Meniscectomy in children and adolescents. A long-term follow-up study.

Thirty-nine patients treated with total meniscectomy younger than 16 years of age were studied. The average follow-up period was 21 years; 71% of the patients reported pain; 68%, stiffness; 54%, swelling; and 41%, giving way. Approximately half the patients described progression of symptoms, but only 27% were asymptomatic. Only 10% noted limitations at work, but 62% had limitations in sports. Twelve percent have had further knee surgery. Forty-nine percent received unsatisfactory subjective/functional ratings. On physical examination, 25% of patients had range of motion loss of greater than 5 degrees, 22% had thigh atrophy of greater than 1 cm, and 20% developed substantial instability. Overall, 27% received unsatisfactory objective ratings. Ninety percent of patients had abnormal roentgenograms. Changes occurred predominantly in the meniscectomized compartment. Forty-four percent of patients had unsatisfactory roentgenographic ratings. Overall ratings indicated that 63% of patients' results rated unsatisfactory. More unsatisfactory results occurred in patients with a follow-up period of longer than 26 years, in those with substantial instability, and in males. Few differences existed between medial and lateral meniscectomies or with increasing durations of symptoms preoperatively.     

The accessory sacroiliac joint: a common anatomic variant

We identified the accessory sacroiliac joint on 13 (13%) of 100 CT scans of the pelvis and in nine (16%) of 56 dried skeletons. The joint is situated between the medial aspect of the posterior superior iliac spine and a rudimentary transverse tuberosity just lateral to the second sacral foramen. Some joints are true diarthrodial joints and are present at birth, but more commonly they are acquired fibrocartilaginous joints that result from the stress of weight-bearing. Our experience suggests that the accessory sacroiliac joint is not rare and that it is visible on CT scans in many patients.     

Epidural steroid injection: a procedure ideally performed with fluoroscopic control

Epidural injection of steroid and local anesthesia can be used to treat low back pain. The injection is best performed with fluoroscopic control, with needle placement documented by means of a limited epidurogram. The technique was used in 116 patients; there were only three failures (2.5%) and one complication.     

Cross-sectional imaging of the patellofemoral joint and surrounding structures

Computed tomography (CT) and magnetic resonance (MR) imaging are extremely useful in the accurate diagnosis of anterior knee pain, a common complaint arising from numerous causes (including fracture, chondromalacia patellae, and alignment and tracking abnormalities). Plain CT is effective for evaluating intraosseous lesions of the knee. Although CT arthrography provides excellent visualization of the patellar articular cartilage, the technique is expensive and invasive. Cine CT is an excellent method for assessing patellofemoral tracking and alignment. Kinematic MR imaging can also perform this function. In addition, MR imaging can provide valuable information concerning the status of patellar cartilage. Although MR imaging can accurately show high-grade chondromalacia patellae, it is less accurate in the detection of low-grade disease. The authors believe that MR imaging and plain radiography offer radiologists the greatest latitude in making a specific diagnosis of the cause of anterior knee pain; however, CT is a useful alternative.     

Sarcoma in Paget disease of bone: clinical, radiologic, and pathologic features in 22 cases

The clinical, radiologic, and histologic features of 22 cases of Paget sarcoma were reviewed to determine in which patients with Paget disease these tumors are most likely to develop and what radiologic findings suggest the diagnosis. Clinical findings at presentation included pain and/or a mass (11 patients), pathologic fracture (seven), and neurologic symptoms (four). Survival time in 20 patients ranged from 5 days to 2.5 years. Two patients were lost to follow-up: one at 2 years and one at 8 years. There were 16 high-grade osteosarcomas, three chondrosarcomas, two fibrosarcomas, and one malignant fibrous histiocytoma. The most common site was the femur. Tumors also were observed in unusual sites. In one case of multifocal osteosarcoma, the tumor involved only pagetic bone. In 15 patients, Paget disease was polyostotic, clinically significant, and had been documented previously. In four patients, a sarcoma developed near the site of a fracture that had occurred between 2 months and 15 years previously. All cases showed radiologic evidence of a destructive lesion; other findings included a mass and evidence of tumor mineralization. Periosteal reaction was not observed. All but one tumor developed in a site of osteoblastic or mixed osteoblastic and lytic Paget disease. Our results suggest that sarcomas can develop in any part of any bone affected by Paget disease but are more likely to occur with advanced disease and to present with a destructive lesion without periosteal reaction.     

Correct placement of epidural steroid injections: fluoroscopic guidance and contrast administration.

We prospectively evaluated 316 caudal-approach epidural steroid injections given by staff radiologists and residents in our department over a 1-year period. Needle placement was checked with fluoroscopy and corrected if necessary. When the needle tip was within the sacral canal, nonionic contrast material was injected. If epidural contrast was not observed, the needle tip was repositioned. Of 111 procedures performed by physicians who had given fewer than 10 epidural steroid injections, 53 (47.7%) resulted in correct nonfluoroscopically directed placement of the needle. For physicians who had performed between 10 and 50 such procedures, 62 (53.4%) of 116 had correct nonfluoroscopically directed placement. For staff physicians, 55 (61.7%) of 89 placements were correct. Even when the sacral hiatus was easily palpated and a staff physician was confident that he or she was within the epidural space, fluoroscopy revealed incorrect placement 14.2% of the time (seven of 49 procedures). In addition, when the needle was positioned within the sacral canal and no blood was evident on Valsalva maneuver or aspiration, the injection was venous in 29 of 316 procedures (9.2%). The presence of blood on the needle stylus was not a reliable indicator of venous placement of the needle. Our findings indicate that fluoroscopy is essential for correct placement of epidural steroid injection. Contrast administration is necessary to avoid venous injection of steroids.     

Occult sacral fractures in osteopenic patients.

The presentation, diagnosis, and treatment of occult sacral fractures in seventeen osteopenic patients were reviewed. Sixteen of the seventeen patients were elderly women, and the fracture usually occurred without trauma (fourteen patients). In ten patients, the sacral fracture was associated with a fracture of the pubic ramus. The sacral fractures were difficult to diagnose because nine patients also had a history of a malignant lesion of the pelvis with or without radiation treatment. Computed tomography and bone-scanning were diagnostic in all patients, but magnetic resonance imaging was not specific. Use of crutches or a walker, a reduction in activity, and use of non-narcotic analgesics allowed for the resolution of symptoms in all twelve patients who did not have mitigating conditions and permitted these patients to walk independently.