New England Baptist Hospital

Autologous cultured chondrocyte transplantation was introduced in Sweden in 1987 for the treatment of large (1.5-12.0 cm2) full thickness chondral defects of the knee. The clinical, arthroscopic, and histologic results from the first 101 patients treated using this technique are reported in this study. Patients were assessed retrospectively using three types of endpoints: patient and physician derived clinical rating scales (five validated and two new); arthroscopic assessment of cartilage fill, integration, and surface hardness; and standard histochemical techniques. Ninety-four patients with 2- to 9-years followup were evaluable. Good to excellent clinical results were seen in individual groups as follows: isolated femoral condyle (92%), multiple lesions (67%), osteochondritis dissecans (89%), patella (65%), and femoral condyle with anterior cruciate ligament repair (75%). Arthroscopic findings in 53 evaluated patients showed good repair tissue fill, good adherence to underlying bone, seamless integration with adjacent cartilage, and hardness close to that of the adjacent tissue. Hypertrophic response of the periosteum or graft or both was identified in 26 arthroscopies; seven were symptomatic and resolved after arthroscopic trimming. Graft failure occurred in seven (four of the first 23 and three of the next 78) patients. Histologic analysis of 37 biopsy specimens showed a correlation between hyalinelike tissue (hyaline matrix staining positive for Type II collagen and lacking a fibrous component) and good to excellent clinical results. The good clinical outcomes of autologous chondrocyte transplantation in this study are encouraging, and clinical trials are being done to assess the outcomes versus traditional fibrocartilage repair techniques.

Chondrogenesis is the earliest phase of skeletal development, involving mesenchymal cell recruitment and migration, condensation of progenitors, and chondrocyte differentiation, and maturation and resulting in the formation of cartilage and bone during endochondral ossification. This process is controlled exquisitely by cellular interactions with the surrounding matrix, growth and differentiation factors, and other environmental factors that initiate or suppress cellular signaling pathways and transcription of specific genes in a temporal-spatial manner. Vertebrate limb development is controlled by interacting patterning systems involving prominently the fibroblast growth factor (FGF), bone morphogenetic protein (BMP), and hedgehog pathways. Both positive and negative signaling kinases and transcription factors, such as Sox9 and Runx2, and interactions among them determine whether the differentiated chondrocytes remain within cartilage elements in articular joints or undergo hypertrophic maturation prior to ossification. The latter process requires extracellular matrix remodeling and vascularization controlled by mechanisms that are not understood completely. Recent work has revealed novel roles for mediators such as GADD45beta, transcription factors of the Dlx, bHLH, leucine zipper, and AP-1 families, and the Wnt/beta-catenin pathway that interact at different stages during chondrogenesis.

Bronchiolitis obliterans organizing pneumonia (BOOP) is increasingly recognized as an important cause of diffuse infiltrative lung disease. It is a diagnostic consideration in patients with a febrile flu-like illness of a few weeks' duration and a roentgenogram showing bilateral patchy infiltrates that are not responsive to a typical course of antibiotics. It is defined as granulated tissue plugs within lumens of small airways that extend into alveolar ducts and alveoli. Clinically, a flu-like illness, cough, and crackles are common. Pulmonary function studies of patients show a decreased vital capacity, normal flow rates (except in smokers), and a decreased diffusing capacity. It is generally idiopathic, but it may occur during the resolution of a viral or mycoplasma pneumonia. It is also associated with a variety of systemic illnesses and clinical settings. These include the connective tissue disorders, antineoplastic and other drugs, and immunological disorders, as well as bone marrow and lung transplantation. There are numerous related disorders, including human immunodeficiency virus infection, radiation therapy, thyroiditis, and alcoholic cirrhosis. In idiopathic BOOP, complete resolution occurs in 65% to 85% of patients treated with corticosteroid therapy. This type of therapy is often effective in patients with associated systemic disorders or in other clinical settings, but there may be limited or no response in patients with dermatomyositis, immunosuppression, or interstitial opacities at the lung bases. Respiratory failure leading to death may occur in 5% of patients. It is important to add BOOP to the differential diagnosis of febrile, noninfectious illnesses that are mimics of pneumonia.

Three hundred and thirty orthopaedic surgeons in the United States participated in a study of transfusion requirements associated with total joint arthroplasty. A total of 9482 patients (3920 patients who had a total hip replacement and 5562 patients who had a total knee replacement) were evaluated prospectively from September 1996 through June 1997. Of those patients, 4409 (46 percent [57 percent of the patients who had a hip replacement and 39 percent of the patients who had a knee replacement]) had a blood transfusion. Two thousand eight hundred and ninety patients (66 percent) received autologous blood, and 1519 patients (34 percent) received allogenic blood. Ordered logistic regression analysis showed the most important predictors of the transfusion of allogenic blood to be a low baseline hemoglobin level and a lack of predonated autologous blood. Preoperative donation of autologous blood decreases the risk of transfusion of allogenic blood; however, inefficiencies in the procedures for obtaining autologous blood were identified. Sixty-one percent (5741) of the patients had predonated blood for autologous transfusion, but 4464 (45 percent) of the 9920 units of the predonated autologous blood were not used. Primary procedures and revision total knee arthroplasty were associated with the greatest number of wasted autologous units. Of the 5741 patients who had predonated blood, 503 (9 percent) needed a transfusion of allogenic blood. The frequency of allogenic blood transfusion varied with respect to the type of operative procedure (revision total hip arthroplasty and bilateral total knee arthroplasty were associated with the highest prevalence of such transfusions) and with a baseline hemoglobin level of 130 grams per liter or less. Transfusion of allogenic blood was also associated with infection (p < or = 0.001), fluid overload (p < or = 0.001), and increased duration of hospitalization (p < or = 0.01). These latter findings warrant further evaluation in controlled studies.

OBJECTIVE: Osteoclast differentiation factor (ODF; also known as osteoprotegerin ligand, receptor activator of nuclear factor kappaB ligand, and tumor necrosis factor-related activation-induced cytokine) is a recently described cytokine known to be critical in inducing the differentiation of cells of the monocyte/macrophage lineage into osteoclasts. The role of osteoclasts in bone erosion in rheumatoid arthritis (RA) has been demonstrated, but the exact mechanisms involved in the formation and activation of osteoclasts in RA are not known. These studies address the potential role of ODF and the bone and marrow microenvironment in the pathogenesis of osteoclast-mediated bone erosion in RA. METHODS: Tissue sections from the bone-pannus interface at sites of bone erosion were examined for the presence of osteoclast precursors by the colocalization of messenger RNA (mRNA) for tartrate-resistant acid phosphatase (TRAP) and cathepsin K in mononuclear cells. Reverse transcriptase-polymerase chain reaction (RT-PCR) was used to identify mRNA for ODF in synovial tissues, adherent synovial fibroblasts, and activated T lymphocytes derived from patients with RA. RESULTS: Multinucleated cells expressing both TRAP and cathepsin K mRNA were identified in bone resorption lacunae in areas of pannus invasion into bone in RA patients. In addition, mononuclear cells expressing both TRAP and cathepsin K mRNA (preosteoclasts) were identified in bone marrow in and adjacent to areas of pannus invasion in RA erosions. ODF mRNA was detected by RT-PCR in whole synovial tissues from patients with RA but not in normal synovial tissues. In addition, ODF mRNA was detected in cultured adherent synovial fibroblasts and in activated T lymphocytes derived from RA synovial tissue, which were expanded by exposure to anti-CD3. CONCLUSION: TRAP-positive, cathepsin K-positive osteoclast precursor cells are identified in areas of pannus invasion into bone in RA. ODF is expressed by both synovial fibroblasts and by activated T lymphocytes derived from synovial tissues from patients with RA. These synovial cells may contribute directly to the expansion of osteoclast precursors and to the formation and activation of osteoclasts at sites of bone erosion in RA.

Total hip arthroplasty, for both primary and revision operations, frequently involves bony abnormalities of the acetabulum. No standard nomenclature currently exists for the definition of acetabular deficiencies. A classification system is presented to assist in the preoperative evaluation and to provide a treatment protocol for these defects.

BACKGROUND: Health care organizations face pressures from patients to improve the quality of care and clinical outcomes, as well as pressures from managed care to do so more efficiently. Coordination, the management of task interdependencies, is one way that health care organizations have attempted to meet these conflicting demands. OBJECTIVES: The objectives of this study were to introduce the concept of relational coordination and to determine its impact on the quality of care, postoperative pain and functioning, and the length of stay for patients undergoing an elective surgical procedure. Relational coordination comprises frequent, timely, accurate communication, as well as problem-solving, shared goals, shared knowledge, and mutual respect among health care providers. RESEARCH DESIGN: Relational coordination was measured by a cross-sectional questionnaire of health care providers. Quality of care was measured by a cross-sectional postoperative questionnaire of total hip and knee arthroplasty patients. On the same questionnaire, postoperative pain and functioning were measured by the WOMAC osteoarthritis instrument. Length of stay was measured from individual patient hospital records. SUBJECTS: The subjects for this study were 338 care providers and 878 patients who completed questionnaires from 9 hospitals in Boston, MA, New York, NY, and Dallas, TX, between July and December 1997. MEASURES: Quality of care, postoperative pain and functioning, and length of acute hospital stay. RESULTS: Relational coordination varied significantly between sites, ranging from 3.86 to 4.22 (P <0.001). Quality of care was significantly improved by relational coordination (P <0.001) and each of its dimensions. Postoperative pain was significantly reduced by relational coordination (P = 0.041), whereas postoperative functioning was significantly improved by several dimensions of relational coordination, including the frequency of communication (P = 0.044), the strength of shared goals (P = 0.035), and the degree of mutual respect (P = 0.030) among care providers. Length of stay was significantly shortened (53.77%, P <0.001) by relational coordination and each of its dimensions. CONCLUSIONS: Relational coordination across health care providers is associated with improved quality of care, reduced postoperative pain, and decreased lengths of hospital stay for patients undergoing total joint arthroplasty. These findings support the design of formal practices to strengthen communication and relationships among key caregivers on surgical units.

Chondrocytes are the single cellular component of hyaline cartilage. Under physiologic conditions, they show steady-state equilibrium between anabolic and catabolic activities that maintains the structural and functional integrity of the cartilage extracellular matrix. Implicit in the loss of cartilage matrix that is associated with osteoarthritis is that there is a disturbance in the regulation of synthetic (anabolic) and resorptive (catabolic) activities of the resident chondrocytes that results in a net loss of cartilage matrix components and deterioration in the structural and functional properties of the cartilage. Multiple mechanisms likely are involved in the disturbance of chondrocyte remodeling activities in OA. They include the development of acquired or age-related alterations in chondrocyte function, the effects of excessive mechanical loading, and the presence of dysregulated cytokine activities. Cytokines are soluble or cell-surface molecules that play an essential role in mediating cell-cell interactions. It is possible to classify the cytokines that regulate cartilage remodeling as catabolic, acting on target cells to increase products that enhance matrix degradation; as anticatabolic, tending to inhibit or antagonize the activity of the catabolic cytokines; and as anabolic, acting on chondrocytes to increase synthetic activity. This review will focus on the role of proinflammatory cytokines and their roles in mediating the increased matrix degradation that characterizes the osteoarthritic cartilage lesion.

BACKGROUND: Our hypothesis that multiple, equally tensioned strands of hamstring graft used for reconstruction of the anterior cruciate ligament are stronger and stiffer than ten-millimeter patellar ligament grafts was tested biomechanically with use of tendons from cadavera. METHODS: In the first part of the study, we measured the strength and stiffness of one, two, and four-strand hamstring grafts, from fresh-frozen cadaveric knees, that had been tensioned equally when clamped. In the second part of the study, we compared four-strand grafts to which tension had been applied by hand and then clamped with similar grafts to which tension had been applied with weights and then clamped. The grafts for the two experiments were obtained from thirty-four paired and ten unpaired knees. We also studied the effects of cooling on the biomechanical properties of grafts by comparing patellar ligament grafts tested at 13 degrees Celsius with those tested at room temperature. RESULTS: Two equally tensioned gracilis strands had 185 percent of the strength and 210 percent of the stiffness (1550+/-428 newtons and 336+/-141 newtons per millimeter, respectively) of one gracilis strand (837+/- 138 newtons and 160+/-44 newtons per millimeter, respectively). Two equally tensioned semitendinosus strands had 220 percent of the strength and 220 percent of the stiffness (2330+/-452 newtons and 469+/-185 newtons per millimeter, respectively) of one semitendinosus strand (1060+/-227 newtons and 213+/-44 newtons per millimeter, respectively). Four combined strands (two gracilis strands and two semitendinosus strands) that were equally tensioned with weights and clamped had the additive tensile properties of the individual strands. With the numbers available, four combined strands that were manually tensioned and clamped were not found to be significantly stronger or stiffer than two semitendinosus strands that were equally tensioned with weights (p>0.07). CONCLUSIONS: Four combined strands that were equally tensioned with weights and clamped were stronger and stiffer than all ten-millimeter patellar ligament grafts that have been described in previous reports. All strands of a hamstring graft must be equally tensioned for the composite to have its optimum biomechanical properties. CLINICAL RELEVANCE: Because of the well recognized donor-site morbidity associated with the use of patellar ligament grafts for reconstruction of the anterior cruciate ligament, multiple-strand hamstring-tendon grafts have become an increasingly popular choice. Our data demonstrate that equally tensioned four-strand hamstring-tendon grafts have initial tensile properties that are higher than those reported for ten-millimeter patellar-ligament grafts; thus, from a biomechanical point of view, they seem to be a reasonable alternative.

The current authors examined the hypothesis that labral lesions contribute to early degenerative hip disease. Between 1993 and 1999, 436 consecutive hip arthroscopies were done by the senior author. In addition, 54 acetabula were harvested from human adult cadavers. Two hundred forty-one of the 436 (55.3%) patients who had arthroscopies had a 261 labral tears, all located at the articular, not capsular margin of the labrum. Stereomicroscopic examination of the 54 acetabula from cadavers revealed 52 labral lesions. Overall, there was no significant difference between the arthroscopic and cadaveric populations in terms of the incidence of labral tears. (Overall, 73% of patients with fraying or a tear of the labrum had chondral change. Arthroscopic and anatomic observations support the concept that labral disruption and degenerative joint disease are frequently part of a continuum of joint disease.

Osteoclasts are specialized macrophages that resorb bone. Mice lacking the AP-1 component c-Fos are osteopetrotic because of a lack of osteoclast differentiation and show an increased number of macrophages. The nature of the critical function of c-Fos in osteoclast differentiation is not known. Microarray analysis revealed that Nfatc1, another key regulator of osteoclastogenesis, was down-regulated in Fos(-/-) osteoclast precursors. Chromatin immunoprecipitation assay showed that c-Fos bound to the Nfatc1 and Acp5 promoters in osteoclasts. In vitro promoter analyses identified nuclear factor of activated T-cells (NFAT)/AP-1 sites in the osteoclast-specific Acp5 and Calcr promoters. Moreover, in Fos(-/-) precursors gene transfer of an active form of NFAT restored transcription of osteoclast-specific genes in the presence of receptor activator of the NF-kappaB ligand (RANKL), rescuing bone resorption. In the absence of RANKL, however, Fos(-/-) precursors were insensitive to NFAT-induced osteoclastogenesis unlike wild-type precursors. These data indicate that lack of Nfatc1 expression is the cause of the differentiation block in Fos(-/-) osteoclast precursors and that transcriptional induction of Nfatc1 is a major function of c-Fos in osteoclast differentiation.

BACKGROUND: Cervical spondylotic myelopathy is the leading cause of spinal cord dysfunction worldwide. The objective of this study was to evaluate the impact of surgical decompression on functional, quality-of-life, and disability outcomes at one year after surgery in a large cohort of patients with this condition. METHODS: Adult patients with symptomatic cervical spondylotic myelopathy and magnetic resonance imaging evidence of spinal cord compression were enrolled at twelve North American centers from 2005 to 2007. At enrollment, the myelopathy was categorized as mild (modified Japanese Orthopaedic Association [mJOA] score ≥ 15), moderate (mJOA = 12 to 14), or severe (mJOA < 12). Patients were followed prospectively for one year, at which point the outcomes of interest included the mJOA score, Nurick grade, Neck Disability Index (NDI), and Short Form-36 version 2 (SF-36v2). All outcomes at one year were compared with the preoperative values with use of univariate paired statistics. Outcomes were also compared among the severity classes with use of one-way analysis of variance. Finally, a multivariate analysis that adjusted for baseline differences among the severity groups was performed. Treatment-related complication data were collected and the overall complication rate was calculated. RESULTS: Eighty-five (30.6%) of the 278 enrolled patients had mild cervical spondylotic myelopathy, 110 (39.6%) had moderate disease, and 83 (29.9%) had severe disease preoperatively. One-year follow-up data were available for 222 (85.4%) of 260 patients. There was a significant improvement from baseline to one year postoperatively (p < 0.05) in the mJOA score, Nurick grade, NDI score, and all SF-36v2 health dimensions (including the mental and physical health composite scores) except general health. With the exception of the change in the mJOA, the degree of improvement did not depend on the severity of the preoperative symptoms. These results remained unchanged after adjusting for relevant confounders in the multivariate analysis. Fifty-two patients experienced complications (prevalence, 18.7%), with no significant differences among the severity groups. CONCLUSIONS: Surgical decompression for the treatment of cervical spondylotic myelopathy was associated with improvement in functional, disability-related, and quality-of-life outcomes at one year of follow-up for all disease severity categories. Furthermore, complication rates observed in the study were commensurate with those in previously reported cervical spondylotic myelopathy series.

BACKGROUND AND PURPOSE: The International Knee Documentation Committee Subjective Knee Form was developed to measure change in symptoms, function, and sports activity in patients treated for a variety of knee conditions. Although previous research has demonstrated reliability and validity of the form, its responsiveness has not been evaluated. The purpose of this study was to determine responsiveness of the International Knee Documentation Committee Subjective Knee Form. STUDY DESIGN: Cohort study (diagnosis); Level of evidence, 1. METHODS: Patients who participated in the original validation study for the International Knee Documentation Committee Subjective Knee Form completed the form and a 7-level global rating of change scale that ranged from greatly worse to greatly better after a mean of 1.6 years (range, 0.5-2.3 years). Analyses included calculation of the standardized response mean and mean change in International Knee Documentation Committee Subjective Knee Form score compared to the patient's perception of change on the global rating of change scale. In addition, a receiver operating characteristic curve was plotted to determine the change in score that best distinguished patients who improved from those who did not. RESULTS: The overall standardized response mean was 0.94, which is considered large. With the exception of those who were slightly worse or unchanged, the mean change in the International Knee Documentation Committee Subjective Knee Form score compared to the patients' perceived global ratings of change was as expected (greatly worse, -15.1; somewhat worse, -8.4; slightly worse, 20.6; no change, 10.7; slightly better, 5.9; somewhat better, 18.1; greatly better, 38.7). The receiver operating characteristic curve analysis revealed that a change score of 11.5 points had the highest sensitivity, and a change score of 20.5 points had the highest specificity to distinguish between those who were or were not improved. CONCLUSION: The International Knee Documentation Committee Subjective Knee Form is a responsive measure of symptoms, function, and sports activity for patients with a variety of knee conditions.

BACKGROUND: Pemphigus vulgaris is a potentially fatal autoimmune mucocutaneous blistering disease. Conventional therapy consists of high-dose corticosteroids, immunosuppressive agents, and intravenous immune globulin. METHODS: We studied patients with refractory pemphigus vulgaris involving 30% or more of their body-surface area, three or more mucosal sites, or both who had inadequate responses to conventional therapy and intravenous immune globulin. We treated the patients with two cycles of rituximab (375 mg per square meter of body-surface area) once weekly for 3 weeks and intravenous immune globulin (2 g per kilogram of body weight) in the fourth week. This induction therapy was followed by a monthly infusion of rituximab and intravenous immune globulin for 4 consecutive months. Titers of serum antibodies against keratinocytes and numbers of peripheral-blood B cells were monitored. RESULTS: Of 11 patients, 9 had rapid resolution of lesions and a clinical remission lasting 22 to 37 months (mean, 31.1). All immunosuppressive therapy, including prednisone, could be discontinued before ending rituximab treatment in all patients. Two patients were treated with rituximab only during recurrences and had sustained remissions. Titers of IgG4 antikeratinocyte antibodies correlated with disease activity. Peripheral-blood B cells became undetectable shortly after initiating rituximab therapy but subsequently returned to normal values. Side effects that have been associated with rituximab were not observed, nor were infections. CONCLUSIONS: The combination of rituximab and intravenous immune globulin is effective in patients with refractory pemphigus vulgaris.

The purpose of the current study was to assess the validity, internal consistency, and reproducibility of a short, self-administered hip score designed for use in younger patients with higher demands and expectations than older patients with degenerative joint disease. Validity and internal consistency was studied with 48 consecutive patients with a mean age of 33 years with intractable hip pain and normal plain radiographs. Reproducibility was assessed from data on an additional random sample of 17 patients with hip pain. The Pearson correlation coefficients were 0.82 and 0.59 between the nonarthritic hip score and the Harris hip score and Short Form-12, respectively showing validity. Cronbach’s coefficient alpha measuring the internal consistency within each of the score’s four domains ranged from 0.69 to 0.92. The test and retest reproducibility ranged from 0.87 to 0.95 for the four subsets and was 0.96 overall. This short, self-administered questionnaire regarding hip pain in young patients with increased activity demands and high treatment expectations is valid compared with previous measures of hip performance, is internally consistent, and is reproducible.

STUDY DESIGN: Cross-sectional study. OBJECTIVES: To determine prevalence rates of spondylolysis, isthmic, and degenerative spondylolisthesis in an unselected adult community-based population; and to evaluate the association of spondylolysis, isthmic, and degenerative spondylolisthesis with low back pain (LBP). SUMMARY OF BACKGROUND DATA: Spondylolysis and spondylolisthesis are prevalent in the general population; however, the relationship between these conditions and LBP is controversial. METHODS: This study was an ancillary project to the Framingham Heart Study. A sample of 3529 participants of the Framingham Heart Study aged 40 to 80 years underwent multidetector CT imaging to assess aortic calcification. One hundred eighty-eight individuals were consecutively enrolled in this study to assess radiographic features potentially associated with LBP. The occurrence of LBP in the preceding 12 months was evaluated using a self-report questionnaire. The presence of spondylolysis and spondylolisthesis was characterized by CT imaging. We used multiple logistic regression models to examine the association between spondylolysis, spondylolisthesis, and LBP, while adjusting for gender, age, and BMI. RESULTS: Twenty-one study subjects demonstrated spondylolysis on computed tomography (CT) imaging. The male-to-female ratio was approximately 3:1. Twenty-one percent of subjects with bilateral spondylolytic defects demonstrated no measurable spondylolisthesis. The male-to-female ratio of degenerative spondylolisthesis was 1:3, and the prevalence of degenerative spondylolisthesis increased from the fifth through 8 decades of life. Thirty-eight subjects (20.4%) reported significant LBP. No significant association was identified between spondylolysis, isthmic spondylolisthesis, or degenerative spondylolisthesis, and the occurrence of LBP. CONCLUSION: Based on CT imaging of an unselected community-based population, the prevalence of lumbar spondylolysis is 11.5%, nearly twice the prevalence of previous plain radiograph-based studies. This study did not reveal a significant association between the observation of spondylolysis on CT and the occurrence of LBP, suggesting that the condition does not seem to represent a major cause of LBP in the general population.

Rheumatoid arthritis, juvenile idiopathic arthritis, the seronegative spondyloarthropathies including psoriatic arthritis, and systemic lupus erythematosus are all examples of rheumatic diseases in which inflammation is associated with skeletal pathology. Although some of the mechanisms of skeletal remodeling are shared among these diseases, each disease has a unique impact on articular bone or on the axial or appendicular skeleton. Studies in human disease and in animal models of arthritis have identified the osteoclast as the predominant cell type mediating bone loss in arthritis. Many of the cytokines and growth factors implicated in the inflammatory processes in rheumatic diseases have also been demonstrated to impact osteoclast differentiation and function either directly, by acting on cells of the osteoclast-lineage, or indirectly, by acting on other cell types to modulate expression of the key osteoclastogenic factor receptor activator of nuclear factor (NF) kappaB ligand (RANKL) and/or its inhibitor osteoprotegerin (OPG). Further elucidation of the mechanisms responsible for inflammation-induced bone loss will potentially lead to the identification of novel therapeutic strategies for the prevention of bone loss in these diseases. In this review, we provide an overview of the cell types, inflammatory mediators, and mechanisms that are implicated in bone loss and new bone formation in inflammatory joint diseases.

Untreated femoro-acetabular impingement is a common cause of osteoarthrosis of the hip. Surgical debridement of the adult hip with femoro-acetabular impingement recently has been advocated with the aim of relieving symptoms and slowing or halting progression of the arthrosis. At surgery, femoral sources of impingement are relieved by debriding the aspheric peripheral portion of the femoral head and the adjacent femoral neck. Acetabular sources of impingement can be relieved by debridement of the anterior rim. The most fundamental questions concerning these procedures relate to the preoperative and postoperative function, postoperative survivorship of these hips and the incidence of osteonecrosis. The current study assesses a group of 23 hips in 23 patients treated by surgical debridement for impingement. Twenty-two patients were treated by full surgical dislocation and one patient was treated by relief of impingement without dislocation. Followup ranged from a minimum of 2 years to 12 years. At most recent evaluation, seven patients had been converted to total hip arthroplasty, one had arthroscopic debridement of a recurrent labral tear, and 15 patients have had no further surgery. No hips developed osteonecrosis. Of the seven patients who had to have their procedure converted to total hip arthroplasty, three of these hips failed early and four patients' hips recovered and functioned well and subsequently deteriorated with total hip arthroplasty done between 6.4 and 9.5 years after debridement. Hips at greatest risk of failure have advanced arthrosis or a combination of impingement and instability preoperatively. The procedure effectively treats hips with impingement and without considerable secondary arthrosis or instability.

Lumbar foraminal stenosis is an important pathologic entity to identify in the patient being treated for radicular symptoms. This update reviews the anatomy, clinical presentation, neuroradiographic evaluation, and treatment of pathology located in the intervertebral foramen. Patients with significant leg pain refractory to conservative treatment and concordance between the demonstrated area of stenosis and radicular symptoms and signs are candidates for the decompressive procedures discussed. The role of arthrodesis and spinal instrumentation in the management of foraminal stenosis also is addressed.

PURPOSE: No graft tissue has consistently shown superiority over others for reconstruction of the anterior cruciate ligament (ACL). Bone-patellar tendon-bone (BPTB) and doubled hamstring tendon (semitendinosus and gracilis) (HT) are the most commonly used autologous grafts. We performed a meta-analysis to compare the effectiveness of ACL reconstruction using either BPTB or HT grafts. TYPE OF STUDY: Systematic review and meta-analysis. METHODS: We searched the MEDLINE database (1966 to April 2003) for English-language randomized or prospective studies comparing BPTB and 3- or 4-strand HT grafts used for ACL reconstruction. For inclusion, studies were required to follow identical rehabilitation protocols within each study, and provide subjective or objective outcome data after a minimum average 2-year follow-up. Comparison data between BPTB and HT for each identified outcome measure were combined using a random-effects model meta-analysis. RESULTS: Eleven reports fulfilled the criteria for inclusion. Outcomes favoring BPTB were found in the following outcome measures: normal Lachman examination (relative risk [RR], 0.91; 95% confidence interval [CI], 0.83-0.99; P = .025), normal pivot-shift (RR, 0.94; 95% CI, 0.88-1.0; P = .067), KT-1000 manual-maximum side-to-side difference of < or = 3 mm (RR, 0.75; 95% CI, 0.55-1.01; P = .057), and fewer reconstructions resulting in flexion loss > 5 degrees (RR, 1.41; 95% CI, 1.01-1.96; P = .04). Intermediate level laxity was more common with the HT graft, as shown by higher rates of abnormal Lachman > 0 (RR, 1.22; 95% CI, 0.99-1.5; P = .06), pivot-shift > 0 (RR, 1.3; 95% CI, 0.96-1.75; P = .09), and KT-1000 manual-maximum side-to-side differences > 3 mm (RR, 1.64; 95% CI, 1.13-2.39; P = .01). Outcome measures that favored HT were absence of patellofemoral crepitance (RR, 1.08; 95% CI, 1.01-1.15; P = .03), fewer results with extension loss > 5 degrees (RR, 0.56; 95% CI, 0.3-1.03; P = .06), and kneeling pain. The incidence of instability, as defined by Lachman grade 2, pivot-shift grade 2, or KT-1000 manual-maximum side-to-side difference > 5 mm, was not significantly different between the 2 grafts. All other outcome measures were not significantly different. CONCLUSIONS: The data presented in this meta-analysis show that the incidence of instability is not significantly different between the BPTB and HT grafts. However, BPTB was more likely to result in reconstructions with normal Lachman, normal pivot-shift, KT-1000 manual-maximum side-to-side difference < 3 mm, and fewer results with significant flexion loss. In contrast, HT grafts had a reduced incidence of patellofemoral crepitance, kneeling pain, and extension loss. The choice of graft by the patient and surgeon must be individualized, and the results of this meta-analysis can aid in the decision by clarifying the risks and benefits of each surgical approach. LEVEL OF EVIDENCE: Level I.