The Cedell method (cerclage wire and staple) leads to less reoperations than the AO method.

Background and purpose - Fractures of the lateral malleolus often require open reduction and internal fixation (ORIF). Despite uneventful fracture healing, many patients will suffer from long-term detriments after ORIF, such as local tenderness that requires hardware removal. In Sweden, there are 2 major fixation methods, either the AO method (plate and screws) or the Cedell method (cerclage wire and staple). The purpose of this study was to establish whether there is a difference in extraction frequency between the 2 methods. Patients and methods - We performed a retrospective comparative study of all isolated fractures through the lateral malleolus that were operated at Skåne University Hospital, Sweden, during the period January 2007 to December 2010. 347 patients fulfilled the inclusion criteria (dislocated Weber B isolated fractures of the lateral malleolus) and were categorized according to fixation method. The numbers of reoperations, with preceding indication, were established from the charts. The median follow-up time was 59 (38-86) months after the primary surgery. Results - 22% of the 110 patients treated with the AO method underwent a reoperation, as compared to 8% of the 237 patients treated with the Cedell method (p < 0.001). The median time to extraction was 16 (4-55) months. Interpretation - Less implant removal is needed with the Cedell method than with the conventional AO method. This favors the use of the Cedell method in uncomplicated Weber B lateral ankle fractures, provided that other clinical parameters are comparable

Acetabular dysplasia at the age of 1 year in children with neonatal instability of the hip.

Background and purpose As much as one-third of all total hip arthroplasties in patients younger than 60 years may be a consequence of developmental dysplasia of the hip (DDH). Screening and early treatment of neonatal instability of the hip (NIH) reduces the incidence of DDH. We examined the radiographic outcome at 1 year in children undergoing early treatment for NIH. Subjects and methods All children born in Malmö undergo neonatal screening for NIH, and any child with suspicion of instability is referred to our clinic. We reviewed the 1-year radiographs for infants who were referred from April 2002 through December 2007. Measurements of the acetabular index at 1 year were compared between neonatally dislocated, unstable, and stable hips. Results The incidence of NIH was 7 per 1,000 live births. The referral rate was 15 per 1,000. 82% of those treated were girls. The mean acetabular index was higher in dislocated hips (25.3, 95% CI: 24.6-26.0) than in neonatally stable hips (22.7, 95% CI: 22.3-23.2). Girls had a higher mean acetabular index than boys and left hips had a higher mean acetabular index than right hips, which is in accordance with previous findings. Interpretation Even in children who are diagnosed and treated perinatally, radiographic differences in acetabular shape remain at 1 year. To determine whether this is of clinical importance, longer follow-up will be required

Advanced Imaging in Femoroacetabular Impingement: Current State and Future Prospects.

Symptomatic femoroacetabular impingement (FAI) is now a known precursor of early osteoarthritis (OA) of the hip. In terms of clinical intervention, the decision between joint preservation and joint replacement hinges on the severity of articular cartilage degeneration. The exact threshold during the course of disease progression when the cartilage damage is irreparable remains elusive. The intention behind radiographic imaging is to accurately identify the morphology of osseous structural abnormalities and to accurately characterize the chondrolabral damage as much as possible. However, both plain radiographs and computed tomography (CT) are insensitive for articular cartilage anatomy and pathology. Advanced magnetic resonance imaging (MRI) techniques include magnetic resonance arthrography and biochemically sensitive techniques of delayed gadolinium-enhanced MRI of cartilage (dGEMRIC), T1rho (T1ρ), T2/T2* mapping, and several others. The diagnostic performance of these techniques to evaluate cartilage degeneration could improve the ability to predict an individual patient-specific outcome with non-surgical and surgical care. This review discusses the facts and current applications of biochemical MRI for hip joint cartilage assessment covering the roles of dGEMRIC, T2/T2*, and T1ρ mapping. The basics of each technique and their specific role in FAI assessment are outlined. Current limitations and potential pitfalls as well as future directions of biochemical imaging are also outlined

Contrast-enhanced MRI of human knee cartilage Clinical applications of the novel dGEMRIC technique to study glycosaminoglycan content in articular cartilage

Delayed gadolinium-enhanced MRI of cartilage (dGEMRIC) is a new technique to study cartilage glycosaminoglycan (GAG) content. The negatively charged contrast agent Gd-DTPA2-, injected intravenously, distributes in the cartilage inversely to the likewise negatively charged GAG. The GAG concentration is reflected by the MRI parameter T1 and the Gd-DTPA2- concentration by the MRI parameter R1 (R1=1/T1). We have made T1 and R1 analyses in standardized regions of interest (ROIs) in lateral and medial femoral weight-bearing cartilage. In paper I, the distribution of Gd-DTPA2- (R1) in 19 healthy volunteers was linearly dose-related after injection of three different doses, showing that no active transportation is involved. The highest R1 was registered two hours post-contrast, suggesting this time as optimal in the clinical situation. Results indicated that the highest dose (triple dose: 0.3 mmol/kg body weight) is most sensitive to minor GAG differences and the triple dose was used in papers II-V. In paper II, 17 knees in 15 patients with normal x-ray but arthroscopically verified fibrillations in the medial or lateral femoral cartilage were investigated. R1 was higher in the diseased compartment after both 1.5 and 3 hours, with the greatest difference (31%) after 1.5 hours. In paper III, T1 was compared in 37 healthy volunteers with different levels of physical activity. Elite runners had 12% longer T1 than moderately exercising individuals, who in turn had 11% longer T1 than sedentary individuals. Results suggest that human knee cartilage adapts to exercise by increasing its GAG content. In paper IV, six investigators performed repeated ROI analyses in 12 volunteers. The intra- and inter-observer variability was low (C.V. less than 2.6%) with our standardized ROI drawing technique. In paper V, we combined GAG analysis of cartilage (dGEMRIC two hours post-contrast) and synovial fluid (biochemical) in 24 patients with an acute anterior cruciate ligament (ACL) rupture. Patients were investigated 3 weeks after the ACL injury and compared with 24 healthy controls. 22/24 patients had contusions of the lateral femoral cartilage, where T1 was 14% shorter than in controls. However, T1 was 12% shorter than controls also in the medial femoral cartilage, indicating that an ACL injury initiates a global loss of GAG from knee cartilage. The GAG concentration in the synovial fluid was increased in the ACL patients and showed a tendency to have a positive correlation with T1. In conclusion, the results of this thesis support dGEMRIC as a sensitive method to detect clinically relevant GAG differences in both healthy and diseased cartilage

Residual hip dysplasia at 1 year after treatment for neonatal hip instability is not related to degenerative joint disease in young adulthood: a 21-year follow-up study including dGEMRIC.

Developmental dysplasia of the hip (DDH) is associated with an increased risk of early hip osteoarthritis (OA). We aimed to examine the outcome at the completion of growth in a cohort of children who had residual acetabular dysplasia at age 1 year following early treatment for neonatal instability of the hip (NIH)

Local Flip Angle Correction for Improved Volume T1-Quantification in Three-Dimensional dGEMRIC Using the Look-Locker Technique

Purpose: To present an evaluation method for three-dimensional Look-Locker (3D-LL) based T1 quantification, calculating correct T1 values independent of local flip angle (FA) variations. The method was evaluated both in phantoms and in vivo in a delayed Gadolinium Enhanced MRI of Cartilage (dGEMRIC) study with 33 subjects. Materials and Methods: T1 was measured with 3D-LL, using both local FA correction and a precalculated FA slice profile. and compared with standard constant FA correction, for all slices in phantoms and in both femur condyles in vivo. T1 measured using two-dimensional Inversion Recovery (2D-IR) was used as gold standard. Results: Due to the FA being slice dependent, the standard constant FA correction results in erroneous T1 (systematic error = 109.1 ms in vivo), especially in the outer slices. With local FA correction. the calculated T1 is excellent for all slices in phantoms (<5% deviation from 2D-IR). In vivo the performance is lower (systematic error = -57.5ms), probably due to imperfect inversion. With precalculated FA correction the performance is very good also in vivo (systematic error = 13.3 ms). Conclusion: With the precalculated FA correction method, the 3D-LL sequence is robust enough for in vivo dGEMRIC, even outside the centermost slices

Estimated effect of secondary screening for hip dislocation

Objectives: To quantify the effect of secondary screening for hip dislocations. Design: Retrospective analysis of hospital files from participants in a prospectively collected nationwide registry. Setting: Child healthcare centres and orthopaedic departments in Sweden. Participants: Of 126 children with hip dislocation diagnosed later than 14 days age in the 2000-2009 birth cohort, 101 had complete data and were included in the study. Interventions: The entire birth cohort was subject to clinical screening for hip instability at 6-8 weeks, 6 months and 10-12 months age. Children diagnosed through this screening were compared with children presenting due to symptoms, which was used as a surrogate variable representing a situation without secondary screening. Main outcome measures: Age at diagnosis and disease severity of late presenting hip dislocations. Results: Children diagnosed through secondary screening were 11 months younger (median: 47 weeks) compared with those presenting with symptoms (p<0.001). Children diagnosed through secondary screening had 11% risk of having a high (severe) dislocation, compared with 38% for those diagnosed due to symptoms; absolute risk reduction 27% (95% CI: 9.7% to 45%), relative risk 0.28 (95% CI: 0.11 to 0.70). Children presenting due to symptoms had OR 5.1 (95% CI: 1.7 to 15) of having a high dislocation, and OR 11 (95% CI: 4.1 to 31) of presenting at age 1 year or older, compared with the secondary screening group. The secondary screening was able to identify half of the children (55%, 95% CI: 45% to 66%) not diagnosed through primary screening. Conclusions: Secondary screening at child healthcare centres may have substantially lowered the age at diagnosis in half of all children with late presenting hip dislocation not diagnosed through primary screening, with the risk of having a high dislocation decreased almost to one-quarter in such cases