescalating knee OA development

Two big problems exist with the all polyethylene cemented tibial component; the polyethylene and the cement. The polyethylene is too weak and flexible to bear high tibial load, so it deforms and loosens. The interface stresses are too high when two flexible structures are poorly bonded and heavily loaded. Modularity between the polyethylene tibial component and the metal-backed tray was introduced in the mid-80's for versatility and to facilitate screw fixation for cementless implants. These designs allow exchange of various polyethylene thicknesses, and aids the addition of stems and wedges. Other advantages include the reduction of inventory, and the potential for isolated tibial polyethylene exchanges as a simpler revision procedure. Several studies have documented the high failure rate of isolated polyethylene exchange procedures, because technical problems related to the original components are left uncorrected. However, revision for wear is the simplest revision ever!. Since the late 1980's the phenomena of polyethylene wear and osteolysis have been observed much more frequently when compared with earlier eras. The reasons for this increased prevalence of synovitis, progressive osteolysis, and severe polyethylene wear remain unclear. There is some association with the widespread use of both cementless and cemented modular tibial designs. Improved polyethylene attachment is the answer even if a screw, a wire, or a pin is needed. Do not abandon the modular tibia

Purpose of study:. “Ganglia are a benign condition taking up the time of competent surgeons who might be more usefully engaged.” – McEvedy. Our aim was to perform a retrospective review comparing preoperative clinical presentation, intraoperative findings and histological diagnosis of all hand and wrist ganglia presenting to the Hand Unit at Chris Hani Baragwanath Hospital. Methods:. A retrospective review of hand and wrist ganglia treated at the Hand Unit at Chris Hani Baragwanath Hospital. Clinical and surgical notes and histology reports were reviewed. All ganglia were removed surgically as directed by clinical findings. Results:. A total of 75 hand and wrist masses were operated over a period of 6 months between January and June 2012. Of these 42 were clinically diagnosed as ganglia. All 42 “ganglia” were removed surgically and sent for histological evaluation. Of these, 40 were diagnosed intra-operatively as ganglia. In 2 cases the diagnoses were changed intra-operatively to synovitis and Giant Cell Tumor of tendon sheath. Histologically 5 out of 42 cases were found not to be ganglia; their diagnoses were as follows:. 1. Granulomatous synovitis. 2. Chronic inflammation (possible tuberculous). 3. Giant Cell Tumour of Tendon Sheath. (Correlates with intra-op diagnosis). 4. Nerve sheath tumour (Schwannoma). 5. Chronic bursitis. Conclusion:. Be wary of “the simple ganglion”. Other conditions may mimic a ganglion with potentially disastrous consequence if misdiagnosed. In our setting histological evaluation is compulsory. Always follow the patient up and confirm histological diagnosis

Introduction. Instability, loosening, and patellofemoral pain belong to the main causes for revision of total knee arthroplasty (TKA). Currently, the diagnostic pathway requires various diagnostic techniques such as x-rays, CT or SPECT-CT to reveal the original cause for the failed knee prosthesis, but increase radiation exposure and fail to show soft-tissue structures around TKA. There is a growing demand for a diagnostic tool that is able to simultaneously visualize soft tissue structures, bone, and TKA without radiation exposure. MRI is capable of visualising all the structures in the knee although it is still disturbed by susceptibility artefacts caused by the metal implant. Low-field MRI (0.25T) results in less metal artefacts and offers the ability to visualize the knee in weight-bearing condition. Therefore, the aim of this study is to investigate the possibilities of low field MRI to image, the patellofemoral joint and the prosthesis to evaluate the knee joint in patients with and without complaints after TKA. Method. Ten patients, eight satisfied and two unsatisfied with their primary TKA, (NexGen posterior stabilized, BiometZimmer) were included. The patients were scanned in sagittal, coronal, and transversal direction on a low field MRI scanner (G-scan Brio, 0.25T, Esaote SpA, Italy) in weight-bearing and non-weight-bearing conditions with T1, T2 and PD-weighted metal artefact reducing sequences (TE/TR 12–72/1160–7060, slice thickness 4.0mm, FOV 260×260×120m. 3. , matrix size 224×216). Scans were analysed by two observers for:. - Patellofemoral joint: Caton-Descamps index and Tibial Tuberosity-Trochlear Groove (TT-TG) distance. - Prosthesis malalignment: femoral component rotation using the posterior condylar angle (PCA) and tibial rotation using the Berger angle. Significance of differences in parameters between weight-bearing and non-weight-bearing were calculated with the Wilcoxon rank test. To assess the reliability the inter and intra observer reliability was calculated with a two-way random effects model intra class correlation coefficient (ICC). The two unsatisfied patients underwent revision arthroplasty and intra-operative findings were compared with MRI findings. Results. In the satisfied group, a significant difference was found between TT-TG distance in non-weight-bearing and weight-bearing condition (p=0.018), with a good interrater reliability ICC=0.89. Furthermore, differences between weight-bearing and non-weight-bearing were found for the CD ratio, however, not significant (p=0.093), with a good interrater reliability ICC=0.89. The Berger angle could be measured with an excellent interrater reliability (ICC=0.94). The PCA was hard to assess with a poor interrater reliability (ICC=0.48). For one unsatisfied patient a deviation was found for tibial component rotation, according to the perioperative findings as, ‘malposition of the tibial component’. For the other unsatisfied patient revision surgery was performed due to aseptic loosening in which the MRI showed a notable amount of synovitis. Conclusion. It is possible to image the patellofemoral joint and knee prosthesis with low field MRI. Patellofemoral measurements and tibial component rotation measurements can reliably be performed. For the two patients with complaints MRI findings were consistent with intra-operative findings. Further research should focus on a larger group of patients with complaints after TKA to verify the diagnostic capacity of low field MRI for peri-prosthetic knee problems. For any figures or tables, please contact authors directly

Introduction and aim. TKR remains one of the most successful surgeries in orthopedics. Still a sizeable number of patients remain dissatisfied reaching to a level of 30%. Our aim was to examine the excised synovium from the suprapatellar region in all osteoarthritic knees and evaluate the histopathological report to know if in a few cases the unrelenting pain and discomfort could be due to some undiagnosed pathology within the joint. Materials and Methods. We selected 40 consecutive knees at our institution operated from Oct 2014 to Jan 2015. Of the total knees 7 patients were operated as single stage bilateral TKR. Supra patellar synovium was thoroughly excised and sent for histopathology examination. Patients who were clinically, serologically and radiologically diagnosed as rheumatoid arthritis or sero negative arthritis were excluded. The implant used was Maxx Freedom knee (PS design). Results. We found abnormal reports in 8 of our 40 knees (20%). 6 of these were proven to be rheumatoid arthritis whilst 2 of the knees showed chronic villous synovitis. Conclusion. 20% of our patients exhibited result which were totally unexpected. This could be one of the many causes in persistently dissatisfied patient after a technically well done TKR. So as a routine we advocate all surgeons to send the excised synvoium for histopathology during a routine TKR. Also a large multi-centric study undertaken at various centers would definitely help to throw more light on this not so well understood topic and thus help reduce this lot of dissatisfied patients

Aim. This study aims to determine the value of MRI in children with hip pain which remained unexplained following routine investigations including ultrasound examination. Materials and methods. Retrospective review of clinical notes and MRI findings in all children who received and MRI scan for undiagnosed hip pain over three years. Results. Fifty five children underwent an MRI scan of their hips for unexplained hip pain. 29 were male and 26 were female. The mean age was 10.9 years. The MR study provided a diagnosis in 22 children (40%), and was normal in 33 children (60%). Five cases were considered to be due to transient synovitis. Three children were diagnosed as osteoid osteoma. Two children were were found to have trochanteric bursitis. Two children were shown to have muscle trauma (one child with adductor trauma and one child with piriformis trauma). Two children were diagnosed with non-specific bone oedema. The remaining eight children were diagnosed with Perthes' disease, haemarthrosis, sacro-iliac infection, synovitis secondary to juvenile idiopathic arthritis, ischio-pubic osteochondrosis, acetabular dysplasia, Klippel-Trenaunay syndrome and resolution of an eosinophilic granuloma. None of the children discharged following a normal scan has subsequently presented with hip disease. Conclusions. It is concluded that MRI is useful in the diagnosis of hip pain in children in whom routine investigation has not yielded an answer

Introduction. The purpose of this study was to assess the rate of revision subacromial decompression and identify different pathologies. Materials/Methods. We analysed the patients who underwent Revision Arthroscopic Subacromial decompression from our prospective database of shoulder patients. Between April 2003 and Dec 2010, 797 patients underwent arthroscopic subacromial decompression. Patients who underwent any other procedure i.e. biceps tenotomy, capsular release, cuff repair were excluded from the study. Of these, 37 underwent a revision subacromial decompression (Revision rate 4.6%). The indication for revision procedure was persistent pain or restricted movements not responding to physiotherapy and injections. Results. We found that 1) Patients having cuff pathology i.e. partial tear or degenerate cuff were more likely to need a revision procedure (11/37 and 92/797, p = 0.001). 2) The rate of ACJ excision done for residual pain after primary subacromial decompression was similar to the rate of ACJ excision at the time of the primary procedure (7/37 vs. 100/797, p= 0.5). 3) Presence of Calcific deposits did not have any influence on the risk of having a revision procedure (2/37 and 12/797, p= 0.1). 4) Patients found to have synovitis in the primary procedure were more likely to need revision procedure (10/37 and 81/797, p = 0.001). 5) Presence of biceps tendonitis did not significantly affect the risk of having a revision procedure after arthroscopic subacromial decompression (3 /37 and 21 /797, p = 0.5). Conclusion. Our revision rate is similar to those published in literature. In our failed cases there was a trend for patients to have an associated partial rotator cuff tear and synovitis

Background. Cartilage lesions in chronic lateral ligament deficiency are common with the incidence rates mentioned in the previous literature up to 30%. However, other intra-articular pathologies in the unstable ankle have received little attention. Anterolateral impingement associated with synovitis and scarring is a less recognised feature in the treatment of chronic instability. The aim of our study was to ascertain the incidence of chondral and anterolateral impingement lesions in the symptomatic lateral ligament complex deficiency. Methods. We performed a retrospective study of all consecutive patients who underwent modified Brostrom repair for symptomatic recurrent instability of the ankle. All patients underwent a MRI scan prior to surgery. Arthroscopy was performed in all the patients before lateral ligament reconstruction. Seventy seven patients with 78 ankles were included in the study. Patients who had previous ankle surgery or inflammatory arthropathy were excluded. Data was obtained from clinical and radiological records. Arthroscopic findings were recorded in detail during the surgery. Results. The mean age was 29.8 years (Range 18.2–58 yrs). There were 44 females and 34 males in the study. The incidence of chondral lesions were 11.5% (9 out of 78 ankles). The commonest site for chondral defect was the anteromedial talar dome. The incidence of anterolateral impingement which required arthroscopic debridement was 48.7 %(38 ankles). A further 10 ankles revealed non-specific synovitis and scarring which was debrided. The sensitivity and specificity of the MRI scans in the assessment of chondral lesions is 91% and 100%. Conclusion. The incidence of chondral lesions in chronic ankle instability is lower than previously published literature. However, soft tissue impingement lesions have a much higher incidence and require debridement. Arthroscopic examination and debridement of impingement prior to lateral ligament reconstruction of the ankle is quintessential in the management of chronic anterolateral instability

Introduction:. Unicompartmental knee arthroplasty (UKA) is a well established method for treatment of single compartment arthritis. However, a subset of patients still present with continued pain after their procedure in the setting of a normal radiographic examination. We propose the use of magnetic resonance imaging (MRI) as a useful modality in determining the etiology of symptoms in symptomatic unicompartmental knee arthroplasties. Materials & Methods:. An IRB-approved retrospective analysis of 300 consecutive unicompartmental knee arthroplasties between 2008–2010 found 28 cases symptomatic for continued pain. Magnetic resonance imaging was performed with a 1.5 T Surface Coil unit after clinical and radiographic assessment. MRI evaluation included assessment for osteoarthritis, synovitis, osteolysis, and loosening. Validated questionnaires including PAQ, WOMAC and UCLA Activity Score were used for clinical assessment. Results:. The average age at surgery was 56.1 ± 10.9 years (34–79). Imaging results indicated progressive arthritis in 28 patients (100%), synovitis in 17 patients (61%), osteolysis in 9 patients (32.0%), and loosening in 3 patients (11%). Based on these results and other clinical findings, a revision or conversion to a TKR was advised for 10 patients and 18 were recommended for nonoperative therapies. One patient received treatment at a separate hospital, and another was lost to follow-up. At post-operative follow-up of 1.4 ± 0.9 years, 7 of the 10 patients (70%) in the operative group experienced improvement in pain and function. The mean PAQ, UCLA and WOMAC index scores for these patients were 8.0 ± 1.4 (7–9), 5.5 ± 6.4 (1–10), and 2.0 ± 2.8 (0–4), respectively. In the nonoperative group, 11 of the 18 patients (61%) experienced improvement in pain and function. Among these patients, the mean PAQ, UCLA and WOMAC index scores were 7.6 ± 3.7 (0–10), 5.9 ± 3.2 (1–10) and 8.9 ± 12.0 (0–28), respectively. Conclusion:. The use of MRI as an imaging modality for symptomatic arthroplasty patients is becoming more commonly used. This study shows how MRI with sound clinical judgment can influence treatment decisions and supports the use of high quality MRI as a diagnostic tool for the symptomatic unicompartmental knee arthroplasty

Two big problems exist with the all-polyethylene cemented tibial component; the polyethylene and the cement. The polyethylene is too weak and flexible to bear high tibial load, so it deforms and loosens. The interface stresses are too high when two flexible structures are poorly bonded and heavily loaded. Modularity between the polyethylene tibial component and the metal-backed tray was introduced in the mid-80's for versatility and to facilitate screw fixation for cementless implants. These designs allow exchange of various polyethylene thicknesses, and aids the addition of stems and wedges. Other advantages include the reduction of inventory, and the potential for isolated tibial polyethylene exchanges as a simpler revision procedure. Several studies have documented the high failure rate of isolated polyethylene exchange procedures, because technical problems related to the original components are left uncorrected. However, revision for wear is the simplest revision ever!. Since the late 1980's the phenomena of polyethylene wear and osteolysis has been observed much more frequently when compared with earlier eras. The reasons for this increased prevalence of synovitis, progressive osteolysis, and severe polyethylene wear remain unclear. There is some association with the widespread use of both cementless and cemented modular tibial designs. Improved polyethylene attachment is the answer even if a screw, a wire, or a pin is needed. Do not abandon the module tibia

Two big problems exist with the all-polyethylene cemented tibial component; the polyethylene and the cement. The polyethylene is too weak and flexible to bear tibial load, so it deforms and loosens. The interface stresses are too high when two flexible structures are poorly bonded and heavily loaded. Modularity between the polyethylene tibial component and the metal-backed tray was introduced in the mid-1980s for versatility and to facilitate screw fixation for cementless implants. These designs allow exchange of various polyethylene thicknesses, and aid the addition of stems and wedges. Other advantages include the reduction of inventory, and the potential for isolated tibial polyethylene exchanges as a simpler revision procedure. Several studies have documented the high failure rate of isolated polyethylene exchange procedures, because technical problems related to the original components are left uncorrected. However, revision for wear is the simplest revision ever!. Since the late 1980s the phenomena of polyethylene wear and osteolysis have been observed much more frequently when compared with earlier eras. The reasons for this increased prevalence of synovitis, progressive osteolysis, and severe polyethylene wear remain unclear. There is some association with the widespread use of both cementless and cemented modular tibial designs. Improved polyethylene attachment is the answer even if a screw, a wire, or a pin is needed. Do not abandon the modular tibia on any patient

Introduction. We previously reported a 28% short-term corrosion-related revision rate of recalled Rejuvenate modular stem. The purpose of this study was to assess the mid-term clinical results and survivorship of this implant. Methods. Between June 2009 and July 2012, 73 total hip arthroplasty (THA) in 63 patients with the Rejuvenate modular neck implant were performed by a single surgeon and prospectively followed. Average age was 63.2 ± 12.6 years (28 to 86). Elevated metal ion (= 2 µg/L), pain, or positive MRI findings were indication for revision surgery. Correlation between patient factors with serum metal ion levels and revisions were analyzed. Results. At an average follow-up of 4.2 ± 0.6 years (3.0 to 5.5), 57 hips (48 patients, 78%) were revised at mean of 3.2 ± 1 years (1 to 5.5); and 6 other have been scheduled for surgery. The Kaplan-Meier survivorship was 22 % at 5.5 years. Visible corrosion was seen at the trunion-stem junction in each revision case. 51 of 57 hips undergoing revision (89%), had elevated preoperative serum Co levels, 24 (42%) had elevated preoperative Cr. The average serum Co and Cr ion levels prior to revision surgery were 10 ± 8 µg/L (0.3 to 40) and 2.3 ± 1.5 µg/L (1 to 7.4), respectively. There was a significant correlation between revision surgery and younger age (p=0.0137). 52 hips underwent MRI evaluation, 22 hips (42%) had positive findings correlated to pain (p=0.025): 11 hips demonstrated adverse local soft tissue reactions such as fluid collection, capsular thickening, osteolysis, or synovitis, and 11 hips showed evidence of pseudotumor. Conclusions. At mid-term follow-up, 86% of the Rejuvenated modular neck stems have been revised or awaiting revision. Given these findings, all patients with a Rejuvenate modular neck stem implant should be followed closely and advised of impending failure

Juvenile idiopathic arthritis(JIA) is chronic inflammation commonly occurs in early childhood. Recently, biological therapies are used in JIA at the early stage as same as rheumatoid arthritis, due to retain joint cartilage. However, some of young patients have painful knee problems requiring knee replacement. We experienced 4 cases of JIA treated by knee arthroplasty. The average age at surgery was 33.5 years (range, 26–38 years) with a mean follow-up of 9.5 years (range, 5–18 years). We evaluated the knee range of motion and functional outcomes by the Knee Society Score (KSS), implant selection, postoperative complication, surgery of another joint. Mean range of motion improved from 76.3° (0°–120°) at pre-operation to 110.6° (80°–130°) at post-operation (P<0.05). Mean KSS increased from 47.3 ±20.1 preoperatively to 86.9 ±11.1 (P<0.01) at last follow-up and the mean KSS function from 27.5 ±25.9 to 62.5±20.2 at last follow-up (P<0.05). All of the TKAs were cemented, 5 were cruciate-retaining implant designs, whereas 2 TKAs had constrained posterior stabilized implant designs. Patellar resurfacing was undergone in all knees. Bone graft required in 1 knee within severe knee deformity. Complication were occurred in 5 knees. Medial instability in 2 knees. Skin necrosis, MCL avulsion, recurrence of the synovitis are one in each. All cases had polyarticular type. Previous THA had undergone in 5 hips, synovectomy in 3 knees, foot surgery in 2 feet. At latest follow-up, 1 of 8 TKAs (12.5%) had been revised, and had revision of its polyethylene exchange only. Patients with JIA often have valgus alignment with a flexion contracture and poor bone quality is also frequently compromised. Prescribed immunosuppressive medication or biological agents may cause to infection. In our series there were no infection, but some of these need much more soft tissue release because of severe deformity and flexion contracture. TKA survivorship for JIA is inferior to that typically seen in younger patients with osteoarthritis or rheumatoid arthritis. The knee of conservative therapy were often caused to severe functional limitations. Timimg of TKA may be indicated no matter how young the patient is. Extending timing of TKA may leads to worse outcome and postoperative function. But it may be caution that the surgical exposure can be difficult, because of stiffness, flexion contracture, bony deformity, osteopenia