he contribution by MRI and CT in the clinical staging of early glottic cancer (T1-T2) for the evaluation of submucosal areas that can change the stage of the disease and reassess the therapeutic approach. In particular, MRI shows a sensitivity of 100% and a specificity of 97% in assessing areas such as paraglottic space, anterior commissure, thyroid, and arytenoid cartilages, with various indications for conservative surgery. Instead, the sensitivity of CT reaches lower values, 40%, but it has high specificity (100%). In our series, CT staging was accurate in 70% of cases, while the MRI was accurate in 80% of cases.

Early Glottic Cancer: Role of MRI in the Preoperative Staging

https://www.hindawi.com/journals/bmri/2014/890385/  

Eugenia Allegra,1 Pierpaolo Ferrise,1 Serena Trapasso,1 Orazio Trapuzzano,2 Antonio Barca,2 Stefania Tamburrini,3 and Aldo Garozzo1

1Department of Experimental and Clinical Medicine-Otolaryngology Head and Neck Surgery, University of Catanzaro, Viale Europa, Località Germaneto, 88100 Catanzaro, Italy
2Department of Experimental and Clinical Medicine-Radiology, University of Catanzaro, Viale Europa, Località Germaneto, 88100 Catanzaro, Italy
3Department of Radiology, Pellegrini Hospital, 80135 Naples, Italy

Received 7 June 2014; Revised 12 July 2014; Accepted 23 July 2014; Published 14 August 2014

Academic Editor: Martin G. Mack

Copyright © 2014 Eugenia Allegra et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Percentage of concordance between pathological, MRI, and CT T staging with  value.

T staging CT MR value Correct stadiations 88% 66% 0.24 Understadiations 11% 0% 0.47 Overstadiations 0% 33% 0.02 Concordance between pathological, MRI, and CT staging with  value, according to laryngeal subsites. Laryngeal site Pathological involvement MRI CT  value Number Number (%)* Number (%)* Paraglottic space 6 6 (100%) 2 (33%) 0.06 Thyroid cartilage 4 4 (100%) 2 (50%) 0.41 Arytenoid cartilage 2 2 (100%) 2 (100%) n.v. Cricoid cartilage 0 0 (100%) 0 (100%) n.v. Anterior commissure 8 8 (100%) 2 (25%) 0.0098 (%)*: accuracy.

Abstract

Introduction. Clinical staging is the most important time in management of glottic cancer in early stage (I-II). We have conducted a prospective study to evaluate if magnetic resonance imaging (MRI) is more accurate than computed tomography (CT) about tumoral extension, to exactly choose the most appropriate surgical approach, from organ preservation surgery to demolitive surgery. Materials and Methods. This prospective study was conducted on 26 male patients, with suspected laryngeal neoplasia of glottic region. The images of MRI and CT were analyzed to define the expansion of glottic lesion to anterior commissure, laryngeal cartilages, subglottic and/or supraglottic site, and paraglottic space. The results of MRI and CT were compared with each other and with the pathology report. Results. CT accuracy was 70% with low sensitivity but with high specific value. MRI showed a diagnostic accuracy in 80% of cases, with a sensitivity of 100% and high specificity. Statistical analysis showed that MRI has higher correlation than CT with the pathology report. Conclusion. Our study showed that MRI is more sensitive than CT in the preoperative staging of early glottic cancer, to select exactly the eligible patients in conservative surgery of the larynx, as supracricoid laryngectomy and cordectomy by CO2 laser.

1. Introduction

Laryngeal cancer represents 4.5% of all malignancies and 28% of cancers of the upper aerodigestive tract. Ninety percent of the malignant tumors of the larynx are composed of squamous cell carcinomas, with different distributions of prevalence based on the specific subsite affected (glottic, supraglottic, and subglottic site) [1]. The clinical staging with the assistance of diagnostic imaging is the most important time of therapeutic planning, which should ensure oncological radicality in respect of the clinical outcomes for patients. For this reason, it is necessary to stage the laryngeal cancer in a correct way in order to choose the most correct therapeutic approach based on the available options, from organ preservation strategies (radiotherapy, partial resection/cordectomy with CO2 laser, and conservative partial reconstructive surgery) to demolitive surgery. This is especially true for glottic tumors at an early stage of disease, which have demonstrated high rates of local control with organ preservation techniques such as radiotherapy (RT) (84%–95%) and partial resections (85%–100%) [2–4]. Indirect laryngoscopy is the first step in diagnosis and clinical evaluation of the tumor extension, but it is an external investigation and therefore has limitations in the assessment of the implication of the deep structures (such as anterior commissure, thyroid cartilage, and paraglottic spaces), which is discriminating for the extension of surgical resection. A valuable aid is provided by computed tomography (MDCT) and magnetic resonance imaging (MRI) for the evaluation of deep structures, because the involvement of these areas is generally considered as a contraindication for radiotherapy and surgical conservative procedures. It is not a formal contraindication, as supracricoid laryngectomies are still preservation surgery. In these cases, frontolateral vertical laryngectomy or vertical hemilaryngectomy or partial supracricoid laryngectomy with cricohyoidoepiglottopexy (CHEP) or cricohyoidopexy (CHP) is oncologically more suitable, because of removing thyroid cartilage, vocal folds, and paraglottic spaces, although with greater morbidity and increased time of hospitalization. In addition, the reconstruction of the vocal folds allows maintenance of physiological larynx functions like phonation and swallowing, with improvement of the quality of life in these patients [4–7]. For these reasons, it is important to evaluate precisely the extent of tumor preoperatively to plan the correct procedure to assure clear margins to the patient to avoid local recurrence.

CT and MR imaging are routinely used to differentiate between limited and gross cartilage invasion.

Some studies have shown that MRI is more sensitive than CT in the evaluation of cartilage tumor invasion [8–10]. However, cartilage invasion is sometimes overestimated [11–13].

The overestimation of the magnetic resonance protocol is probably related to the presence of peritumoral inflammation, which amplifies/inflates the boundaries of abnormal tissues [14].

We have conducted a prospective study to evaluate if MRI is able to provide more accurate information than CT about the tumoral extension to the anterior commissure, the cartilages, and the possible infiltration of paraglottic spaces in laryngeal glottic cancer at an early stage (I-II); the purpose is to exactly select patients who are eligible for laryngeal conservative surgery (supracricoid laryngectomy and cordectomy by CO2 laser), to ensure the oncological radicality and improve clinical outcome.

2. Materials and Methods

2.1. Patients

The study was conducted at the Department of Otolaryngology, University of Catanzaro (Italy). From August 2011 to November 2013, 26 male patients, aged 52–79 years (median, 63.6 years), with suspected laryngeal cancer of glottic region assessed by indirect laryngoscopy were enrolled; the symptomatology was predominantly characterized by hoarseness and cough. The study was performed with the approval of Institutional Review Board of "Magna Graecia" University of Catanzaro, Italy; all patients give their informed consent to the study.

All patients were subjected to a diagnostic workup including indirect laryngoscopy, MRI and CT of the neck (with and without contrast), and biopsy. In order not to invalidate the results, MRI and CT scans were performed before laryngeal biopsy, so that the images do not prove altered by the presence of peritumoral inflammation. The evaluation of CT and MRI was performed independently by two radiologists who were unaware of the laryngoscopic features and surgical findings. Of 26 patients six were excluded from the study because they were treated with radiotherapy after biopsy confirmed tumor diagnosis (four patients refused surgery and two patients had poor general conditions). Of 20 patients, 14 were smokers, four ex-smokers, and two had never smoked.

Stage of disease in all patients was clinically assessed according to the 7th edition of the TNM classification established by the American Joint Committee on Cancer (AJCC) [15]. The physical examination by indirect laryngoscopy showed unilateral involvement vocal fold in 8/20 (40%) patients and bilateral vocal fold involvement in 12/20 (60%) patients. The T staging by indirect laryngoscopy classified eight patients as T1a, 6 T1b, and 6 T2, with impaired cordal motility.

Patients are currently included in a follow-up program including visits every 3 months with video-laryngoscopy and radiological examinations such as ultrasound of the neck, chest radiography, CT, and MRI, in agreement with clinical evidence.

2.2. Staging by MRI

MR images were obtained with a Philips Achieva 1.5 T MR system. MR examinations were performed with an anterior surface neck coil and T1-weighted spin echo and T2 turbo spin echo images in axial and coronal projection, without contrast, diffusion weighted imaging (DWI) and T1w spin echo sequences with fat saturation after paramagnetic contrast infusion of gadolinium chelate were obtained. The number of the sections was 20 for all sequences. The sections were 3-4 mm of interspace thickness with a 1 mm intersection gap. The evaluation of cartilage invasion followed the new criteria proposed by Becker et al. Specifically, T2-weighted or T1-weighted post-Mdc cartilage signal intensity greater than that of the adjacent tumor was considered to indicate inflammation, and signal intensity similar to that of the adjacent tumor was considered to indicate neoplastic invasion [16]. The DWI was performed to better discriminate peritumoral edema from neoplastic tissue, but, at present, there are no studies reporting the performance of DWI. The advantage introduced by DWI sequence consists in obtaining information about the cellularity of tissues [14–16].

The T staging by MRI classified eight patients as T1a, 6 T1b, and 6 T3.

2.3. Staging by CT

CT images were obtained with a Toshiba Aquilion CX 64 Multislice CT system. The axial cuts of neck and chest were performed with 2-3 mm of thickness and with 1 mm of intersection gap, before and after intravenous administration of contrast medium [17]. CT criteria used for determining neoplastic invasion of the thyroid cartilage include sclerosis, erosion, lysis, and transmural extralaryngeal tumor spread [17]. The T staging by CT classified 12 patients as T1a and 4 T3; the presence of the disease was not detected in four cases.

2.4. Statistical Analysis

The images of MRI and CT were studied to define the expansion of glottic lesion, involvement of anterior commissure, infiltration of laryngeal cartilages and the possible extension to subglottic and/or supraglottic, and the invasion of paraglottic space. The results of MRI and CT were compared with each other and with the definitive pathological examination, each of the two methods for calculating the sensitivity, and the specificity and positive predictive value. For statistical analysis we employed the MedCalc software (version 13.0.6) using the "comparison of proportion" test; the values lower than 0.05 () were considered statistically significant.

3. Results

Through histopathological examination, 18 of 20 (90%) were histologically diagnosed as squamous cell carcinoma of the glottis and were staged according to AJCC pTNM staging system, 7th edition [15], resulting in eight as pT1a, 4 pT1b, and 6 pT3; two of the ten patients clinicoradiologically classified as T1a had histopathological diagnosis of squamous cell papilloma.

According to preoperative clinicoradiological staging the classification was T1a in 10 patients (50%), T1b in 4 patients (20%), and T3 in 6 patients (30%). Based on clinicoradiological staging, patients were subjected to excisional biopsy with CO2 laser in two cases (classified as squamous cell papillomas by histopathological examination), cordectomy with CO2 laser in four cases (4 T1a without involvement of anterior commissure), supracricoid laryngectomy with CHEP and reconstruction of vocal cords in 10 cases (4 T1a, 4 T1b, and 2 T3), and total laryngectomy in four cases (4 T3).

3.1. Concordance between MRI and Pathological Staging

MRI classified in a correct way 16 of 20 patients (80%), with four overstaged patients: two lesions classified as cT1b by MR were pT1a and two lesions classified as cT1a were squamous cell papillomas at pathological examination (no tumor).

About the examination of anterior commissure, laryngeal cartilages, and paraglottic space, MRI has been shown to be a very sensitive method (100%), with two false positives, high specificity (97%), and a positive predictive value of 90%, as calculated from the data in Table 1.

Table 1: Concordance between MRI and pathological staging: true positive (TP), false positive (FP), true negative (TN), and false negative (FN), according to laryngeal subsites.

3.2. Concordance between CT and Pathological Staging

CT classified in a correct way 14 of 20 patients (70%), with six understaged patients: two lesions classified as cT1a by CT were pT1b, two lesions classified as cT1a were pT3, and two tumors were not detected by CT examination. The two cases of squamous cell papillomas were interpreted in a correct way. About the examination of anterior commissure, laryngeal cartilages and paraglottic space, CT has been shown to be a little sensitive method (40%), with eight false negatives (Figures 1 and 2) but with high specificity (100%), as calculated from the data in Table 2.

Table 2: Concordance between CT and pathological staging: true positive (TP), false positive (FP), true negative (TN), and false negative (FN), according to laryngeal subsites.

Figure 1: Carcinoma of the right vocal cord: (a) endoscopic view; (b) CT image: the paraglottic space seems preserved (green indicator) without cartilaginous alterations; (c) T2w MR image: the paraglottic space seems involved with focal invasion of the thyroid cartilage (green indicator).

Figure 2: Bilateral glottic carcinoma with involvement of anterior commissure: (a) endoscopic view; (b) CT image: contrast enhancement of right vocal fold, but the commissure seems preserved (green indicator); (c) T1w MR image after contrast shows involvement of right true vocal cord, anterior commissure, and anterior part of left vocal fold (green indicator).

3.3. Data Analysis

In our series, there is a statistically significant difference between MRI and CT in identifying the involvement of anterior commissure (), and a considerable difference also exists in the study of paraglottic space, even if it does not reach statistical significance () (Table 3). Moreover, taking into account the correspondence of the clinical-radiologic T staging with pT staging, a percentage of understadiations equal to 0% for MRI and 33% for CT emerge, which reaches statistical significance (). CT scans are charged with a large number of false negatives, while MR has found two cases of false positives. In our study, CT does not overstage the cases in contrast to MRI, but the difference does not reach statistical significance. CT scans showed no lesions in patients with papillomas, while MR showed asymmetry of the glottis with gradient contrast enhancement of the lesion and suspicion of malignancy. CT has estimated the involvement of paraglottic spaces in two cases of six and the infiltration of thyroid cartilage in two cases of six, while MRI is not responsible for errors in these assessments. In two cases there was an involvement of arytenoid cartilage; both CT and MRI have been equaled in these assessments. Results of data comparison are summarized in Table 4.

Table 3: Concordance between pathological, MRI, and CT staging with  value, according to laryngeal subsites.

Table 4: Percentage of concordance between pathological, MRI, and CT T staging with value.

4. Discussion

This prospective study evaluates the contribution by MRI and CT in the clinical staging of early glottic cancer (T1-T2) for the evaluation of submucosal areas that can change the stage of the disease and reassess the therapeutic approach. In particular, MRI shows a sensitivity of 100% and a specificity of 97% in assessing areas such as paraglottic space, anterior commissure, thyroid, and arytenoid cartilages, with various indications for conservative surgery. Instead, the sensitivity of CT reaches lower values, 40%, but it has high specificity (100%). In our series, CT staging was accurate in 70% of cases, while the MRI was accurate in 80% of cases. By Kuno et al., the accuracy of CT in staging was 80% and 87.5% for the MR, without significant differences between RMI and TC in the assessment of anterior commissure and paraglottic space, while for the determination of cartilaginous invasion MR showed a higher sensitivity than CT, which instead resulted to be significantly more specific. However cartilage invasion is sometimes overestimated, resulting in unnecessary total laryngectomies in some patients [13].

Again, the integration of DWI into the magnetic resonance protocol has the potential to increase the specificity [16].

The ability of CT in the evaluation of the cartilage invasion has been studied by several authors resulting in a variable sensitivity from 46% to 74% and a specificity variable from 87% to 94% [8, 10, 18–20]. By applying Becker's criteria for cartilage invasion for the evaluation of all laryngeal cartilages (extralaryngeal spreads and erosion/lysis) and for the evaluation of cricoid and arytenoid (single sclerosis), the sensitivity arrives at 82% and specificity at 79% [17]. Hartl et al. evaluated the role of CT for detecting cartilage invasion in early glottic tumors and showed a sensitivity of 10.5% and a specificity of 94%, overestimating the cartilage invasion in case of injury involving the commissure and overestimating it in case of lesion with impaired vocal fold mobility; they emphasized the inability of CT in the evaluation of focal invasion of the internal perichondrium in thyroid cartilage [21].

About RMI, Castelijns et al. asserted that CT and MRI were equally specific, while MRI was more sensitive than CT [8]. Becker claimed higher sensitivity of MRI than CT (89% versus 66%) but less specificity (84% versus 94%) [10]. In 1998, Declercq et al. showed a sensitivity of MRI equal to 100% [22] and in 2001 Atula et al. showed equivalence of the sensitivity and specificity of 67% [23]. Banko et al. have demonstrated accuracy equal to 100% in the evaluation of anterior commissure using MRI [24], similar to that found by Zbaren et al. equal to 83% [18]. About the evaluation of early glottic carcinomas, Bertrand et al. considered CT as a first line investigation, using only later on MRI for the examination of dubious areas such as the anterior commissure, subglottis, and arytenoid cartilages [20]. Anterior commissure is an area of particular interest, because its particular conformation may be a resistant space to tumoral deep space extension, until the thyroid cartilage, and configures it as a decisive factor for the choice of surgical resection. In fact, X-space's dense fibrous structures act as a barrier to extension in depth and may lead to spreading along the surface on the mid line till subglottic region [25–27]. This behavior contraindicates conservative surgery. In our series, CT has understaged the invasion of thyroid cartilage and paraglottic space; in a patient with bilateral glottic cancer, CT has not evaluated the invasion of anterior commissure, and in another case of glottic tumor it has not identified any tumoral alterations.

In the literature, the debate about the best therapeutic approach for glottic cancer that involves the anterior commissure is still open. In a review, 64 patients with T1 glottic cancer were treated with radiotherapy; 14 patients had involvement of commissure and they had a local control rate of 76% at 2 years and 58% at 5 years, with statistically significant difference [28]. In another review, 53 patients with glottic carcinoma were treated with radiotherapy: 8/14 (57.1%) patients with involvement of anterior commissure had locoregional recurrence of disease [29]. In another series, 200 cases classified as T1 were treated with radiotherapy and they had a local control rate of 89% in case of commissure involvement compared to 94%, when the commissure was not involved [30]. The anterior commissure, therefore, remains as one of the most adverse independent prognostic factors [31]. The CO2 laser treatment for glottic carcinomas involving the anterior commissure is supported by Steiner et al., while Eckel argues that it is burdened by high rates of recurrence (37.1%) [32, 33]. Sachse et al. compare the effectiveness of two conservative treatments, CO2 laser excision and partial laryngectomy, in 119 tumors classified as T1-T2, and they show that the involvement of anterior commissure greatly reduces the local control rate in patients treated with CO2 laser resection [34]. Zohar et al. and Laccourreye et al. reported a local control rate of 90% with supracricoid laryngectomy (SCL) in case of glottic tumors involving the anterior commissure, compared to 72% with radiotherapy [35, 36]. The modified supracricoid laryngectomy (MSCL) with reconstruction of vocal folds results oncologically safe in case of involvement of anterior commissure without recurrence at five years and with a local control rate equal to 90.5%, also increasing the quality of voice and life than the SCL [4–7].

Based on these considerations, it is clear in the treatment of early glottic cancer that it is important to identify the involvement of anterior commissure, paraglottic spaces, and laryngeal cartilages: the possible involvement of these deep structures could contraindicate CO2 laser treatment or radiation, because of its high rate of recurrence or chondronecrosis. Any focal involvement of arytenoid cartilages or paraglottic space and thyroid cartilage requires a more radical treatment, using LSC or MSCL, preserving functional laryngeal functions [5].

5. Conclusion

In our study, statistical analyses have showed that MRI could be considered a helpful diagnostic method for preoperative staging of laryngeal tumor and decision making of the best therapeutic option in these patients. MR imaging has several advantages with respect to multislice CT and few limitations (artifacts related to movement, namely, breathing, swallowing, and vessel pulsation). MRI allows a multiparameter analysis (T1 weighted, T2 weighted, DWI, and postcontrast acquisition). This multiparameter approach amplifies the contrast resolution. Moreover the lack of accurate evaluation radiologic imaging and substaging of disease can change therapeutic planning and patients survival. Data from our study are very encouraging. Even though MRI is more expensive, longer, and not always feasible for patients compared to CT scan (poor compliance, any contraindications), based on the above considerations, we believe that it could be considered the investigation of choice in the clinical evaluation of early glottic lesions for the planning of therapeutic interventions, because of its high sensitivity and elevated degree of diagnostic accuracy. However, the evaluation of MR images needs high experience and an interdisciplinary collaboration.

Conflict of Interests

The authors declare that there is no conflict of interests regarding the publication of this paper.

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Computer Assisted Tomography

Imaging of Usual and Unusual Complication of Rotator Cuff Repair Several complications may be encountered after rotator cuff (RC) repair. A thorough knowledge of surgical interventions, normal postoperative findings, and postoperative complications is crucial to provide a timely diagnosis, improving the clinical outcome of patients. Postoperative complications may involve RC, implanted device, osteochondral tissue, surgical-site infection, peripheral nerves, soft tissues, and vascular structures. In this review, we discuss the usual and unusual complications detectable after RC repair.

An Ancillary Sign in the Diagnosis of Bankart and Bankart Variants in Patients With Glenohumeral Instability on Nonarthrographic Magnetic Resonance Imaging: Preglenoid Fat Thickness Objective We investigated whether preglenoid fat thickness can be used as an ancillary sign for preliminary diagnosis of Bankart and its variants on nonarthrographic magnetic resonance imaging. Materials and Methods Sixty-eight anterior dislocation patients were included in this retrospective study. Forty-eight patients with Bankart and its variants, as detected by arthroscopy and magnetic resonance arthrography, were included in the study group. The study group was divided into osseous Bankart, labral Bankart, Perthes, and anterior labroligamentous periosteal sleeve avulsion subgroups. Twenty patients with no detected labral pathologies by arthroscopy and magnetic resonance arthrography were included in the control group. In these patients, preglenoid fat tissue thickness at the anteroinferior portion was measured at the level of the glenoid tubercle. Thickness of preglenoid fat tissue was compared between groups with different labral pathologies and those with normal labrum. Results The preglenoid fat tissue thickness was 2.65 ± 1.05 mm in the control group and 0.90 ± 0.59 mm in the study group (P < 0.0001). Patients with preglenoid fat tissue thinner than 1.6 mm showed a significantly increased likelihood of having Bankart and its variants in receiver operating characteristic analysis (sensitivity of 95.8% and specificity of 85%). There was no significant difference in preglenoid fat tissue thickness between the subgroups of the study group (osseous Bankart, labral Bankart, Perthes, and anterior labroligamentous periosteal sleeve avulsion). Conclusion Preglenoid fat tissue measurement can be used as an ancillary sign in the diagnosis of Bankart and Bankart variants in glenohumeral instability patients.

Comparison of Cone-Beam Computed Tomography and Multislice Computed Tomography in the Assessment of Extremity Fractures Objectives The aims of this study were to evaluate the agreement between cone-beam computed tomography (CBCT) and multislice computed tomography for the characterization of extremity fractures and to compare image quality, radiation dose, and patient tolerance. Methods Thirty-six patients with suspected fracture affecting distal extremities or who required preoperative fracture assessment were enrolled prospectively. Each patient underwent CBCT and multislice computed tomography the same day. Both examinations were evaluated independently twice by 2 trained radiologists using the Müller AO classification for fracture characterization. Results Cohen κ coefficient for agreement between the imaging techniques was almost perfect for fracture characterization, κ = 0.94 [95% confidence interval, 0.91–0.98]. There was substantial to almost perfect agreement for secondary findings. Cone-beam computed tomography was well tolerated and significantly less irradiant and had better subjective image. Conclusions An excellent agreement between both imaging techniques was found. This confirms the ability of CBCT to assess fractures and its potential in the management of patients with distal limb trauma.

Dual-Energy Computed Tomography in Loosening of Revision Hip Prosthesis: A Comparison Between MARS and non-MARS Images Purpose The aim of the study was to assess potential endoprosthesis loosening in patients after revision total hip arthroplasty, based on monochromatic dual-energy computed tomography (DECT) images obtained with and without metal artifact reduction software (MARS) and comparison with the clinical examination and hip function. Materials and Methods Twenty-five consecutive patients underwent DECT examinations. Two monochromatic data sets were generated: with MARS (75-keV MARS) and without MARS (140-keV non-MARS) and evaluated for signs of loosening, using a dedicated radiological score. The Harris Hip Score (HHS) was used to evaluate patients' hip function. Results The mean radiological score for loosening in the non-MARS group was 16.2, in the MARS group 17.0 and was significantly higher (P < 0.001). Radiological loosening evaluation in non-MARS images correlated with the HHS score (ρ = 0.43, P = 0.03), whereas there was no correlation between MARS images and HHS (ρ = 0.15, P = 0.47). New MARS-related artifacts, which hinder implant-bone interface evaluation, were found in 75-keV MARS images ("pseudo-loosening" in 33 of 34 prostheses, "ground-glass blurring" in 20 of 32). Conclusions High-energy monochromatic DECT images are superior to low-energy DECT MARS images in assessment of the potential loosening and correlate better with the clinical examination outcomes. For revision total hip arthroplasty evaluation, 2 data sets should be assessed inseparably because of extra artifacts in MARS images.

Value of the Cinematic Rendering From Volumetric Computed Tomography Data in Evaluating the Relationship Between Deep Soft Tissue Sarcomas of the Extremities and Adjacent Major Vessels: A Preliminary Study Objective The aim of the study was to assess the value of cinematic rendering (CR) from volumetric computed tomography data in evaluating the relationship between deep soft tissue sarcomas (STSs) of the extremities and the adjacent major vessels. Methods Preoperative contrast-enhanced axial imaging (CEAI) in the arterial phase with three-dimensional volume rendering (VR) and CR of contrast-enhanced computed tomography were used to assess adjacent vascular invasion in 43 cases of deep STSs of the extremities. The imaging assessments were compared with surgical findings and interpreted as negative (no vascular invasion) or positive (vascular invasion was present). Intrareader and interreader agreement were assessed using Cohen κ statistics. The diagnostic performance of CEAI, VR, and CR was evaluated by receiver operating curve analysis and compared using the DeLong test. Results Thirty-four and nine cases were classified as negative and positive, respectively, in surgery. Intrareader agreement values for the CEAI, VR, and CR assessments were all excellent (0.984, 0.934, and 0.914, respectively), whereas the interreader agreement for CEAI assessments was greater than that for VR and CR (0.969 vs 0.804 and 0.761). Cinematic rendering showed lower accuracy (0.698), sensitivity (0.778), specificity (0.676), positive predictive values (0.389), and negative predictive values (0.920) for vascular invasion diagnosis than CEAI or VR; the accuracy, sensitivity, specificity, positive predictive values, and negative predictive values increased to 0.767, 0.889, 0.735, 0.471, and 0.962 for both CEAI and VR. The results were not statistically significant (all P > 0.05). Conclusions Cinematic rendering has the potential to be used to evaluate vascular invasion in cases of deep STSs of the extremities, but it should be used alongside the traditional methods such as CEAI.

Kinematic Analysis of the Distal Radioulnar Joint in Asymptomatic Wrists Using 4-Dimensional Computed Tomography–Motion Pattern and Interreader Reliability Purpose The aim of this study was to determine the normal measurement values and interobserver performance of the distal radioulnar joint during wrist pronation-supination using 4-dimensional computed tomography (CT). Methods Four-dimensional CT examinations were performed on the asymptomatic contralateral wrists of 10 patients with unilateral chronic wrist pain. Measurements were conducted using the modified radioulnar (mRU) line and epicenter (Epi) methods. Volar subluxation of the ulnar head was demonstrated with negative values. Wilcoxon rank sum test was used to determine the measurement changes. Interobserver agreements were assessed using interclass correlation coefficients. Results In pronation, mRU line measurements (median, 0.09; interquartile range, 0–0.15) were significantly larger than in supination (median, −0.1; interquartile range, −0.18 to 0; P = 0.008).The Epi measurements were not significantly different in pronation (median, 0.03; interquartile range, 0.01–0.07) and supination (median, 0.06; interquartile range, 0.01–0.1; P = 0.799). There was an excellent inter-observer agreement between the two readers using mRU and Epi methods in pronation (0.982, 0.898), midpoint (0.994, 0.827) and supination (0.989, 0.972) positions, respectively. Conclusions Using 4-dimensional CT examination, distal radioulnar joint kinematics in asymptomatic wrists demonstrate excellent interobserver agreements with increased volar ulnar subluxation with supination as detected using mRU, but not the Epi method.

Computed Tomography Angiography and Magnetic Resonance Angiography of Congenital Anomalies of Pulmonary Veins We aimed to review computed tomography and magnetic resonance angiography of congenital anomalies of pulmonary veins. Total anomalous pulmonary venous return shows all pulmonary veins drain abnormally in another site rather than left atrium. Imaging can detect anomalous veins either supracardiac, infracardiac, or mixed. Partial anomalous pulmonary venous return shows some pulmonary vein have abnormal drainage that well delineated with computed tomography angiography. Scimitar syndrome is a type of partial anomalous pulmonary venous return where the pulmonary veins of the right lung drain infracardiac and is associated with right lung hypoplasia and dextrocardia. Pseudoscimitar show anomalous vein that takes a tortuous course and drains into the left atrium producing a false-positive scimitar sign. Cor triatriatum shows septum divide left atrium with proximal chamber receives blood flow from the pulmonary veins. Levoatriocardinal vein is an anomalous connection between the left atrium and anomalous vein from systemic venous system that is embryo logically derived from the cardinal veins. Computed tomography angiography can detect pulmonary vein stenosis, atresia, hypoplasia, and varix. Imaging is important for intimal diagnosis and detects the anomalous vessels and its connection, presence of stenosis, and associated other congenital cardiac anomalies. Also, it is a great role in assessment of patients after surgery.

Circulatory Stasis or Thrombus in Left Atrial Appendage, An Easy Diagnostic Solution Objective The purpose of this study was to assess the diagnostic performance of prone position cardiac multidetector computed tomography (MDCT) in the detection of left atrial appendage (LAA) thrombi and to make differentiate between thrombus and circulatory stasis using transesophageal echocardiography (TEE) as the criterion-standard imaging modality. Methods From December 2014 to April 2016, 53 consecutive patients were admitted to the hospital because of circulatory stasis or/and thrombus. All patients underwent prone-position MDCT and TEE. Prone-position MDCT and TEE sensitivity, specificity, positive predictive value, and negative predictive value were calculated. Results For the MDCT scan in the prone position, the sensitivity, specificity, positive predictive value, and negative predictive value results were 100%, 100%, 100%, and 100%, respectively. Conclusions Multidetector computed tomography scanning in the prone position differentiates circulatory stasis and LAA thrombus, is clinically useful for detecting and ruling out LAA thrombus, and may be an alternative to TEE as a diagnostic tool.

Cardiovascular Magnetic Resonance Provides Evidence of Abnormal Myocardial Strain and Primary Cardiomyopathy in Marfan syndrome Objective Marfan syndrome is an autosomal-dominant genetic disorder caused by mutations in the fibrillin-1 gene. The condition is a connective tissue disease that frequently involves the cardiovascular system. The existence of a primary cardiomyopathy in Marfan syndrome, however, is controversial. The aims of this study were to investigate the prevalence of left ventricular dysfunction with both transthoracic echocardiography and cardiovascular magnetic resonance (CMR) in a cohort of Marfan syndrome patients and to investigate patterns of myocardial strain across the cohort. Methods We used an institutional database to identify all patients with a firm diagnosis of Marfan syndrome based on Ghent criteria. Inclusion required left ventricular ejection fraction (LVEF) to have been measured by both CMR and transthoracic echocardiography within 12 months of each other. Normal LVEF was defined as a value of >55% when measured by CMR. Velocity vector imaging was used to measure left ventricular longitudinal strain patterns by application of feature tracking to cine magnetic resonance images. Results were compared with data from 20 age-matched control subjects. Results Sixty-nine Marfan syndrome patients met the inclusion criteria. The mean age was 35.4 ± 15.0 years, and 56.5% were male. The mean LVEF was 59.0% ± 7.0% by CMR and 59.1% ± 5.8% by echo. One-fifth of Marfan syndrome patients (15/69; 21.7%) had reduced function with LVEF ≤55% by CMR, but only 5 of these were identified by echo. Furthermore, echo identified 5 Marfan syndrome patients as having reduced LVEF in the presence of a normal LVEF by CMR. Some Marfan syndrome patients had abnormal longitudinal strain patterns even with LVEF within the reference range. Conclusions These data provide support for a primary cardiomyopathy in some Marfan syndrome patients. Cardiovascular magnetic resonance is more sensitive than echo for identifying cases with mild systolic dysfunction. Strain analysis may be more sensitive than simple LVEF assessment for identifying at-risk individuals.

Does the Tube Voltage Affect the Characterization of Coronary Plaques on 100- and 120-kVp Computed Tomography Scans Objective The aim of this study was to compare the diagnostic performance of 100- and 120-kVp coronary computed tomography (CT) angiography (CCTA) scans for the identification of coronary plaque components. Methods We included 116 patients with coronary plaques who underwent CCTA and integrated backscatter intravascular ultrasound studies. On 100-kVp scans, we observed 24 fibrous and 24 fatty/fibrofatty plaques; on 120-kVp scans, we noted 27 fibrous and 41 fatty/fibrofatty plaques. We compared the fibrous and the fatty/fibrofatty plaques, the CT number of the coronary lumen, and the radiation dose on scans obtained at 100 and 120 kVp. We also compared the area under the receiver operating characteristic (ROC) curve of the coronary plaques on 100- and 120-kVp scans with their ROC curves on integrated backscatter intravascular ultrasound images. Results The mean CT numbers of fatty and fatty/fibrofatty plaques were 5.71 ± 36.5 and 76.6 ± 33.7 Hounsfield units (HU), respectively, on 100-kVp scans; on 120-kVp scans, they were 13.9 ± 29.4 and 54.5 ± 22.3 HU, respectively. The CT number of the coronary lumen was 323.1 ± 81.2 HU, and the radiation dose was 563.7 ± 81.2 mGy-cm on 100-kVp scans; these values were 279.3 ± 61.8 HU and 819.1 ± 115.1 mGy-cm on 120-kVp scans. The results of ROC curve analysis identified 30.5 HU as the optimal diagnostic cutoff value for 100-kVp scans (area under the curve = 0.93, 95% confidence interval = 0.87–0.99, sensitivity = 95.8%, specificity = 78.9%); for 120-kVp plaque images, the optimal cutoff was 37.4 HU (area under the curve = 0.87, 95% confidence interval = 0.79–0.96, sensitivity = 82.1%, specificity = 85.7%). Conclusions For the discrimination of coronary plaque components, the diagnostic performance of 100- and 120-kVp CCTA scans is comparable.

Alexandros Sfakianakis
Anapafseos 5 . Agios Nikolaos
Crete.Greece.72100
2841026182

6948891480

alsfakia@gmail.com

Bone & Joint Surgery

Publons: The Next Step in Reviewer Recognition No abstract available

What's New in Orthopaedic Trauma No abstract available

Use of Povidone-Iodine Irrigation Prior to Wound Closure in Primary Total Hip and Knee Arthroplasty: An Analysis of 11,738 Cases Background: Povidone-iodine (PI) irrigation is often used prior to wound closure in total joint arthroplasty, but there are limited reports evaluating its efficacy in decreasing joint infections. The goal of this study was to compare the rate of any reoperation for infection (both superficial and deep) in primary total hip arthroplasty (THA) and primary total knee arthroplasty (TKA) among patients who did and did not receive PI irrigation prior to wound closure. Methods: Using our institution's total joint registry, we identified 5,534 primary THA and 6,204 primary TKA procedures performed from 2013 to 2017. Cases were grouped on the basis of whether or not the wound was irrigated with 1 L of 0.25% PI prior to closure. PI irrigation was used in 1,322 (24%) of the THA cases and in 2,410 (39%) of the TKA cases. The rates of reoperation for infection at 3 months and 1 year were compared between the 2 groups. The same comparisons were then performed using propensity scores to account for differences in baseline characteristics. Results: The rate of reoperation for infection as assessed at 3 months following THA was similar between those who received dilute PI irrigation (0.9%) and who did not (0.7%) (p = 0.7). At 1 year, the rate of reoperation for infection was similar between those who received dilute PI irrigation (0.7%) and those who did not (0.9%) (p = 0.6). After using the propensity score, there was no difference between the groups in the risk of septic reoperations. For TKA, the rate of reoperation as assessed at 3 months was similar between those who received dilute PI irrigation (0.8%) and those who did not (0.3%) (p = 0.06). At 1 year, there was a greater rate of reoperations for infection among those who received dilute PI irrigation (1.2%) compared with those who did not (0.6%) (p = 0.03). However, there was no difference in the risk of septic reoperations between the groups after using the propensity score. Conclusions: Despite enthusiasm for and progressive adoption of the use of dilute PI irrigation at our institution, there was not a significant reduction in the risk of reoperation for infection as assessed at 3 months and 1 year following primary THA and TKA. Level of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Povidone-Iodine Wound Lavage to Prevent Infection After Revision Total Hip and Knee Arthroplasty: An Analysis of 2,884 Cases Background: Postoperative infection remains a major challenge in revision total hip arthroplasty (THA) and revision total knee arthroplasty (TKA). Wound irrigation with dilute povidone-iodine (PI) solution has emerged as a simple, inexpensive, and potentially successful means of reducing postoperative infections. The aim of this study was to assess its effectiveness in reducing infection following revision THA and TKA in, to our knowledge, the largest revision cohort to date. Methods: Using our institution's total joint registry, we identified 1,402 revision THAs and 1,482 revision TKAs performed during the study period (2013, when the PI irrigation protocol was first implemented, to 2017). The PI lavage protocol was employed in 27% of the revision THA cases and 34% of the revision TKA cases; in the remaining cases, the protocol was not used. Demographics, comorbid conditions, underlying surgical diagnoses, and whether the revision was for a septic or an aseptic etiology were compared between the groups (use or no use of PI irrigation). Any reoperation due to infection, as assessed at 3 and 12 months following revision arthroplasty, was compared between the groups and propensity scores were calculated to account for differences in baseline characteristics between the groups. Results: After adjusting for baseline differences between the groups using the propensity-score weighted models, we found no significant difference in the rate of reoperation for infection at 3 months (p = 0.58 for revision THA, and p = 0.06 for revision TKA) and at 12 months (p = 0.78 for revision THA, and p = 0.06 for revision TKA). Nonetheless, the hazard ratios from the propensity-score model trended higher for patients who received PI lavage: 1.6 and 1.3 for revision THA at 3 and 12 months, respectively, and 2.9 at both 3 and 12 months for revision TKA. Conclusions: PI wound lavage demonstrated no benefit in reducing any reoperation for infection following revision THA and TKA. Moreover, the trend toward higher rates for reoperation for infection among patients who received PI irrigation merit further consideration. Level of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Association of Race and Ethnicity with Total Hip Arthroplasty Outcomes in a Universally Insured Population Background: Prior studies have documented racial and ethnic disparities in total hip arthroplasty (THA) outcomes in the U.S. The purpose of this study was to assess whether racial/ethnic disparities in THA outcomes persist in a universally insured population of patients enrolled in an integrated health-care system. Methods: A U.S. health-care system total joint replacement registry was used to identify patients who underwent elective primary THA between 2001 and 2016. Data on patient demographics, surgical procedures, implant characteristics, and outcomes were obtained from the registry. The outcomes analyzed were lifetime revision (all-cause, aseptic, and septic) and 90-day postoperative events (infection, venous thromboembolism, emergency department [ED] visits, readmission, and mortality). Racial/ethnic differences in outcomes were analyzed with use of multiple regression with adjustment for socioeconomic status and other potential confounders. Results: Of 72,755 patients in the study, 79.1% were white, 8.2% were black, 8.5% were Hispanic, and 4.2% were Asian. Compared with white patients, lifetime all-cause revision was lower for black (adjusted hazard ratio [HR], 0.79; 95% confidence interval [CI], 0.66 to 0.94; p = 0.007), Hispanic (adjusted HR, 0.73; 95% CI, 0.61 to 0.87; p = 0.002), and Asian (adjusted HR, 0.49; 95% CI, 0.37 to 0.66; p < 0.001) patients. Ninety-day ED visits were more common among black (adjusted odds ratio [OR], 1.15; 95% CI, 1.05 to 1.25; p = 0.002) and Hispanic patients (adjusted OR, 1.18; 95% CI, 1.08 to 1.28; p < 0.001). For all other postoperative events, minority patients had similar or lower rates compared with white patients. Conclusions: In contrast to prior research, we found that minority patients enrolled in a managed health-care system had rates of lifetime reoperation and 90-day postoperative events that were generally similar to or lower than those of white patients, findings that may be related to the equal access and/or standardized protocols associated with treatment in the managed care system. However, black and Hispanic patients still had higher rates of 90-day ED visits. Further research is required to determine the reasons for this finding and to identify interventions that could reduce unnecessary ED visits. Level of Evidence: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Regional or General Anesthesia in the Surgical Treatment of Distal Radial Fractures: A Randomized Clinical Trial Background: Most patients undergoing surgery for the treatment of a distal radial fracture are treated in a day-surgery setting and are given either general anesthesia (GA) or regional anesthesia (RA). The main purpose of this study was to investigate the impact of the anesthesia method on patients' postoperative opioid consumption during the first 3 days following surgery. Methods: This was a single-center randomized clinical trial. A total of 88 patients aged 18 to 74 years who were undergoing day surgery for the treatment of a displaced distal radial fracture with volar-plate fixation were randomized to GA (n = 44) or RA with a supraclavicular brachial plexus blockade (n = 44). The primary outcome was total opioid equivalent consumption (OEC) during the first 3 postoperative days (72 hours). Secondary outcomes included OEC during days 1, 2, and 3, visual analog scale (VAS) for pain scores, maximum pain, postoperative nausea and vomiting, perioperative time consumption (surgical, preoperative, and postoperative anesthesia care time), functional outcomes, and Patient-Rated Wrist Evaluation (PRWE) and EuroQol-5 Dimensions-3 Levels (EQ-5D-3L) scores up to 6 months. Results: The total median OEC during the first 3 postoperative days was 85 mg (range, 0 to 218 mg) in the GA group and 60 mg (range, 3 to 150 mg) in the RA group (p = 0.1). The groups differed significantly in OEC and VAS for pain scores during the first 24 hours after surgery; the median OEC was higher in the GA group before discharge (p < 0.001), while it was higher in the RA group after discharge (p < 0.001). Patients in the GA group reported more pain immediately after surgery (median score, 6; width of interquartile range [IQR], 7) and at 2 hours postoperatively (median score, 2; width of IQR, 3) compared with patients in the RA group (median score, 0; width of IQR, 0 at both time points) (p < 0.001). Maximum pain occurred at a median of 1 hour (range, 1 hour to 22 hours) after the end of surgery in the GA group compared with a median of 11 hours (range, 1 hour to 24 hours) in the RA group (p < 0.001). The total median perioperative time consumption was 244 minutes (range, 114 to 389 minutes) in the GA group compared with 146 minutes (range, 74 to 390 minutes) in the RA group (p < 0.001). There were no significant differences in functional outcomes or PRWE or EQ-5D-3L scores at 6 months. Conclusions: The anesthesia method (GA vs. RA) significantly influenced the early patterns of postoperative pain and opioid consumption after surgical treatment of a distal radial fracture, but neither total OEC over the first 3 postoperative days nor longer-term outcomes differed between the groups. Level of Evidence: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Step Activity After Surgical Treatment of Ankle Arthritis Background: Ambulatory activity is reduced in patients with ankle arthritis. In this study, we measured step activity over time in 2 treatment groups and secondarily compared step activity with results of patient-reported outcome measures (PROMs). Methods: Patients who were treated with either ankle arthrodesis or ankle arthroplasty wore a step activity monitor preoperatively and at 6, 12, 24, and 36 months postoperatively. Changes from preoperative baseline in total steps per day and per-day metrics of low, medium, and high-activity step counts were measured in both treatment groups. Step activity was compared with each subject's PROM scores as reported on the Musculoskeletal Function Assessment (MFA) and the Short Form-36 (SF-36) physical function and bodily pain subscales. Results: Of the 3 activity levels, combined group high-activity step counts showed the greatest increase (mean of 278 steps [95% confidence interval (CI), 150 to 407 steps], a 46% improvement from preoperatively). At 6 months, the mean high-activity step improvement for the arthroplasty group was 194 steps compared with a mean decline of 44 steps for the arthrodesis group (mean 238-step difference [95% CI, −60 to 536 steps]). By 36 months postoperatively, the greater improvement in high-activity steps for the arthroplasty versus the arthrodesis group was no longer present. There were no significant pairwise differences in improvement based on surgical treatment method at any individual follow-up time point. For a within-patient increase of 1,000 total steps, there was a mean change in the MFA, SF-36 physical function, and SF-36 bodily pain scores of −1.8 (95% CI, −2.4 to −1.2), 3.8 (95% CI, 2.8 to 4.8), and 2.8 (95% CI, 1.8 to 3.9), respectively (p < 0.0001 for all associations). There was no evidence that the association differed by study visit, or by study visit and surgical procedure interaction (p > 0.10). Conclusions: Surgical treatment of ankle arthritis significantly improves ambulatory activity, with greater change occurring at high activity levels. Improvement may occur more quickly following arthroplasty than arthrodesis, but at 3 years, we detected no significant difference between the 2 procedures. Step counts, while associated with PROMs, do not parallel them, and thus may be a useful supplementary measure, particularly in longitudinal studies. Level of Evidence: Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.

Cemented Versus Cementless Total Knee Arthroplasty of the Same Modern Design: A Prospective, Randomized Trial Background: Highly porous surfaces promoting biologic fixation have renewed interest in cementless total knee arthroplasty (TKA), but the potential for failed biologic fixation remains. The purpose of this study was to compare the clinical outcomes of cemented and cementless versions of the same TKA design at an average of 2 years postoperatively. Methods: This was an institutional review board-approved, prospective, randomized controlled trial of patients from 18 to 75 years of age who were undergoing a primary TKA. Patients with inflammatory arthritis, a body mass index (BMI) of >40 kg/m2, infection, a neuromuscular disorder, or grossly osteoporotic bone or bone defects were excluded. Patients were randomized to receive a cemented or cementless cruciate-retaining TKA of the same design. The cementless implant has highly porous fixation surfaces. Oxford Knee, Knee Society, and Forgotten Joint Scores were collected. Patients were asked to rate the knee with the TKA as a percentage of normal. Power analysis indicated that 130 patients were necessary to demonstrate a 5-point difference in the Oxford Knee Score at 90% power. Results: One hundred and forty-seven patients were enrolled, and 141 (96%) of them were analyzed at an average of 2 years postoperatively. There was no difference in age, sex, BMI, American Society of Anesthesiologists (ASA) score, or duration of follow-up (p = 0.1 to 0.9). There was also no difference in the change in the hemoglobin level from the preoperative measurement to postoperative day 1 between the 2 cohorts (mean and standard deviation, −2.6 ± 1.4 g/dL compared with −2.5 ± 0.9 g/dL, p = 0.5), but the total operative time was decreased in the cementless cohort (82.1 ± 16.6 compared with 93.7 ± 16.7 minutes, p = 0.001). There were no differences in any clinical outcome measure at 4 to 6 weeks, 1 year, or an average of 2 years postoperatively (p = 0.1 to 0.9) between the cemented and cementless cohorts. There was no radiographic evidence of component subsidence or loosening in either cohort. Conclusions: This study demonstrated that a recently introduced cementless TKA had results, both perioperatively and at an average of 2 years postoperatively, that were equivalent to those of its cemented predecessor, without any aseptic failures of either implant. Thus, this study justifies continued surveillance of this device to elucidate both its survivorship and if it can provide any long-term benefits. Level of Evidence: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Virtual Mechanical Testing Based on Low-Dose Computed Tomography Scans for Tibial Fracture: A Pilot Study of Prediction of Time to Union and Comparison with Subjective Outcomes Scoring Background: Quantitative outcomes assessment remains a persistent challenge in orthopaedic trauma. Although patient-reported outcome measures (PROMs) and radiographic assessments such as Radiographic Union Scale for Tibial Fractures (RUST) scores are frequently used, very little evidence has been presented to support their validity for measuring structural bone formation or biomechanical integrity. Methods: In this pilot study, a sequential cohort of patients with a tibial shaft fracture were prospectively recruited for observation following standard reamed intramedullary nailing in a level-I trauma center. Follow-up at 6, 12, 18, and 24 weeks included radiographs and completion of PROMs (EuroQol 5-Dimension [EQ-5D] and pain scores). Low-dose computed tomography (CT) scans were also performed at 12 weeks. Scans were reconstructed in 3 dimensions (3D) and subjected to virtual mechanical testing via the finite element method to assess torsional rigidity in the fractured limb relative to that in the intact bone. Results: Patients reported progressive longitudinal improvement in mobility, self-care, activity, and health over time, but the PROMs were not correlated with structural bone healing. RUST scoring showed moderate intrarater agreement (intraclass coefficient [ICC] = 0.727), but the scores at 12 weeks were not correlated with the time to union (R2 = 0.104, p = 0.193) and were only moderately correlated with callus structural integrity (R2 = 0.347, p = 0.010). In contrast, patient-specific virtual torsional rigidity (VTR) was significantly correlated with the time to union (R2 = 0.383, p = 0.005) and clearly differentiated 1 case of delayed union (VTR = 10%, union at 36 weeks) from the cases in the normally healing cohort (VTR > 60%; median union time, 19 weeks) on the basis of CT data alone. Conclusions: PROMs provide insight into the natural history of the patient experience after tibial fracture but have limited utility as a measure of structural bone healing. RUST scoring, although reproducible, may not reliably predict time to union. In contrast, virtual mechanical testing with low-dose CT scans provides a quantitative and objective structural callus assessment that reliably predicts time to union and may enable early diagnosis of compromised healing. Level of Evidence: Therapeutic Level IV. Please see Instructions for Authors for a complete description of levels of evidence.

The Effect of Coronal Alignment on Tibial Component Migration Following Total Knee Arthroplasty: A Cohort Study with Long-Term Radiostereometric Analysis Results Background: Recent short-term studies of total knee arthroplasty (TKA) have claimed improved clinical outcomes and implant survival when aiming to restore constitutional joint kinematics, as compared with neutral mechanical axis alignment. However, implant durability may be compromised when aligned in varus or valgus. With use of data pooled from 3 long-term radiostereometric analysis (RSA) studies, the aim of the present study was to assess the effects of coronal alignment on tibial component migration. Methods: Coronal alignment parameters from full-leg radiographs were measured and the constitutional leg alignment was determined for each patient. We evaluated the effect of the postoperative hip-knee-ankle angle, relative to both the mechanical axis and the constitutional alignment, on tibial component migration. In-range knees were defined as within ±3° of either the neutral mechanical axis or constitutional alignment of the patient. Analysis was performed with a linear mixed-effects model, corrected for study, age, sex, preoperative alignment, diagnosis, and body mass index. Results: A total of 85 cemented TKAs were included, of which 3 were revised for aseptic loosening and another 4 were considered loose. The median follow-up was 11 years. No loose tibial components were observed in mechanically in-range knees, whereas all loose tibial components were out of range. Mechanically varus knees showed the highest mean migration (maximum total point motion) of 1.55 mm (95% confidence interval [CI], 1.16 to 2.01 mm) after 5 years, compared with 1.07 mm (95% CI, 0.63 to 1.64 mm) and 0.77 mm (95% CI, 0.53 to 1.06 mm) for valgus and in-range knees, respectively (p < 0.001). In contrast, looking at constitutional alignment, loose tibial components were found among both constitutionally in-range and out-of-range knees. Mixed-model analysis showed comparable migration among constitutionally in-range, more-in-varus, and more-in-valgus aligned knees. Conclusions: Mechanically out-of-range alignment, especially mechanical varus, led to higher tibial component migration. However, matching the constitutional alignment of the patient did not preclude high implant migration. RSA trials randomizing different alignment techniques are needed to confirm the results of the present study. Level of Evidence: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Alexandros Sfakianakis
Anapafseos 5 . Agios Nikolaos
Crete.Greece.72100
2841026182

6948891480

alsfakia@gmail.com