The New Bern Chondrolabral Classification Is Reliable and Reproducible

BACKGROUND

Several classification systems have been used to describe early lesions of hip cartilage and the acetabular labrum in young adults with hip pain. Some of them were introduced before the concept of femoroacetabular impingement was proposed. Others were developed for other joints (such as the patellofemoral joint). However, these often demonstrate inadequate reliability, and they do not characterize all possible lesions. Therefore, we developed a novel classification system.

QUESTION/PURPOSE

We asked: What is the (1) intraobserver reliability, (2) interobserver reproducibility, and (3) percentage of nonclassifiable lesions of the new classification system for damage to the hip cartilage and labrum compared with six established classification systems for chondral lesions (Beck et al. [4], Konan et al. [10], Outerbridge et al. [14]) and labral lesions (Beck et al. [3], Lage et al. [12], Peters and Erickson [15])?

METHODS

We performed a validation study of a new classification system of early chondrolabral degeneration lesions based on intraoperative video documentation taken during surgical hip dislocations for joint-preserving surgery in 57 hips (56 patients) performed by one surgeon with standard video documentation of intraarticular lesions. The exclusion criteria were low-quality videos, inadequate exposure angles, traumatic lesions, and incomplete radiographic documentation. This left 42 hips (41 patients) for the blinded and randomized analysis of six raters, including those with cam-pincer-type femoroacetabular impingement (FAI) (19 hips in 18 patients), isolated cam-type FAI (10 hips), extraarticular FAI due to femoral anteversion (seven hips), isolated pincer-type FAI (two hips), focal avascular necrosis (two hips), localized pigmented villonodular synovitis (one hip), and acetabular dysplasia as a sequelae of Perthes disease (one hip). The raters had various degrees of experience in hip surgery: Three were board-certified orthopaedic fellows and three were orthopaedic residents, in whom we chose to prove the general usability of the classification systems in less experienced readers. Every rater was given the original publication of all existing classification systems and a visual guide of the new Bern classification system. Every rater classified the lesions according the existing classifications (cartilage: Beck et al. [4], Konan et al. [10], and Outerbridge et al. [14]; labrum: Beck et al. [3], Peters and Erickson [15], and Lage et al. [12]) and our new Bern chondrolabral classification system. The intraclass correlation coefficient with 95% confidence interval was used to assess the intraobserver reliability and interobserver reproducibility. The percentage of nonclassifiable lesions was calculated as an absolute number and percentage.

RESULTS

The intraobserver intercorrelation coefficients (ICCs) for cartilage lesions were as follows: the Bern classification system (0.68 [95% CI 0.61 to 0.70]), Beck (0.44 [95% CI 0.34 to 0.54]), Konan (0.39 [95% CI 0.29 to 0.49]), and the Outerbridge classification (0.57 [95% CI 0.48 to 0.65]). For labral lesions, the ICCs were as follows: the Bern classification (0.70 [95% CI 0.63 to 0.76]), Peters (0.42 [95% CI 0.31 to 0.51]), Lage (0.26 [95% CI 0.15 to 0.38]), and Beck (0.59 [95% CI 0.51 to 0.67]). The interobserver ICCs for cartilage were as follows: the Bern classification system (0.63 [95% CI 0.51 to 0.75), the Outerbridge (0.14 [95% CI 0.04 to 0.28]), Konan (0.58 [95% CI 0.40 to 0.76]), and Beck (0.52 [95% CI 0.39 to 0.66]). For labral lesions, the ICCs were as follows: the Bern classification (0.61 [95% CI 0.49 to 0.74]), Beck (0.31 [95% CI 0.19 to 0.46]), Peters (0.28 [95% CI 0.16 to 0.44]), and Lage (0.20 [95% CI 0.09 to 0.35]). The percentage of nonclassifiable cartilage lesions was 0% for the Bern, 0.04% for Beck, 17% for Konan, and 25% for the Outerbridge classification. The percentage of nonclassifiable labral lesions was 0% for Bern and Beck, 4% for Peters, and 25% for Lage.

CONCLUSION

We have observed some shortcomings with currently used classification systems for hip pathology, and the new classification system we developed seems to have improved the intraobserver reliability compared with the Beck and Konan classifications in cartilage lesions and with the Peters and Lage classifications in labral lesions. The interrater reproducibility of the Bern classification seems to have improved in cartilage lesions compared with the Outerbridge classification and in labral lesions compared with the Beck, Peters, and Lage classifications. The Bern classification identified all present cartilage and labral lesions. It provides a solid clinical basis for accurate descriptions of early degenerative hip lesions independent of etiology, and it is reproducible enough to use in the reporting of clinical research. Further studies need to replicate our findings in the hands of nondevelopers and should focus on the prognostic value of this classification and its utility in guiding surgical indications.

LEVEL OF EVIDENCE

Level II, diagnostic study.

Outpatient Evaluation of Knee Pain

Knee pain is present in up to 20% of the adult general population and can be significantly debilitating to patients. A thorough history and physical examination can help localize the source of inflammation or injury to further determine if imaging, physical therapy, specialty referral, or surgery is necessary. By following a systematic approach to evaluating knee pain, primary care physicians can make the correct diagnosis and formulate an appropriate therapeutic strategy for patients.

[Prediction of response to TNF-α inhibitors treatment with use of swollen to tender joint count ratio (STR)]

INTRODUCTION

STR is swollen to tender joint count ratio. The aim of this study was to determine the usefulness of STR in predicting response to treatment with biological agents in patients with RA.

MATERIAL AND METHODS

The study included 27 biologically naive patients treated with TNF inhibitors: infliximab (6), etanercept (10), adalimumab (5) and certolizumab (6). STR index was assessed at baseline and after 3 and 9 months (m) . Patients due to the STR value were divided into two groups: group1 with value of STR < 1 and group 2 with value of STR ≥ 1. Group 1 included 18 patients (17 F, 1 M). Group 2 consisted of 9 persons (7 F 2 M).

RESULTS

At the beginning of the observation the average values for the group 1 were: the number of swollen joints (SJ) 6/28 (2-14), the number of tender joints (TJ) 11/28 (5-21), STR 0.46 (0.2-0.9), CRP 27.8 mg/I (1-130.2), DAS28 4.95 (4.03-7.56), disease activity VAS 50 mm (20-75), ESR 35 (8-95). In group 1, the DAS28 improved after 3 months on average - 1.68 (0.08-3.91) and ESR decreased about 16 mm. On the assessment after 9 months of treatment DAS 28 improved on average - 2.89 (0.74-5.17); ESR dropped by 21 mm compared to the baseline. At the beginning of the observation average values for group 2 were: SJ 13/28 (8-19), TJ 19 (4-15), STR 1.48 (1-2.5), CRP 19.27 (7.7-32.1), DAS28 5.75 (5.25-6.47), disease activity - VAS 57 mm (47-66), ESR 25 (14-41). After 3 months of treatment DAS28 reduced on average - 2.52 (1.97-3.71), ESR decreased circa 11 mm. Six patients from group 2 were evaluated after 9 months of treatment. There was observed improvement both in DA528 on average 3.28 (1.86-3.95) and ESR, which dropped by 10 mm. Patients with >1 STR achieved greater improvement in DAS28 after 3 m (p=0.0395) and after 9 months (Ns) compared to patients with STR <1. However, decrease of ESR was higher both after 3 and 9 months in patients with STR <1.

CONCLUSIONS

We conclude that the STR may be useful in predicting response to treatment with TNF inhibitors.

Development of a bedside pain assessment kit for the classification of patients with osteoarthritis

There are no standardized bedside assessments for subtyping patients with osteoarthritis (OA) based on pain mechanisms. Thus, we developed a bedside sensory testing kit (BSTK) to classify OA patients based on sensory profiles potentially indicative of pain mechanism. After usability and informal reliability testing (n = 22), the kit was tested in a formal reliability study (n = 20). Patients completed questionnaires and sensory testing: pressure algometry to detect hyperalgesia; repeat algometry after heterotopic noxious conditioning stimulation to measure diffuse noxious inhibitory control (DNIC); light touch using Von Frey filaments; and cold allodynia using a brass rod. The procedure was brief and well tolerated. Algometry and filament testing were highly reliable [intra-class correlation coefficients (ICCs) 0.71-0.91]; DNIC was acceptably reliable (ICCs 0.53-0.91); brass rod reliability was inconclusive. Patients were classified empirically into four groups: "All abnormal findings" (primary and secondary hyperalgesia and dysfunctional DNIC); "all normal findings"; and two intermediate groups. The "all abnormal findings" group had more neuropathic pain symptoms, and lower WOMAC total, stiffness, and activity scores than the "all normal findings" group. Simple BSTK procedures, consolidated in a kit, reliably classified OA patients into subgroups based on sensory profile, suggesting that OA patients differ in underlying pain mechanisms. Further research is needed to confirm these subgroups and determine their validity in predicting response to treatment.

Results of arthroscopic treatment of rotator cuff tear with the resection of symptomatic acromioclavicular joint with degenerative changes

BACKGROUND

Rotator cuff (RC) tear is one of the most common disorders affecting the shoulder. Acromioclavicular (AC) joint arthritis is an equally common pathology of the shoulder. The coexistence of both disorders is common, although RC tear is more frequently the cause of shoulder pain than AC joint arthritis. The purpose of this study was to compare the results of arthroscopic treatment of RC tear and simultaneous resection of symptomatic AC joint with arthritis.

MATERIAL/METHODS

We retrospectively evaluated 40 patients who underwent arthroscopic RC repair between January 2008 and December 2009. Patients were divided into two groups. The first group consisted of 20 patients with symptomatic arthritis of AC joint, specifically painful joint palpation test and painful cross-body adduction test. The control group included 20 patients with asymptomatic degenerative changes of AC joint. The first group of patients underwent RC resection and AC joint repair; the second group had an isolated RC repair. Follow-up period lasted from 44 to 68 months, an average of 54.4 months.

RESULTS

Analysis using chi-squared test for independence has shown no statistically significant difference in terms of subjects' gender or age in both groups. No significant difference in terms of pain intensity (VAS) was observed before and after surgery in either group. Significant reduction in pain intensity after surgery was observed in both groups, the AC joint resection group (p<0.001) and the without joint resection group (p<0.001). An increase in Constant's scale score was recorded in both groups after the surgery. Analysis has shown that patients who had undergone AC joint resection, had lower scores on a Constant's scale (p<0.022) before the surgery than those who were not resected. There were no statistically significant differences between the two groups after the surgery.

CONCLUSIONS

Supplementary resection of a painful AC joint with arthritis during RC tear repair provides good, long-term outcomes. In contrast to patients with asymptomatic AC joint arthritis, the coexistence of a torn RC and symptomatic AC joint with arthritis, can worsen shoulder function in the preoperative period.

Platelet-rich plasma injection is more effective than hyaluronic acid in the treatment of knee osteoarthritis

PURPOSE OF THE STUDY

There is increasing use of platelet-rich plasma (PRP) in orthopaedics as it is a simple, cheap and minimally invasive technique. This study aimed to compare the effects of the use of PRP and hyaluronic acid (HA) injections in the knee of patients diagnosed with and being followed-up for degenerative arthritis.

MATERIALS AND METHODS

This prospective study included 90 patients with complaints of knee pain with findings of mild or moderate degenerative arthritis. In the PRP group (n=45), one intra-articular injection was applied and in the HA group (n=45), three doses of intra-articular injection were applied. Clinical evaluation was made by Knee Injury and Osteoarthritis Outcome Score (KOOS) and a visual pain scale.

RESULTS

No severe adverse events was observed. Statistically significant better results in the KOOS score and visual pain scale was determined in PRP group than HA group at 3 months and 6 months follow up. The cost of the application for the PRP group was lower than that of the HA group.

CONCLUSION

The results of this study have shown the application of single dose PRP to be a safe, effective and low-cost method for treating OA. However, further studies are required for a more clear result.

Diagnosis and classification of pelvic girdle pain disorders, Part 2: illustration of the utility of a classification system via case studies

Pelvic girdle pain (PGP) disorders are complex and multi-factorial and are likely to be represented by a series of sub-groups with different underlying pain drivers. Both the central and peripheral nervous systems have the potential to mediate PGP disorders. Even in the case of a peripheral pain disorder, the central nervous system can modulate (to promote or diminish) the pain via the forebrain (cognitive factors). It is hypothesised that the motor control system can become dysfunctional in different ways. A change in motor control may simply be a response to a pain disorder (adaptive), or it may in itself promote abnormal tissue strain and therefore be 'mal-adaptive' or provocative of a pain disorder. Where a deficit in motor control is 'mal-adaptive' it is proposed that it could result in reduced force closure (deficit in motor control) or excessive force closure (increased motor activation) resulting in a mechanism for ongoing peripheral pain sensitisation. Three cases are presented which highlight the multi-dimensional nature of PGP. These cases studies outline the practical clinical application of a classification model for PGP and the underlying clinical reasoning processes inherent to the application of this model. The case studies demonstrate the importance of appropriate classification of PGP disorders in determining targeted intervention directed at the underlying pain mechanism of the disorder.

The role of fibular tape in the prevention of ankle injury in basketball: A pilot study

STUDY DESIGN

Prospective nonrandomized controlled trial.

OBJECTIVES

To determine the effect of fibular repositioning tape (FRT) on incidence and severity of ankle injury.

BACKGROUND

Pain and functional disability is common following ankle sprain and a major problem in sport. A novel method of taping, FRT, which has been described to prevent ankle sprain, requires less tape than traditional methods and is easier to apply. The objective of this study was to determine the effect of FRT on the incidence and severity of ankle injury in basketball.

METHODS AND MEASURES

One hundred twenty-five male basketball players were assigned at time of play to either the control (209 exposures) or FRT (224 exposures) condition in a manner of convenience. Control participants had the choice on the use and type of prophylaxis, excluding FRT. FRT participants were taped using the method described by Mulligan. Ankle injury data were collected after each exposure. Injury severity was determined by functional limitation, pain levels, and days to return to play.

RESULTS

Four hundred forty-three measured basketball exposures resulted in 11 ankle injuries. All injuries occurred in subjects with a history of previous ankle sprain. Significantly less ankle injuries were sustained by members of the FRT condition (n = 2), compared to members of the control condition (n = 9) (Fisher exact test, P = .03). The odds ratio of sustaining an ankle injury was 0.20 (P = .04; 95% confidence interval [CI]: 0.04, 0.93) when taped with FRT and the number needed to treat was 22 (95% CI, 12-312).

CONCLUSIONS

This study provides preliminary data regarding the prophylactic effects of FRT on ankle injury in male basketball players.

Utilization of pharmaceuticals among patients with temporomandibular disorders: a controlled study

OBJECTIVE

Pharmaceuticals are among factors that might be associated with temporomandibular disorders (TMDs), but knowledge about their utilization is limited. The purpose was to systematically register the regular use of medication in general among TMD patients and matched controls to enable comparisons to be made.

MATERIAL AND METHODS

Three hundred consecutive patients referred for diagnosis and treatment of TMDs and fulfilling the Research Diagnostic Criteria were examined prospectively and any medication recorded. Matched controls were registered parallel in time. The pharmaceuticals used were categorized according to the Anatomical Therapeutic Chemical Classification System (ATC).

RESULTS

Forty-four percent of the patients received a main diagnosis of "muscle disorder", 39% "disk disorder", and 17% "joint disorder". Fifty-one percent of all patients used some medication on a regular basis compared to 36% of the controls (p<0.001). The average number of ATC categories used among all patients was 0.9 and among controls 0.5 (p<0.001). Of the female patients with the diagnosis "muscle disorder", 23% used antidepressants (N06A), 6% tranquilizers (N05B), and 7% sleep medication or sedatives (N05C) significantly more frequently than controls. Of the female patients diagnosed with a "joint disorder", 26% used antidepressants (N06A) significantly more frequently than controls. All other ATC categories differed non-significantly.

CONCLUSIONS

The results suggest that the use of pharmaceuticals differs between patients and controls. TMD patients, particularly women diagnosed with "muscle" or "joint" disorders, appear to use drugs for depression more frequently than ordinary dental patients.

Short-term analgesic effects of intra-articular injections after knee arthroscopy

PURPOSE

To study the effects of 3 different intra-articular analgesic combinations on postoperative pain, and whether the timing of the injection, either preoperative or postoperative, had an effect on postoperative analgesia.

TYPE OF STUDY

Prospective, randomized, double-blind clinical trial.

METHODS

Patients undergoing knee arthroscopy performed by a single surgeon under general anesthesia were randomized into 6 study groups. Each patient received an intra-articular injection 20 minutes before incision and at the end of the procedure. One injection contained the study medications, and the other contained normal saline solution (placebo). The patients, surgeon, and data collection personnel were blinded to the contents of the injections. Outcome measures included visual analogue pain scores at 0, 60, and 120 minutes after the procedure, and total recovery room fentanyl consumption.

RESULTS

Fifty patients successfully completed the study protocol. Patients receiving combinations of morphine, bupivacaine, and epinephrine or bupivacaine and epinephrine yielded lower pain scores and narcotics consumption than patients receiving epinephrine alone, which was statistically significant irrespective of the timing of injection (P < .0001). Patients receiving the study medication preoperatively had significantly lower pain scores at the first measurement (t = 0) than those receiving the study medication postoperatively (P = .0343). There was no statistically significant effect of timing of the treatment medication administration at either 60 or 120 minutes postoperatively. Comparison of fentanyl consumption between groups receiving the treatment medication preoperatively versus postoperatively showed no significant difference.

CONCLUSIONS

The combination of morphine, bupivacaine, and epinephrine, as well as the combination of bupivacaine and epinephrine provide excellent postoperative pain control when used either preoperatively or postoperatively in knee arthroscopy. There was a trend that patients receiving preoperative analgesic injections experienced superior pain control than did those injected postoperatively.

LEVEL OF EVIDENCE

Level I, Randomized Controlled Trial.

Intra-articular ropivacaine 0.75% and bupivacaine 0.50% for analgesia after arthroscopic knee surgery: a randomized prospective study

PURPOSE

Intra-articular administration of local anesthetic solution provides analgesia after arthroscopic knee surgery. Bupivacaine is considered the gold standard local anesthetic in this indication, but ropivacaine, which is less toxic than bupivacaine, can consequently be administered in higher doses, potentially increasing the duration of analgesia. We compared the analgesic effect of intra-articular injection of ropivacaine 225 mg and bupivacaine 150 mg in patients undergoing arthroscopic surgery.

TYPE OF STUDY

Double-blind, randomized prospective clinical study.

METHODS

The study included 45 patients scheduled for knee meniscus repair under arthroscopy, who were allocated randomly into 3 groups to receive, intra-articularly, 30 mL of isotonic saline, bupivacaine 0.5%, or ropivacaine 0.75% solutions at the end of surgery. Postoperatively, pain was measured using a visual analog scale (VAS) at rest and on mobilization. Propacetamol was given when patients complained of pain.

RESULTS

VAS scores at rest and on mobilization were higher in the saline group compared with the ropivacaine group (P = .006 and P = .01, respectively). No difference in VAS scores was documented between bupivacaine and the saline groups. The median delay between the intra-articular administration and propacetamol administration was shorter in the saline group (15 minutes; range, 15 to 120 minutes) compared with the ropivacaine group (240 minutes; range 15 to 720 minutes) but no difference was documented between the bupivacaine group (30 minutes; range, 15 to 360 minutes) and the other 2 groups.

CONCLUSIONS

This level I study documents that intra-articular ropivacaine 0.75% provides better analgesia than bupivacaine 0.5% after knee arthroscopic surgery.

LEVEL OF EVIDENCE

Level I.

Prevalence of temporomandibular disorder subtypes, psychologic distress, and psychosocial dysfunction in Asian patients

AIMS

To use the Research Diagnostic Criteria for Temporomandibular Disorders (RDC/TMD) to investigate the physical diagnoses, psychologic distress, and psychosocial dysfunction in Asian TMD patients. The RDC/TMD Axis I and II findings were compared to those of Swedish and American TMD patients.

METHODS

One hundred ninety-one patients (53 male and 138 female) referred to 2 institutionalized TMD clinics in Singapore were enrolled in the study. The mean age of the predominantly Chinese population (83.2%) was 33.6 +/- 9.3 years. Data from a RDC/TMD history questionnaire and clinical examination were fed directly by patients and clinicians into a computerized diagnostic system (NUS TMDv1.1). Axis I and II findings were generated on-line, based on RDC/TMD rule engines. Data were automatically exported to SPSS for statistical analysis.

RESULTS

Group I (muscle) disorders were found in 31.4% of the patients; Group II (disc displacement) disorders were found in 15.1% and 15.7% of the patients in the left and right temporomandibular joints, respectively; and Group III (arthralgia, arthritis, and arthrosis) disorders were found in 12.6% and 13.0% of the patients in the left and right joints, respectively. Axis II assessment of psychologic status showed that 39.8% of patients experienced moderate to severe depression and 47.6% had moderate to severe nonspecific physical symptom scores. Psychosocial dysfunction was observed in only 4.2% of patients based on graded chronic pain scores.

CONCLUSION

Axis I and II findings of Asian TMD patients were generally similar to their Swedish and American cohorts. In all 3 populations, women of child-bearing age represented the majority of patients. Muscle disorders were the most prevalent type of TMD. A substantial portion of TMD patients were depressed and experienced moderate to severe somatization.

Elbow tendinopathy: tennis elbow

The pathoanatomy of overuse tendinopathy is noninflammatory angiofibroblastic tendinosis. The areas of elbow abnormality are specific, including the ECRB-EDC complex laterally, the pronator teres, flexor carpi radialis medially, and triceps posteriorly. The goals of nonoperative treatment are to revitalize the unhealthy pain-producing tendinosis tissue. The key to nonoperative treatment is rehabilitative resistance exercise with progression of the exercise program. If rehabilitation fails, the surgical interventions as described are highly successful.

Reliability of classifications derived from Cyriax's resisted testing in subjects with painful shoulders and knees

STUDY DESIGN

Intrarater and interrater reliability.

OBJECTIVES

Examine intrarater and interrater reliability of the resisted-testing component of Cyriax's selective tension testing for patients with painful shoulders and knees.

BACKGROUND

Clinicians make diagnostic and intervention decisions about lesions in contractile tissues based on resisted testing. Diagnostic and intervention decisions require reliable data gathering, especially when more than 1 physical therapist manages a patient. No studies have examined agreement of the results of the resisted tests used in selective tension testing, either within or between physical therapists, in subjects having pathology.

METHODS AND MEASURES

Subjects with pain in 1 knee (18 male, 22 female; mean age +/- SD = 31.8 +/- 9.5 years) or shoulder (21 male, 25 female; mean age +/- SD = 34.3 +/- 12.9 years) were examined twice. Referring diagnoses included ligament injuries, overuse syndromes, joint instability, and postsurgical symptoms, with some subjects seeking initial diagnosis. Two physical therapists used standardized positions to evaluate 2 knee motions or 6 shoulder and elbow motions. Evaluators applied maximal isometric manual resistance and rated the contraction as strong or weak while subjects identified the presence or absence of pain during the contraction. Evaluators did not interview the subjects and were masked to previous test results. Analyses included percentage of agreement, kappa coefficients, confidence intervals, and maximum kappa coefficients.

RESULTS

Intrarater kappa coefficients ranged from 0.44 to 0.82 and interrater coefficients ranged from 0.00 to 0.46. The small number of subjects who were classified as weak affected the kappa coefficients. In the intrarater condition, evaluators averaged 91% of maximum kappa for the knee and 66.5% for the shoulder. In the interrater condition, they averaged 60.4% of the maximum kappa for both the knee and the shoulder.

CONCLUSIONS

Based on 2 physical therapist evaluators with previous education in the selective tension system and an additional 6 hours of formal training on the methods, intrarater reliability of resisted tests was generally acceptable for the knee but not for the shoulder. Interrater reliability of these tests, however, was generally not acceptable. Results were limited by subjects who were younger and had mostly chronic conditions that were mildly to moderately severe and by the small subject samples in the analyses. Reliability might be improved by more intensive training of the evaluators and by standardizing the magnitude of the applied resistance and stabilization of the subjects.

Determinants of the clinical course of musculoskeletal complaints in general practice: design of a cohort study

BACKGROUND

Musculoskeletal complaints are frequent and have large consequences for public health. Information about the prognosis after presentation in general practice is far from complete. Knowledge about determinants of the clinical course of musculoskeletal complaints is essential for management decisions and to inform patients about their prognosis. The purpose of this study is to provide information about the prognosis of musculoskeletal complaints other than low back pain by studying the course of these complaints in general practice and to identify determinants of this course.

METHODS

Patients of 18 years and older, who present in general practice with a new episode of a musculoskeletal complaint of the neck, shoulder, elbow, wrist, hand, arm, hip, knee, ankle or foot, are recruited by their general practitioner (GP). Participants will receive complaint-specific questionnaires by mail at baseline and after 3, 6, 12 and 18 months. The following putative determinants of the course of the complaints will be investigated: sociodemographic characteristics, characteristics of the complaint, psychosocial job characteristics, physical workload, physical activity during leisure time, pain coping, mood, kinesiophobia, social support, optimism. The primary outcomes are perceived recovery, pain, functional status, sick leave and overall quality of life.

Does joint effusion on T2 magnetic resonance images reflect synovitis? Part 2. Comparison of concentration levels of proinflammatory cytokines and total protein in synovial fluid of the temporomandibular joint with internal derangements and osteoarthrosis

OBJECTIVE

We sought to clarify the nature of joint effusion (JE) on T2-weighted magnetic resonance images of the temporomandibular joint (TMJ) by analysis of the synovial fluid in the superior compartment of patients with internal derangement and osteoarthrosis.

STUDY DESIGN

One hundred symptomatic TMJs (100 patients) with 65 internal derangements and 35 osteoarthroses were scanned by means of magnetic resonance imaging, and, the synovial fluid was sampled on the same day. The amount of JE was evaluated on a scale of 0 to 3. Grades 0 and 1 indicated absence of JE or a negligible amount of JE, respectively, and grades 2 and 3 indicated the presence of JE. Correlation was evaluated among the amount of JE and the concentrations of the total protein and interleukin-1beta(IL-1beta), IL-6, IL-8, and tumor necrosis factor-alpha in the synovial fluid.

RESULTS

Magnetic resonance imaging revealed the absence of JE in 40 joints (grade 0, 17 joints; grade 1, 23 joints) and the presence of JE in 60 joints (grade 2, 31 joints; grade 3, 29 joints). The joints with JE had, on average, significantly higher concentrations of total protein (1,675 microg vs 714 microg; P = .0001) and IL-6 (42.9 pg vs 10.6 pg; P = .009) than did the joints without JE. Furthermore, there were significant correlations between the JE grade and the concentrations of the total protein (P = .0001), IL-6 (P = .001), and IL-8 (P = .004). The detection ratio of cytokines among the presence-absence groups of JE showed a significant difference in tumor necrosis factor-alpha (68.3% vs 47.5%; P = .037) and IL-6 (86.7% vs 67.5%; P = .012). Conclusions. JE may contain the released products when there is pronounced synovitis. It is probably composed of high concentrations of total protein with inflammatory cytokines. Furthermore, IL-6 and IL-8 seem to have an important role in the pathogenesis of JE in TMJ disorders.

Electroacupuncture versus diclofenac in symptomatic treatment of osteoarthritis of the knee: a randomized controlled trial

BACKGROUND

The purpose of this study was to compare the efficacy of electroacupuncture (EA), diclofenac and their combination in symptomatic treatment of osteoarthritis (OA) of the knee.

METHODS

This study was a randomized, single-blind, placebo controlled trial. The 193 out-patients with OA of the knee were randomized into four groups: placebo, diclofenac, EA and combined (diclofenac plus EA). Paracetamol tablets were prescribed as a rescue analgesic during the study. The patients were evaluated after a run-in period of one week (week 0) and again at the end of the study (week 4). The clinical assessments included the amount of paracetamol taken/week, visual analog scale (VAS), Western Ontario and McMaster Universities (WOMAC) OA Index, Lequesne's functional index, 50 feet-walk time, and the orthopedist's and patient's opinion of change.

RESULTS

One hundred and eighty six patients completed the study. The improvement of symptoms (reduction in mean changes) in most outcome parameters was greatest in the EA group. The proportions of responders and patients with an overall opinion of "much better" were also greatest in the EA group. The improvement in VAS was significantly different between the EA and placebo group as well as the EA and diclofenac group. The improvement in Lequesne's functional index also differed significantly between the EA and placebo group. In addition, there was a significant improvement in WOMAC pain index between the combined and placebo group.

CONCLUSION

EA is significantly more effective than placebo and diclofenac in the symptomatic treatment of OA of the knee in some circumstances. However, the combination of EA and diclofenac treatment was no more effective than EA treatment alone.

Pressure-pain thresholds and MRI effusions in TMJ arthralgia

It has been suggested that MRI-depicted effusions identify patients with TMJ arthralgia. The Research Diagnostic Criteria (RDC) propose a pressure-pain threshold (PPT) of 1 pound for the identification of TMJ arthralgia. The hypotheses in this study were that: (1) there is no association between MRI-depicted effusions and TMJ arthralgia, and (2) a PPT of 1 pound does not discriminate between subjects with and those without arthralgia. Thirty females with TMJ disc displacement with reduction were divided into two groups based on the presence or absence of the self-report of TMJ pain. Bilateral TMJ PPTs and MRIs were obtained. Increasing palpation pressure from 1 to 3 pounds increased the sensitivity for identifying arthralgia from 22% to 100%, with a corresponding decrease in the specificity from 100% to 81%. The sensitivity and specificity of effusions for identifying arthralgia were 85% and 28%, respectively. These results suggest that the use of palpation pressures greater than 1 pound is a valid test for TMJ arthralgia. However, TMJ effusions lack adequate specificity for identifying TMJ arthralgia and were not associated with pain.

Outcome of arthroscopic surgery for internal derangement of the temporomandibular joint: long-term results covering 10 years

OBJECTIVES

To investigate the long-term success (10-year results) of arthroscopic surgery of the temporomandibular joint.

PATIENTS AND METHOD

A survey was undertaken of 37 patients who had been treated with arthroscopic surgery for TMJ internal derangement from 1986 to 1990. Thirty-three patients responded, of whom 30 were women and three men, whose age at surgery ranged from 14 to 77 years (mean: 35.1 years). The mean follow-up period was 10 years and 2 months. All patients rated their pain level on a visual analogue scale (VAS), and also recorded pain, jaw dysfunction, and activities of daily living (ADL) before surgery, and at the time of the survey. Interincisal opening was self-assessed (mm). Pre- and postoperative pain, dysfunction and ADL scores were compared for outcome and statistically analyzed with the Student's t-test.

RESULTS

Intensity of pain as rated on the VAS was significantly reduced from 5.15 to 0.34 (p<0.01). Pain, dysfunction and ADL scores also decreased from 8.25 to 1.09, 6.5 to 1.93, and 9.1 to 1.32, respectively (p<0.01). At the preoperative examination, 36 of the 37 patients showed limited jaw opening of less than 38 mm, reduced to only three postoperatively. For the success rate of TMJ surgery, the responding 33 plus data of one re-operated patient were assessed. Of these, 27 were rated as excellent, four as good, and three (including two re-operated patients) as poor. The success rate was 83.8% when three patients who did not respond were included in the data.

CONCLUSION

The long-term, 10 year outcome of TMJ arthroscopic surgery was considered to be acceptable and stable when compared with other surgical procedures and with the results of previously published middle to long-term treatment outcome studies.

Evaluation of clinical tests used in classification procedures in pregnancy-related pelvic joint pain

Pain in the pelvic joints and lower back, a major problem for pregnant women, has proved resistant to precise measurement and quantification. To develop a classification system, the clinical tests used must be able to separate pelvic from low back pain; they must also have a high inter-examiner reliability, sensitivity and specificity, and preferably be easy to perform. The aim of this study was to describe a standardised way of performing tests for examining the pelvis, and to evaluate inter-examiner reliability, and establish the sensitivity and specificity of 15 clinical tests. It was designed as a longitudinal, prospective, epidemiological cohort study. First, 34 pregnant women were examined by blinded examiners to establish inter-examiner reliability. Second, a cohort of 2269 consecutive pregnant women, each responded to a questionnaire and underwent a thorough and highly standardised physical examination (15 tests with 48 possible responses) of the pelvic joints and surrounding areas. The 535 women who reported daily pain from the pelvic joints and had objective findings from the joints were divided, according to symptoms, into four classification groups and one miscellaneous group. The results of the study showed inter-examiner agreement of the tests was high, calculated in percentage terms, at between 88 and 100%. Using the Kappa coefficient, most tests kept the high agreement: six tests had an inter-examiner agreement of between 0.81 and 1.00, three between 0.61 and 0.80, and two between 0.60 and 0.41. Five tests showed superior sensitivity. The specificity of the tests was between 0.98 and 1.00, except the value for pelvic topography, which was 0.79. These results show that it is possible to standardise examination and interpretation of clinical tests of the pelvic joints, resulting in a high degree of sensitivity, specificity and inter-examiner reliability.

The persistently irritable joint in childhood an orthopaedic perspective

Persistent joint or periarticular irritability and pain in children can have numerous explanations. This overview explores the diverse range of orthopaedic conditions, both acquired and congenital, that may lead to such a presentation.

Ulnar-sided wrist pain and instability

A variety of lesions have been associated with ulnar-sided wrist pain and/or VISI instability. A staging system for ulnar-sided perilunate instability describes progressive disruptions associated with lunotriquetral dissociation that can lead to VISI instability and emphasizes the importance of the dorsal radiocarpal ligament in preventing VISI instability. Previous studies have emphasized association between type II carpal morphology and arthrosis at the proximal pole of the hamate, which was identified as the most common location of arthrosis in the wrist. The pisotriquetral joint is another common site of degenerative changes. A better understanding of the normal anatomy and kinematics of the ulnar side of the wrist will better enable physicians to identify and treat problems in the ulnar aspect of the wrist.

Outcome of arthroscopic surgery to the temporomandibular joint correlates with stage of internal derangement: five-year follow-up study

We studied the 5-year long-term outcome of arthroscopic surgery, and also investigated whether outcome correlates with stage of internal derangement of the temporomandibular joint (TMJ). A consecutive group of 41 patients (56 joints) who had been followed up for between 3 and 5 years were involved in this study. The result was excellent in 22 patients (54%) and fair in 15 (37%). 7/14 were excellent and 5/14 were fair in stage III, 7/12 were excellent and 4/12 were fair in stage IV, and 8/15 were excellent and 6/15 were fair in stage V. Arthroscopic surgery of the TMJ is an effective and minimally invasive technique for various stages of internal derangement.

Reliability of radiographic evaluation for acromial morphology

OBJECTIVE

Bigliani's classification system of acromial morphology utilizing the standard outlet radiograph has become in accepted method for evaluating patients with rotator cuff disease. This study evaluates the interobserver and intraobserver reliability of Bigliani's classification system using observers at various levels of training.

PATIENTS AND DESIGN

Supraspinatus outlet view radiographs of 40 patients (aged 18-78 years) with shoulder pain were reviewed twice, 4 months apart, in a masked protocol by six reviewers, including two attending (fellowship-trained) shoulder surgeons, an attending musculoskeletal radiologist, an orthopedic surgery sports fellow, and two orthopedic residents (PGY-2 and PGY-5). The reviewers were given standard diagrams of the Bigliani classification system and were asked to classify each film as a type I, II, or III acromion. Interobserver reliability and intraobserver repeatability values were calculated using kappa statistic analysis (0-0.2 slight, 0.21-0.4 fair, 0.41-0.6 moderate, 0.61-0.8 substantial, and 0.8-1.0 excellent).

RESULTS AND CONCLUSION

For each of the two readings, all six observers agreed only 18% of the time. Kappa values for pairwise comparison of interobserver reliability among the six observers ranged from 0.01 to 0.75 (mean 0.35), and intraobserver repeatability ranged from 0.26 (PGY-5 resident) to 0.80 (fellowship-trained surgeon), with a mean of 0.55. Intraobserver repeatability was not significantly different for the different levels of expertise. More definitive criteria are needed to distinguish and classify the acromion.

[Climacteric arthralgia and hand arthrosis]

This study aimed at a possible classification of climacteric arthroses of the hand. 132 females suffering from arthralgias of the wrist and finger joints who had consulted our outpatient department originally because of climacteric complaints, were examined while asking them to complete a questionnaire with clinical criteria for classifying arthroses of the hand. The requisite number of criteria required for classification as ¿arthrosis of the hand¿ were attained in all three groups of females (premenopausal and postmenopausal women without operation, as well as hysterectomised and/or ovarectomised women¿, although the ex-ray showed no signs of degenerative arthritis. The subjective complaints voiced by the patients are opposed to the x-ray finding, so that it is not permissible to classify climacteric arthralgias of the wrist and finger joints as ¿arthritis¿.