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➤ Careful history and examination may reveal a constellation of musculoskeletal conditions associated with generalized joint laxity, including shoulder instability, posterolateral rotatory instability of the elbow, wrist ganglia, thumb base pathology, hip labral pathology, and patellar and ankle instability. ➤ Subtle but highly suggestive findings associated with generalized joint laxity may be recognized on radiographs or magnetic resonance imaging that can impact the clinician's decision-making. ➤ Increasing evidence has suggested that clinical outcomes of various surgical procedures around the shoulder, hip, knee, and ankle may be impacted in patients with generalized joint laxity. Surgeons should counsel these patients accordingly to manage expectations. ➤ Patients presenting to orthopaedic specialists should be queried about symptoms and injuries in other joints to identify patients with generalized joint laxity in order to initiate early management and injury prevention protocols. [ABSTRACT FROM AUTHOR]

Background: Recent total hip arthroplasty designs have introduced modularity at the neck-stem junction. There are reports of failure of this class of designs due to corrosion at the modular junction. The purpose of this study was to evaluate patients implanted with a recently recalled modular total hip arthroplasty system.Methods: This was a prospective study of 216 total hip arthroplasties in 195 patients performed by a single surgeon. All hips had a titanium-alloy stem, but 199 had a modular cobalt-chromium neck and seventeen were monolithic. The mean patient age was 65.4 years (range, twenty to eighty-eight years); seventy-nine were men and 116 were women. Patients were evaluated for infection and with metal ion assays and MRI (magnetic resonance imaging). Intraoperative tissue samples were graded, and retrieved implants were examined.Results: At a mean follow-up of 19.3 months, eighty (37%) of 216 hips had been revised. An adverse local tissue reaction (ALTR) was the cause for revision in seventy-three of these eighty hips; all had the modular neck design. Assay results for the patients requiring revision showed higher levels of cobalt (mean, 8.6 ng/mL) than chromium (mean, 1.8 ng/mL). MRI showed moderate to severe levels of synovial response in sixty-three of 166 hips. The mean ALVAL (aseptic lymphocyte-dominated vasculitis-associated lesion) score for the revised hips was 8.1. Corrosion was visible on all tapers at the neck-stem junction but not the head-neck junction.Conclusions: Early failures of modular total hip arthroplasty occur due to fretting and corrosion at the neck-stem junction, resulting in ALTR. Surveillance utilizing metal ion levels and MRI may be indicated for all patients regardless of symptoms, as the early survivorship is poor and the ultimate failure rate may be catastrophically high. [ABSTRACT FROM AUTHOR]

The article examines on the intrinsic capacity for articular cartilage restoration on symptomatic defects refractory to nonoperative management that provides both functional improvement and pain relief. It states the use of magnetic resonance imaging (MRI) as a method for noninvasive evaluation of chondral lesions and procedures. It also provides an overview on the imaging techniques of quantitative and semiquantitative cartilage to evaluate cartilage composition.

Background: Although pseudotumors have been reported at the sites of well-functioning and painful metal-on-metal hip prostheses, there are no objective data on the magnitude of the adverse reaction. This observational study was performed to investigate the ability of modified magnetic resonance imaging (MRI) to detect and quantify adverse synovial responses in symptomatic and asymptomatic subjects following metal-on-metal hip resurfacing. We hypothesized that the magnitude of the synovial reactions would be greater in symptomatic patients. Methods: Sixty-nine patients (seventy-four hips) with hip resurfacing were divided into three groups: asymptomatic (twenty-two hips), symptomatic with a mechanical cause (twenty), and unexplained pain (thirty-two). The volume of synovitis was calculated on MRI for all patients. Results: Synovitis was detected in fifteen asymptomatic hips (68%), fifteen (75%) with symptoms with a mechanical causes, and twenty-five (78%) with unexplained pain. The mean volume (and standard deviation) of the synovitis in these groups was 5 ± 7 cm3, 10 ± 16 cm3, and 31 ± 47 cm3, respectively. The coefficient of repeatability between the examiners was 1.8 cm3 for measurement of synovitis. Of the thirteen subjects with revision arthroplasty, six had an adverse local tissue reaction. This subgroup had the highest volumes of synovitis on MRI. Conclusions: An adverse synovial reaction was detected on MRI in both symptomatic and asymptomatic subjects. We found a larger volume of synovitis in symptomatic patients; this increase reached significance only in the group with an adverse local tissue reaction. Synovial volume on MRI may be a valuable marker in the longitudinal assessment of asymptomatic patients with a metal-on-metal hip resurfacing and in identifying patients with adverse local tissue reaction. Level of Evidence: Diagnostic Level III. See Instructions for Authors for a complete description of levels of evidence. [ABSTRACT FROM AUTHOR]

Background: The purpose of this study was to compare the outcomes of treatment with bone marrow aspirate concentrate, a simple, one-step, autogenous, and arthroscopically applicable method, with the outcomes of microfracture with regard to the repair of full-thickness cartilage defects in an equine model.Methods: Extensive (15-mm-diameter) full-thickness cartilage defects were created on the lateral trochlear ridge of the femur in twelve horses. Bone marrow was aspirated from the sternum and centrifuged to generate the bone marrow concentrate. The defects were treated with bone marrow concentrate and microfracture or with microfracture alone. Second-look arthroscopy was performed at three months, and the horses were killed at eight months. Repair was assessed with use of macroscopic and histological scoring systems as well as with quantitative magnetic resonance imaging.Results: No adverse reactions due to the microfracture or the bone marrow concentrate were observed. At eight months, macroscopic scores (mean and standard error of the mean, 9.4 + or - 1.2 compared with 4.4 + or - 1.2; p = 0.009) and histological scores (11.1 + or - 1.6 compared with 6.4 + or - 1.2; p = 0.02) indicated improvement in the repair tissue in the bone marrow concentrate group compared with that in the microfracture group. All scoring systems and magnetic resonance imaging data indicated that delivery of the bone marrow concentrate resulted in increased fill of the defects and improved integration of repair tissue into surrounding normal cartilage. In addition, there was greater type-II collagen content and improved orientation of the collagen as well as significantly more glycosaminoglycan in the bone marrow concentrate-treated defects than in the microfracture-treated defects.Conclusions: Delivery of bone marrow concentrate can result in healing of acute full-thickness cartilage defects that is superior to that after microfracture alone in an equine model.Clinical Relevance: Delivery of bone marrow concentrate to cartilage defects has the clinical potential to improve cartilage healing, providing a simple, cost-effective, arthroscopically applicable, and clinically effective approach for cartilage repair. [ABSTRACT FROM AUTHOR]

The article discusses several approaches in treating internal impingement of the shoulder of overhead athletes. It is stressed that internal impingement is a specific type of shoulder injury to the posterior labrum and the rotator cuff that is seen primarily in throwing athletes. It is stated that when treating internal impingement, it is suggested that nonoperative treatment should always be attempted first.

The article presents abstracts on total knee arthroplasty which includes the creation of a cost-effective diagnostic approach in order to evaluate a dissatisfaction patient after undergoing total knee arthroplasty, the new diagnosis of infection about a total knee replacement, and the treatments available in treating infections after total knee arthroplasty.

Standardized, validated magnetic resonance imaging sequences that are sensitive for articular cartilage are available for clinical use in magnetic resonance imaging units. Whereas two-dimensional sequences are helpful in the assessment of repair morphology, three-dimensional sequences with isotropic voxels measure cartilage volumes and provide an accurate assessment of fill following repair. Protocols should be modified so that sequences are not limited by instrumentation. The addition of quantitative magnetic resonance imaging techniques provides an objective assessment of repair-tissue bio-chemistry as well as of the tissue at the peripheral integration with the host hyaline cartilage. [ABSTRACT FROM AUTHOR]

Background: Clinical studies have demonstrated a high rate of incomplete healing of rotator cuff tendon repair. Since healing of such a repair is dependent on bone ingrowth into the repaired tendon, we hypothesized that osteoinductive growth factors would improve rotator cuff tendon-healing. Methods: Seventy-two skeletally mature sheep underwent detachment of the infraspinatus tendon followed by immediate repair. The animals received one of three treatments at the tendon-bone interface: (1) an osteoinductive bone protein extract on a Type-I collagen sponge carrier, (2) the collagen sponge carrier alone, and (3) no implant. The animals were killed at six and twelve weeks, and the repaired rotator cuff was evaluated with use of magnetic resonance imaging, plain radiographs, histologic analysis, and biomechanical testing. Results: A gap consistently formed between the end of the repaired tendon and bone in this model, with reparative scar tissue and new bone spanning the gap. Magnetic resonance imaging showed that the volume of newly formed bone (p < 0.05) and soft tissue (p < 0.05) in the tendon-bone gap were greater in the growth factor-treated animals compared with the collagen sponge control group at both time-points. Histologic analysis showed a fibrovascular tissue in the interface between tendon and bone, with a more robust fibrocartilage zone between the bone and the tendon in the growth factor-treated animals. The repairs that were treated with the osteoinductive growth factors had significantly greater failure loads at six weeks and twelve weeks (p < 0.05); however, when the data were normalized by tissue volume, there were no differences between the groups, suggesting that the treatment with growth factor results in the formation of poor-quality scar tissue rather than true tissue regeneration. The repairs that were treated with the collagen sponge carrier alone had significantly greater stiffness than the growth factor-treated group at twelve weeks (p = 0.005). Conclusions: This model tests the effects of growth factors on scar tissue formation in a gap between tendon and bone. The administration of osteoinductive growth factors resulted in greater formation of new bone, fibrocartilage, and soft tissue, with a concomitant increase in tendon attachment strength but less stiffness than repairs treated with the collagen sponge carrier alone. Clinical Relevance: This study is the first, as far as we know, to demonstrate the possibility of increasing tissue formation in a tendon-bone gap with use of a biologic agent. It shows the importance of the use of magnetic resonance imaging to evaluate the repaired tendon, since the findings on gross observation and even histologic examination could easily be interpreted as representing an intact repair. Further studies with use of more clinically relevant models of tendon-bone repair may support the use of growth factors to improve clinical outcomes. [ABSTRACT FROM AUTHOR]

Background: Osteochondral allograft reconstruction of articular cartilage defects is a well-established cartilage repair strategy. Currently, fresh osteochondral allograft tissue is commercially available to clinicians approximately thirty days following graft harvest. Little clinical information is available on the outcome of patients who have been treated with fresh allografts stored for several weeks or more. The purpose of this study was to prospectively analyze the clinical outcome and graft morphology of patients who received fresh, hypothermically stored, allograft tissue for the treatment of symptomatic chondral and osteochondral defects of the knee.Methods: Nineteen patients with symptomatic chondral and osteochondral lesions of the knee who were treated with fresh osteochondral allografts between 1999 and 2002 were prospectively followed. The mean age at the time of surgery was thirty-four years. Validated outcomes instruments (the Activities of Daily Living Scale and the Short Form-36) were used; all patients must have had a baseline functional score prior to surgery and a minimum two-year follow-up evaluation. All grafts were obtained from commercial vendors; the mean preimplantation storage time of the graft was thirty days (range, seventeen to forty-two days). The mean lesion size was 602 mm(2). Magnetic resonance imaging was used to evaluate the morphologic characteristics of the implanted grafts.Results: The mean duration of clinical follow-up was forty-eight months (range, twenty-one to sixty-eight months). The mean score (and standard deviation) on the Activities of Daily Living Scale increased from a baseline of 56 +/- 24 to 70 +/- 22 at the time of the final follow-up (p < 0.05). The mean Short Form-36 score increased from a baseline of 51 +/- 23 to 66 +/- 24 at the time of final follow-up (p < 0.005). With the numbers studied, we could not correlate graft storage time, body mass index, lesion size, lesion location, or patient age with the functional outcome scores. At a mean follow-up interval of twenty-five months, cartilage-sensitive magnetic resonance imaging demonstrated that the normal articular cartilage thickness was preserved in eighteen implanted grafts, and allograft cartilage signal properties were isointense relative to normal articular cartilage in eight of the eighteen grafts. Osseous trabecular incorporation of the allograft was complete or partial in fourteen patients and poor in four patients. Complete or partial trabecular incorporation positively correlated with Short Form-36 scores at the time of follow-up (r = 0.487, p < 0.05).Conclusions: Fresh osteochondral allografts that were hypothermically stored between seventeen and forty-two days were effective in the short term both structurally and functionally in reconstructing symptomatic chondral and osteochondral lesions of the knee.Level Of Evidence: Therapeutic Level IV. See Instructions to Authors for a complete description of levels of evidence. [ABSTRACT FROM AUTHOR]

Background: Microfracture is a frequently used technique for the repair of articular cartilage lesions of the knee. Despite the popularity of the technique, prospective information about the clinical results after microfracture is still limited. The purpose of our study was to identify the factors that affect the clinical outcome from this cartilage repair technique.Methods: Forty-eight symptomatic patients with isolated full-thickness articular cartilage defects of the femur in a stable knee were treated with the microfracture technique. Prospective evaluation of patient outcome was performed for a minimum follow-up of twenty-four months with a combination of validated outcome scores, subjective clinical rating, and cartilage-sensitive magnetic resonance imaging.Results: At the time of the latest follow-up, knee function was rated good to excellent for thirty-two patients (67%), fair for twelve patients (25%), and poor for four (8%). Significant increases in the activities of daily living scores, International Knee Documentation Committee scores, and the physical component score of the Short Form-36 were demonstrated after microfracture (p < 0.05). A lower body-mass index correlated with higher scores for the activities of daily living and SF-36 physical component, with the worst results for patients with a body-mass index of >30 kg/m(2). Significant improvement in the activities of daily living score was more frequent with a preoperative duration of symptoms of less than twelve months (p < 0.05). Magnetic resonance imaging in twenty-four knees demonstrated good repair-tissue fill in the defect in thirteen patients (54%), moderate fill in seven (29%), and poor fill in four patients (17%). The fill grade correlated with the knee function scores. All knees with good fill demonstrated improved knee function, whereas poor fill grade was associated with limited improvement and decreasing functional scores after twenty-four months.Conclusions: Microfracture repair of articular cartilage lesions in the knee results in significant functional improvement at a minimum follow-up of two years. The best short-term results are observed with good fill grade, low body-mass index, and a short duration of preoperative symptoms. A high body-mass index adversely affects short-term outcome, and a poor fill grade is associated with limited short-term durability. [ABSTRACT FROM AUTHOR]

Background: Microfracture is a frequently used technique for the repair of articular cartilage lesions of the knee. Despite the popularity of the technique, prospective information about the clinical results after microfracture is still limited. The purpose of our study was to identify the factors that affect the clinical outcome from this cartilage repair technique.Methods: Forty-eight symptomatic patients with isolated full-thickness articular cartilage defects of the femur in a stable knee were treated with the microfracture technique. Prospective evaluation of patient outcome was performed for a minimum follow-up of twenty-four months with a combination of validated outcome scores, subjective clinical rating, and cartilage-sensitive magnetic resonance imaging.Results: At the time of the latest follow-up, knee function was rated good to excellent for thirty-two patients (67%), fair for twelve patients (25%), and poor for four (8%). Significant increases in the activities of daily living scores, International Knee Documentation Committee scores, and the physical component score of the Short Form-36 were demonstrated after microfracture (p < 0.05). A lower body-mass index correlated with higher scores for the activities of daily living and SF-36 physical component, with the worst results for patients with a body-mass index of >30 kg/m(2). Significant improvement in the activities of daily living score was more frequent with a preoperative duration of symptoms of less than twelve months (p < 0.05). Magnetic resonance imaging in twenty-four knees demonstrated good repair-tissue fill in the defect in thirteen patients (54%), moderate fill in seven (29%), and poor fill in four patients (17%). The fill grade correlated with the knee function scores. All knees with good fill demonstrated improved knee function, whereas poor fill grade was associated with limited improvement and decreasing functional scores after twenty-four months.Conclusions: Microfracture repair of articular cartilage lesions in the knee results in significant functional improvement at a minimum follow-up of two years. The best short-term results are observed with good fill grade, low body-mass index, and a short duration of preoperative symptoms. A high body-mass index adversely affects short-term outcome, and a poor fill grade is associated with limited short-term durability. [ABSTRACT FROM AUTHOR]

Background: Microfracture is a frequently used technique for the repair of articular cartilage lesions of the knee. Despite the popularity of the technique, prospective information about the clinical results after microfracture is still limited. The purpose of our study was to identify the factors that affect the clinical outcome from this cartilage repair technique. Methods: Forty-eight symptomatic patients with isolated full-thickness articular cartilage defects of the femur in a stable knee were treated with the microfracture technique. Prospective evaluation of patient outcome was performed for a minimum follow-up of twenty-four months with a combination of validated outcome scores, subjective clinical rating, and cartilage-sensitive magnetic resonance imaging. Results: At the time of the latest follow-up, knee function was rated good to excellent for thirty-two patients (67%), fair for twelve patients (25%), and poor for four (8%). Significant increases in the activities of daily living scores, International Knee Documentation Committee scores, and the physical component score of the Short Form-36 were demonstrated after microfracture (p < 0.05). A lower body-mass index correlated with higher scores for the activities of daily living and SF-36 physical component, with the worst results for patients with a body-mass index of >30 kg/m². Significant improvement in the activities of daily living score was more frequent with a preoperative duration of symptoms of less than twelve months (p < 0.05). Magnetic resonance imaging in twenty-four knees demonstrated good repair-tissue fill in the defect in thirteen patients (54%), moderate fill in seven (29%), and poor fill in four patients (17%). The fill grade correlated with the knee function scores. All knees with good fill demonstrated improved knee function, whereas poor fill grade was associated with limited improvement and decreasing functional scores after twenty-four months. Conclusions: Microfracture repair of articular cartilage lesions in the knee results in significant functional improvement at a minimum follow-up of two years. The best short-term results are observed with good fill grade, low body-mass index, and a short duration of preoperative symptoms. A high body-mass index adversely affects short-term outcome, and a poor fill grade is associated with limited short-term durability. Level of Evidence: Therapeutic Level IV. See Instructions to Authors for a complete description of levels of evidence. [ABSTRACT FROM AUTHOR]

Background: The evaluation of periprosthetic osteolysis in patients who have had a total hip arthroplasty is challenging, and traditional imaging techniques, including magnetic resonance imaging and computerized tomography, are limited by metallic artifact. The purpose of the present study was to investigate the use of modified magnetic resonance imaging techniques involving commercially available software to visualize periprosthetic soft tissues, to define the bone-implant interface, and to detect the location and extent of osteolysis. Methods: Twenty-eight hips in twenty-seven patients were examined to assess the extent of osteolysis (nineteen hips), enigmatic pain (five), heterotopic ossification (two), suspected tumor (one), or femoral nerve palsy (one). The results were correlated with conventional radiographic findings as well as with intraoperative findings (when available). Results: Magnetic resonance imaging demonstrated the bone-implant interface and the surrounding soft-tissue envelope in all hips. Radiographs consistently underestimated the extent and location of acetabular osteolysis when compared with magnetic resonance imaging. Magnetic resonance imaging also disclosed radiographically occult extraosseous soft-tissue deposits that were similar in signal intensity to areas of osteolysis, demonstrated the relationship of these deposits to adjacent neurovascular structures, and allowed further visualization of hypertrophic synovial deposits that accompanied the bone resorption in twenty-five of the twenty-eight hips. Conclusions: Magnetic resonance imaging is effective for the assessment of the periprosthetic soft tissues in patients who have had a total hip arthroplasty. While not indicated for every patient who has pain at the site of an arthroplasty, these techniques can be effective for the evaluation of the surrounding soft-tissue envelope as well as intracapsular synovial deposits and are more effective than radiographs for the detection and evaluation of osteolysis, thus aiding in clinical management. Level of Evidence: Diagnostic study, Level III-1 (study of nonconsecutive patients [no consistently applied reference "gold" standard]). See Instructions to Authors for a complete description of levels of evidence. [ABSTRACT FROM AUTHOR]

Background: Traumatic posterior hip subluxation is a potentially devastating injury that is often misdiagnosed as a simple hip sprain or strain. The purpose of the present study was to outline the injury mechanism, pathoanatomy, clinical and radiographic findings, and treatment of traumatic hip subluxation in an athletic population.Methods: Over a nine-year period, eight participants in American football who had sustained a traumatic posterior hip subluxation were evaluated and treated. The injury mechanism, clinical findings, and radiographic findings were reviewed. The mean duration of follow-up was thirty-four months.Results: The most common mechanism of injury was a fall on a flexed, adducted hip. Physical examination revealed painful limitation of hip motion. Initial radiographs demonstrated a characteristic posterior acetabular lip fracture. Initial magnetic resonance images revealed disruption of the iliofemoral ligament, hemarthrosis, and a viable femoral head. Two players were treated acutely with hip aspiration, and all eight players were treated with a six-week regimen of toe-touch weight-bearing with use of crutches. Six players recovered and returned to the previous level of competition. Two players had development of severe osteonecrosis and ultimately required total hip arthroplasty.Conclusion: The pathognomonic radiographic and magnetic resonance imaging triad of posterior acetabular lip fracture, iliofemoral ligament disruption, and hemarthrosis defines traumatic posterior hip subluxation. Patients in whom large hemarthroses are diagnosed on magnetic resonance images should undergo acute aspiration, and all players should be treated with a six-week regimen of toe-touch weight-bearing with use of crutches. Patients who have no sign of osteonecrosis on magnetic resonance imaging at six weeks can safely return to sports activity. Patients in whom osteonecrosis is diagnosed at six weeks are at risk for collapse and joint degeneration, and they should be advised against returning to sports. [ABSTRACT FROM AUTHOR]

Background: Patients have been shown to be at greater risk for deep venous thrombosis, particularly proximal thrombosis, after total hip arthroplasty. Proximal thrombi are more likely to develop into pulmonary emboli than are distal thrombi. The purpose of this randomized, prospective study was to compare the prevalence of pelvic and proximal lower-extremity deep venous thrombosis after primary total hip arthroplasty between patients treated with an impulse mechanical compression device for prophylaxis and those treated with prophylactic stockings.Methods: One hundred patients were evaluated, with use of magnetic resonance venography, for proximal deep venous thrombosis after total hip arthroplasty. Fifty patients were treated with a mechanical compression device on both lower extremities, and the other fifty patients received only prophylactic stockings. Both groups of patients received hypotensive epidural anesthesia and 325 mg of aspirin twice a day.Results: Overall, proximal deep venous thrombi were found in 15% of the 100 patients. Of the fifty patients treated with mechanical compression, 8% (four) had a positive venogram. Of the fifty control patients, 22% (eleven) had a positive venogram (p < 0.05). However, overall the rate of occlusive thrombi was 6% (six) compared with an overall rate of nonocclusive thrombi of 9% (nine). The rate of occlusive thrombi was 2% (one of fifty) in the study group and 10% (five of fifty) in the control group (p = 0.04).Conclusions: On the basis of this study, we concluded that patients managed with total hip arthroplasty benefit from a reduction in the rates of femoral and pelvic deep vein thrombosis when they are treated with hypotensive epidural anesthesia, mechanical compression, and aspirin and are subsequently assessed with magnetic resonance venography. [ABSTRACT FROM AUTHOR]

In this article, the author discusses aspects of the cartilage thickness, joint fluid volumes, and posttraumatic bone marrow lesions following acute anterior cruciate ligament (ACL) disruption.

The article discusses chondral lesions on the hip and knee joints. The articular pathology of chondral lesions for the hip and knee joints is done through magnetic resonance imaging as it is noninvasive but delayed gadolinium-enhanced magnetic resonance imaging and other methods are being developed. Also being developed are surgical resurfacing methods for chondral lesions as alternatives to magnetic resonance imaging.