Osteochondritis dissecans of the humeral trochlea in two pediatric athletes: two cases and review of literature

We herein report two unusual cases of osteochondritis dissecans (OCD) of the trochlea. The injury consisted of a focal alteration of subchondral bone secondary to repetitive micro trauma from overhead maneuvers (pitching) in two male adolescents. Only 23 other cases of OCD affecting the trochlea have been reported. We comment on this discrepancy, explore the radiographic features, and detail the non-operative management that was undertaken. We substantiate our report with a systematic review of all OCD cases of the trochlea and provide information on patient demographics, sport type, management, recuperation and finally significance of radiographic grading.

Validity and interobserver agreement of a new radiographic grading system for intervertebral disc degeneration: Part III. Thoracic spine

Purpose The aim of this study was to assess the validity and objectivity of a new quantitative radiographic grading system for thoracic intervertebral disc degeneration. Methods The new grading system involves the measurement variables “Height loss” and “Osteophyte formation”, which are determined from lateral radiographs, resulting in the “Overall degree of degeneration” on a four-point scale from 0 (no degeneration) to 3 (severe degeneration). Validation was performed by comparing the radiographic degrees of degeneration of 54 human intervertebral discs to the respective macroscopic degrees, which were defined as the “real” degrees of degeneration. Interobserver agreement was examined using radiographs of 135 human thoracic intervertebral discs. Agreement was quantified by means of quadratically weighted Kappa coefficients with 95% confidence limits (CL). Results Validation revealed almost perfect agreement between the radiographic and the macroscopic overall degrees of degeneration (Kappa 0.968, CL 0.944–0.991), while the macroscopic grades tended to be underestimated in low degeneration grades. Radiographic grading of two independent observers also exhibited almost perfect agreement (Kappa 0.883, CL 0.824–0.941) as well as tendencies towards rater-dependent differences in low degeneration grades. Conclusion The new quantitative radiographic grading scheme represents a valid, reliable, and almost objective method for assessing the degree of degeneration of individual thoracic intervertebral discs. Potential effects of interindividual variations and the radiographic superimposition of anatomical structures represent a limitation of this method should be taken into account when using the grading system for clinical and experimental purposes, especially with regard to specific morphological as well as patient- and donor-specific characteristics.

IF NEEDED TO BE SURGICALLY INTERVENED UPON, IN THE PAEDIATRIC DIAPHYSEAL FRACTURES, WHICH IS THE BETTER AMONG THE AVAILABLE FIXATION DEVICES-A CASE SERIES CONSIDERATION.

Humeral fractures, in the paediatric age group, have two peaks of incidence. It has a high incidence in babies below three years of age, and again also in children, above 10 years of age. The objective of our study, was to compare the most popular operative techniques for handling humeral diaphyseal fractures, in the paediatric age group, such as Plate Osteosynthesis (Locking Compression Plate), Elastic Stable Intramedullary Nailing System (ESIS), and the External Fixation devices (EF). This prospective study was conducted at Chettinad Hospital and Research Institute (CH&RI), Kelambakkam, from July 2017 to June 2020. A total of 15 patients were a part of this study, of which, 8 were males and 7 were females. The functional outcomes were assessed using the DASH, the Borberg and Morrey scoring system and the radiographic assessment was done using Stan's Radiographic Grading system, in all the three methods of treatment. The Follow up period was for a minimum of twelve months. The Broberg and Morrey Score points were 88.4 (74-95) for LCP, 80.67 for ESIS (70- 91) and 83.87 (80-87) for EF (p value>0.05). In the DASH score, the average was 19.2 in the LCP group, 21.17 and 21.10, respectively, in the ESIS and EF groups. Stan's Radiographic Grading showed Grade 2 to 3 fracture union status, in all the xation modalities of our study. The prudence of the surgeon, his surgical experience, the age of the patient, the geometry of the fracture and the nature of the humeral diaphyseal fracture, all needs to be carefully weighed, analyzed and on a case-to-case basis, the decision has to be taken, regarding which xation device is best suited for that very particular fracture. All the three modalities have been showcased to highlight their pros and cons, not with-standing the fact that, all the three modalities have faired superiorly in giving good to excellent result outcomes.

Clinical Outcomes and PROMIS Scores with the Use of Synthetic Cartilage Implant (CARTIVA) in Hallux Rigidus at a Non-Industry Sponsored, Multi-Surgeon, Academic Institution

Category: Midfoot/Forefoot Introduction/Purpose: Hallux rigidus is a common arthritic condition seen by foot and ankle specialists. Historically, surgical treatment options have varied from an isolated cheilectomy to first metatarsophalangeal joint fusion. More recently, first metatarsophalangeal (MTP) joint hemiarthroplasty with a polyvinyl alcohol (PVA) hydrogel implant (Cartiva) has become a popular surgical option. A randomized clinical trial sponsored by the manufacturers of the implant showed equivalent pain relief and functional outcome scores at 2 year follow-up when compared to patients undergoing first MTP fusion. In addition, the study reported no bone loss, implant wear or loosening. We retrospectively reviewed 1 year PROMIS score outcomes, clinical outcomes and implant survivorship of patients treated with first MTP hemiarthroplasty with the Cartiva implant at an academic, multi-surgeon center. Methods: We retrospectively reviewed 54 consecutive patients that underwent first MTP hemiarthroplasty with Cartiva for hallux rigidus between January 1, 2017 and December 1, 2017. Minimum follow-up criteria was 1 year, with the average being 1.37 years and maximum follow-up of 1.9 years. The Coughlin radiographic grading of disease severity averaged 2.18 at the time of implantation on a scale of 0 to 4. Surgery was performed by 8 fellowship-trained orthopedic foot and ankle surgeons at an academic institution. Baseline PROMIS scores (physical function, pain interference, global function, global mental, depression) and PROMIS scores acquired at 1 year postoperative were compared and evaluated using the Wilcoxon signed t-test. Clinical outcomes and postoperative complications/events were documented through review of electronic medical records. At the time of the study, 49 patients had reached 1 year follow-up with an average age of 56 (range, 33 - 74) years at the time of implantation. Results: Physical function, pain interference, global function and depression scores all demonstrated clinically and statistically significant improvement at 1 year postoperative. Global mental score did not show significant improvement at the one year follow-up. One patient underwent revision surgery to a 1st MTP fusion for persistent pain. Three patients had postoperative soft tissue swelling requiring prolonged retained sutures. Five patients underwent therapeutic injection with steroid between 2 - 11 months postoperative for persistent discomfort which improved. Five patients were prescribed orthotics between 3 - 6 months follow-up. One patient sustained a metatarsal fracture during the application of the implant requiring ORIF but retained the implant. Implant retention at 1 year was 98% (48/49). No correlation between preoperative radiographic grading and the incidence of poor clinical outcomes. Conclusion: To our knowledge, this is the first study that demonstrates the outcomes of synthetic cartilage implants using a large series of surgeons without affiliation or consultation for the implant company. One year following first MTP hemiarthroplasty with PVA hydrogel implant (Cartiva), functional and pain scores improved significantly, but did not show significant improvement with global mental scores. The implant displayed excellent survivorship at the 1 year time point, with only one patient undergoing surgical revision. Treatment of hallux rigidus with the PVA hydrogel implant - Cartiva, shows improved patient outcomes and has reassuring results at one year.

Inter- and Intraobserver Reliabilities of Four Different Radiographic Grading Scales of Osteoarthritis of the Knee Joint

The purpose of this study was to investigate the interobserver and intraobserver reliabilities of four different radiographic grading scale of osteoarthritis (OA) of the knee joint, namely, Kellgren–Lawrence (KL), Ahlback, Brandt, and OA Research Society International (OARSI). One consultant orthopaedic surgeon and one rheumatologist who were familiar with these OA grading scales participated in the study. Radiological assessments were performed in random order by each observer on two separate occasions, at least 2 weeks apart. K-statistics were used to establish a relative level of agreement between the observers for the two readings and between separate readings by the same observer. A total of 140 patients (53 males and 87 females) with a mean age of 61.2 years (range, 50–72 years) were included in the study. Intraobserver reliability for KL was substantial for observer A (κ: 0.753) and moderate for observer B (κ: 0.573). Interobserver reliability for KL was moderate for both observers (κ: 0.499 and 0.458, respectively). Intraobserver reliability for Ahlback was substantial for observer A (κ: 0.768) and moderate for observer B (κ: 0.561). Interobserver reliability for Ahlback was fair for both observers (κ: 0.365 and 0.204, respectively). Intraobserver reliability for Brandt was substantial for observer A (κ: 0.741) and moderate (κ: 0.425) for observer B. Interobserver reliability for Brandt was fair for both observers (κ: 0.308 and κ: 0.246, respectively). Intraobserver reliability for OARSI was substantial for observer A (κ: 0.792) and moderate for observer B (κ: 0.508). Interobserver reliability for OARSI was moderate for observer A (κ: 0.425) and slight for observer B (κ: 0.175). None of the studied OA grading scales showed acceptable reliability (κ > 0.80). The evaluation of patients with OA should not be dependent on radiographic findings alone; clinical findings should also guide the treatment and follow-up.

Immune Mediators in Osteoarthritis: Infrapatellar Fat Pad-Infiltrating CD8+ T Cells Are Increased in Osteoarthritic Patients with Higher Clinical Radiographic Grading

Osteoarthritis is a condition of joint failure characterized by many pathologic changes of joint-surrounding tissues. Many evidences suggest the role of both innate and adaptive immunity that interplay, resulting either in initiation or in progression of osteoarthritis. Adaptive immune cells, in particular T cells, have been demonstrated to play a role in the development of OA in animal models. However, the underlying mechanism is yet unclear. Our aim was to correlate the frequency and phenotype of tissue-infiltrating T cells in the synovial tissue and infrapatellar fat pad with radiographic grading. Our results show that CD8+ T cells are increased in osteoarthritic patients with higher radiographic grading. When peripheral blood CD8+ T cells were examined, we show that CD8+ T cells possess a significantly higher level of activation than its CD4+ T cell counterpart (P<0.0001). Our results suggest a role for CD8+ T cells and recruitment of these activated circulating peripheral blood CD8+ T cells to the knee triggering local inflammation within the knee joint.