Diagnostic Imaging and Biomechanics

Wrist imaging and biomechanical principles for evaluating trauma, degenerative joint disease, and complex pathologies like Kienböck's disease.

Overview

Clinical decision-making in orthopaedics relies on integrating biomechanical principles with radiographic and functional data. For distal radius fractures, radiographic criteria explain 49% of the variation in treatment recommendations, whereas surgeon and patient factors account for only 1% [83]. Understanding anatomy, biomechanics, indications, and contraindications is essential for guiding patient selection in distal radius malunion [12]. Recognition of modern implant principles and techniques is fundamental to achieving optimal outcomes in distal femoral fractures [85]. In obstetrical brachial plexus palsy, a developed kinematics protocol provides objective, quantified data to supplement clinical evaluation and compare results before and after treatment [5].

Evidence regarding long-term functional outcomes remains limited for several interventions. Bone grafting in distal radius fractures shows only short-term or radiographic benefits in most controlled series, with long-term functional outcomes largely inconclusive [2]. Advanced microfracture techniques show promise for cartilage restoration in isolated patellar chondral defects, but indications and technique variability require elucidation in higher-level studies [81]. Similarly, further biomechanical and clinical investigation is indicated for distal radius allograft as a novel osteochondral reconstruction option for glenoid bone loss [22]. More studies are needed to determine the biomechanical and clinical efficacy of reconstructing the distal oblique bundle of the interosseous membrane to restore distal radioulnar joint stability [16]. Additional biomechanical and larger long-term clinical studies are also required to evaluate the transection-free patellar tendon imbrication technique for patella alta correction [17].

Biomechanical findings must be interpreted alongside clinical outcomes and complication profiles. Nonanatomic and anatomic techniques exceeded the minimum acceptable threshold of stability and failure loads in controlled testing, while nonanatomic and suture-based coracoclavicular stabilization techniques provided adequate stability at a lower implant cost compared with anatomic techniques [79]. Biomechanical comparisons of open versus percutaneous primary mid-substance Achilles tendon repair must be contextualized with clinical outcomes data to inform surgical decision-making [82]. In revision total knee arthroplasty, all indications except severe stiffness demonstrated similar clinical outcomes maintained up to 7.5-year follow-up [23].

Anatomy & Pathophysiology

Kinematics and Imaging

Early diagnosis and proper management of acute scaphoid fractures are crucial to ensure preservation of wrist function and kinematics [10]. Despite many studies attempting to explain carpal mechanics, no unanimous theory or model fully explains wrist anatomy and function [45]. A unifying kinetic theory of wrist motion is based on isometric constraints and rules-based motion, derived from forward kinematic analysis of the carpus [64]. Wrist kinematic coupling parameters are task specific in healthy individuals [47]. Forearm orientation affects contact mechanics and end-range carpal kinematics [39]. Large distal radius forces and moments can occur during pushup and active wrist motions [66].

Four-dimensional computed tomography provides a detailed description of forearm kinematics [40]. It is a promising, non-invasive, and affordable method to assess and quantify wrist kinematics by incorporating the temporal dimension [77]. Three-dimensional imaging of carpal ligaments provides understanding of wrist kinematics, the function of individual ligaments, and their roles in joint motion, stability, and injuries [48]. Optical motion capture studies following International Society of Biomechanics standards quantify normative upper body kinematics during functional upper limb tasks [76]. Anatomic and biomechanical research of the wrist improves basic knowledge of carpal morphology and function and provides information to better assess and improve treatments for various wrist joint problems [56]. A high-fidelity finite element model of the forearm musculoskeletal system provides a robust platform for exploring forearm biomechanics and guiding clinical applications [59].

Osseous Morphology and Joint Mechanics

Lunate morphology affects the three-dimensional kinematics of the carpus during wrist flexion and extension [61]. Wrist positions significantly influence the biomechanical behavior of the radiocapitellar joint during elbow extension [50]. Surgical treatments for scapholunate advanced collapse result in decreased wrist kinematic motion and functional performance compared with individuals with normal wrists [31]. Wrist biomechanics are significantly altered following trapeziectomy, with ligamentous reconstruction and tenodesis (LRTI) most closely resembling intact biomechanics in a cadaveric model [52].

Ligamentous and Soft Tissue Biomechanics

Computed fiber elongations of dorsal carpal ligaments vary linearly with wrist position despite complex carpal bone anatomy and kinematics [68]. All fixed-angle volar distal radius plate constructs met anticipated demands given their biomechanical properties and the loads transmitted across the native wrist [75]. Information from studies on distal radioulnar joint reaction force following ulnar shortening is not enough at this point to carry over into clinical practice [62].

Classification

Cemented Femoral Stem: A new four-part classification system for cemented femoral stem design and cementation techniques was proposed to aid in comparing results and understanding implant biomechanics [33].

Complex Olecranon Fractures: A novel fragment-specific classification of complex olecranon fractures is anatomically based and considers deforming forces from ligaments and tendons [35].

Trapeziometacarpal Arthritis: Inconsistent agreement using the current common radiographic classification system for trapeziometacarpal arthritis suggests a need for better radiographic tools to quantify disease severity [49].

Knee Cartilage Repair: No current MRI classification system has been shown to correlate with clinical outcomes after all types of cartilage repair surgery in the knee [53].

General Classification Systems: No classification system is universally accepted, and every classification system is subject to interobserver variability, raising questions about its suitability in research and clinical contexts [55].

Hemophilic Arthropathy: A new four-category, 7-point classification system for hemophilic arthropathy demonstrated interobserver reproducibility and correlation with joint function equivalent to the Pettersson et al. system [57]. This system was easier to apply and more sensitive in discriminating advanced arthropathy than the Arnold and Hilgartner system [57].

Degenerative Glenohumeral Arthritis: A 3-dimensional classification system for degenerative glenohumeral arthritis based on humeroscapular alignment can be applied to describe the disease comprehensively using combined humeroscapular alignment and glenoid erosion [58].

Rotator Cuff Assessment: Twenty-six different criteria described by multiple classification systems have been identified for the magnetic resonance assessment of rotator cuff after repair [60]. A comprehensive classification system integrating historical and newer descriptions of rotator cuff lesions may help to guide treatment [72].

Proximal Interphalangeal Joint Osteoarthritis: A proposed PIP-Kellgren functional-radiological classification system may help stratify surgical candidates and standardize severity assessment for proximal interphalangeal joint osteoarthritis [65].

Distal Humeral Fractures: Three-dimensional reconstructions improve the reliability, but not the accuracy, of fracture classification and characterization for distal humeral fractures [67].

Complex Extremity Fractures: Existing classification systems for complex extremity fractures are inadequate and lack therapeutic recommendations [69].

Acetabular Bone Loss: A validated classification system for acetabular bone loss in revision total hip arthroplasty guides treatment and prognosticates outcomes [71].

Ballistic Fractures: Existing classification systems for ballistic fractures are inadequate because they fail to account for soft-tissue injury, anatomical location, and joint involvement [73].

Rheumatoid Arthritis Glenoid Deformity: A radiological classification system for glenoid deformity in rheumatoid arthritis identifies three types of glenoid fossa shape changes and six total deformity types when including upward humeral head migration [74].

Other Considerations: No classification system is universally accepted, and every classification system is subject to interobserver variability, raising questions about its suitability in research and clinical contexts [55].

Clinical Presentation

Early and accurate diagnosis of pediatric spinal tumors and tumor-like conditions is often possible based on clinical history, physical examination, and plain radiographic imaging [1]. Specific physical signs, history topics, and diagnostic tools like MRI or ultrasound should not be used as independent maneuvers for diagnosis [6]. Diagnosis of carpal instability requires a thorough history, physical examination, and appropriate imaging [7]. In-office diagnostic imaging can provide a more detailed and accurate diagnostic assessment of intra-articular knee pathology than MRI [8]. Imaging techniques allow for a better understanding of conditions that affect the shoulder [9].

Early diagnosis and proper management are crucial to ensure preservation of wrist function and kinematics in acute scaphoid fractures [10]. MRI serves as a noninvasive tool that overcomes the shortcomings of radiography by detecting preclinical disease and subtle early abnormalities, evolving as a complete answer for cartilage-imaging requirements regarding lesion description, treatment planning, and outcome measurement [15]. Diagnosis of distal radioulnar joint (DRUJ) instability is made clinically and corroborated by imaging studies, with a thorough history and physical examination serving as the foundation [26]. Effective diagnosis and management of golf injuries require a thorough understanding of golf swing biomechanics and forces [27].

Presentation factors that increase the likelihood of a diagnostic X-ray for knee pain include pain for longer than 6 months, the presence of medial or diffuse pain, and mechanical symptoms [28]. Further clinical and biomechanical verification is needed to establish a scientific approach for the diagnosis and management of midcarpal instability [29]. Careful clinical and radiographic evaluation, coupled with a thorough understanding of the anatomy and biomechanics of the foot, allows for accurate evaluation of adult flatfoot [30]. Determining the etiology of ulnar-sided wrist pain is often challenging due to overlapping history and physical examination findings; a detailed history, systematic physical examination with provocative maneuvers, and appropriate diagnostic imaging are essential for diagnosis [32].

Diagnostic imaging is essential to differentiate between injuries with common clinical presentations, determine the degree of injury, estimate time to return to activity, and document healing in athletes with leg pain [34]. The diagnosis of iliotibial band syndrome is typically made based on a characteristic patient history and physical examination, with imaging studies reserved for cases of recalcitrant disease [36]. The diagnosis of femoroacetabular impingement (FAI) syndrome is made based on a combination of clinical symptoms, physical examination findings, and imaging studies, as no single pathognomonic finding exists for FAI [37]. Diagnosis of compressive neuropathies relies on a combination of clinical presentation, physical examination findings, and use of imaging modalities and electrodiagnostic studies, as there is no true diagnostic gold standard for most conditions [38].

Systematic clinical examination, proper radiographs, and histology are essential for the diagnosis of carpal bone involvement in gout [42]. Functional kinematic and kinetic biomechanical strategies at the hip and knee are associated with patellar tendon abnormality identified on imaging and symptomatic limbs in male collegiate basketball players during the preseason [43]. Acute distal radioulnar joint instability is primarily a clinical diagnosis, and physical examination remains a mainstay of diagnosis [44].

Investigations

Plain radiography: Early and accurate diagnosis of pediatric spinal tumors and tumor-like conditions is often possible based on clinical history, physical examination, and plain radiographic imaging [1]. Plain radiographic evaluation remains the initial diagnostic modality for femoroacetabular impingement [100]. Radiographs remain the appropriate initial investigation for assessing intra-articular distal radial fractures [93]. Radiographs, CT, and MRI all demonstrated excellent inter-rater agreement with no significant difference in bias from the true ulnar variance when compared to each other [90].

MRI: Noninvasive imaging technologies, particularly MRI, provide objective measures to better understand the natural history and mechanisms of diseases, optimize treatment, and assess the integrity of joint tissues [3]. Long-term follow-up studies are required to validate the predictive validity of noninvasive imaging technologies for clinical outcomes [3]. MRI serves as a noninvasive tool that overcomes the shortcomings of radiography by detecting preclinical disease and subtle early abnormalities [15]. MRI is evolving as a complete answer to cartilage-imaging requirements for lesion description, treatment planning, and outcome measurement [15]. Compositional MRI techniques may allow for an earlier diagnosis of cartilage injury before morphologic changes manifest [89]. Recent advances in noninvasive musculoskeletal imaging, particularly MRI sequences detecting biochemical changes, may offer a great advance in the diagnosis and treatment of osteoarthritis by identifying the disease at a stage when it is potentially reversible [84]. Functional MRI techniques improve tissue characterisation and staging of bone and soft-tissue tumours compared to structural imaging [94]. Functional MRI techniques have limitations with overlap between benign and malignant tumours [94].

Specific applications include: * Knee: In-office diagnostic imaging can provide a more detailed and accurate diagnostic assessment of intra-articular knee pathology than MRI [8]. By constructing predictive models, MRI could significantly improve diagnostic validity compared with radiography in the functional integrity evaluation of the anterior cruciate ligament in patients with knee osteoarthritis [97]. In symptomatic cases with inconspicuous conventional MRI imaging, additional MRI imaging only in the axial plane in a 20° of knee flexion could be beneficial and useful in clinical daily routine for understanding patellofemoral instability [98]. * Shoulder: Imaging techniques allow better understanding of conditions that affect the shoulder [9]. MRI review by musculoskeletal-specialized radiologists is likely to lead to more correct diagnoses of subscapularis tendon tears [80]. * Hip: Three-dimensional imaging such as MRI and CT is often obtained for the evaluation of labral and cartilage pathology, definition of bony anatomy, and surgical planning in femoroacetabular impingement [100].

Advances in 3-dimensional MRI techniques create the opportunity to improve understanding of articular morphology and joint biomechanics [14]. Advances in 3-dimensional MRI techniques have the potential to enhance preoperative planning and the effectiveness of arthroscopic techniques [14].

CT: CT is the preferred imaging modality for detail in assessing intra-articular distal radial fractures [93]. The difference between CT and MRI tibiofemoral rotation measurements correlated with the degree of knee flexion during image acquisition [87].

Other Considerations: Analysis of imaging features and evaluation of the diagnostic value of various methods can provide imaging basics for the development of accurate and appropriate treatment options for tibial shaft fractures with concomitant posterior malleolar fractures [88]. Non-invasive imaging modalities and mechanical testing techniques, as well as the assessment of bone composition, need to complement each other to provide comprehensive and ideal information on the bone quality of human bone specimens [96]. The anatomic and radiographic locations of the posterior oblique ligament (POL) and its biomechanical properties were successfully recorded [99].

Treatment

Non-Operative

Nonoperative management is frequently the initial strategy for a variety of conditions, though its efficacy and indications vary by pathology. For osteoarthritis, current non-surgical treatments do not alter the clinical course or arrest disease progression, with joint replacement reserved for end-stage disease [109]. Similarly, nonoperative treatment cannot correct hallux valgus deformity but serves to control symptoms [110]. In rotator cuff tears, early nonoperative treatment is critical for predicting optimal pain and functional outcomes [101]. For primary and posttraumatic elbow arthritis, nonoperative treatment is almost always initiated, with surgery indicated only if conservative management fails [108]. Nonoperative management is also favored for the first episode of traumatic shoulder dislocation, particularly in patients with multi-directional instability, soft-tissue laxity, older age, or younger patients not engaged in overhead activities [105]. Stable metacarpal fractures are often managed nonoperatively, although literature remains sparse and controversial regarding the optimal algorithm [106]. Morton’s interdigital neuroma is initially managed nonoperatively, with operative intervention indicated only after conservative measures fail [104]. Selected anteromedial coronoid fractures can be treated nonoperatively, yielding good clinical and radiographic outcomes [103]. Nonoperative treatment may be appropriate for minimally displaced medial epicondylar apophyseal avulsion fractures in youth throwers [102]. For Ehlers-Danlos syndromes, nonoperative treatment is preferable, though specific joint stabilization and nerve decompression procedures can provide symptomatic relief for carefully selected patients when conservative measures fail [95].

Operative

Indications: Surgical repair is the preferred choice over conservative treatment for meniscus medial posterior root tears to mitigate osteoarthritis progression by reinstating optimal joint contact pressures and kinematics [51]. Conservative treatment or non-anatomical repair of distal biceps brachii tendon rupture results in significant loss of supination strength and variable loss of flexion strength [70]. Impaction grafting indications have been refined by recent long-term data, but it should be used with caution in association with severe defects on the acetabular side [91]. Proper indication for autologous osteochondral grafting relies on identifying and simultaneously correcting malalignment and/or traumatic changes in affected joints [63].

Surgical Approach / Technique: Trochleoplasty demonstrates improved radiographic parameters, excellent clinical outcomes, and no recurrent instability in early follow-up for patellar instability in patients with severe trochlear dysplasia [4]. Kinematic alignment provides better functional outcomes and faster recovery than mechanical alignment at two-year follow-up, though its true value remains to be determined [13]. Reconstruction of the distal oblique bundle of the interosseous membrane requires more studies to determine biomechanical and clinical efficacy [16]. Additional biomechanical and larger long-term clinical studies are needed to evaluate the efficacy of the transection-free patellar tendon imbrication technique for correction of patella alta [17]. Further biomechanical and clinical investigation is indicated for distal radius allograft as a novel osteochondral allograft reconstruction option in the setting of glenoid bone loss [22].

Implant Selection: Evidence regarding bone grafting in distal radius fractures is largely inconclusive for long-term functional outcomes, with most controlled series showing only short-term or radiographic benefits [2]. Both matrix-associated autologous chondrocyte implantation (ACI) with spheroid technology and arthroscopic microfracture demonstrate efficacy regarding functional outcomes and morphological repair for cartilage defects of the knee [41].

Other Considerations: Knee arthroscopy is effective in treating patients with symptomatic osteoarthritis and mechanical symptoms, with 76% reporting good and excellent results [46]. With appropriate treatment practices, excellent results with good functional outcomes are expected for extensor tendon injuries specific to the pediatric patient [54].

Complications

Infection (PJI): The provided evidence does not contain specific data regarding infection rates, risk factors, or management strategies for periprosthetic joint infection.

Aseptic loosening: Mechanical loosening has not occurred to date in semiconstrained arthroplasty for the treatment of rheumatoid arthritis of the elbow, but a much longer follow-up period is necessary for full assessment of the long-term benefit of this procedure and device [92]. More biomechanical and clinical analysis is needed to assess longer-term outcomes of cement-in-cement revision for selected Vancouver Type B1 femoral periprosthetic fractures [18].

Instability: Early follow-up of trochleoplasty for patellar instability in patients with severe trochlear dysplasia demonstrates improved radiographic parameters coupled with excellent clinical outcomes and no recurrent instability [4]. Nonoperative treatment often provides good results for patellofemoral instability, but surgical treatment can yield substantial improvement in symptoms and patient satisfaction when indicated [114]. A complete history and physical examination with selective imaging studies should lead to an accurate diagnosis of patellofemoral instability [114].

Periprosthetic fracture: The provided evidence does not contain specific data regarding periprosthetic fracture incidence, risk factors, or management strategies beyond the mention of Vancouver Type B1 fractures requiring further analysis [18].

Thromboembolism: The provided evidence does not contain specific data regarding thromboembolic events, risk factors, or management strategies.

Patellar / Extensor-mechanism: Early follow-up of trochleoplasty for patellar instability in patients with severe trochlear dysplasia demonstrates improved radiographic parameters coupled with excellent clinical outcomes and no recurrent instability [4]. Nonoperative treatment often provides good results for patellofemoral instability, but surgical treatment can yield substantial improvement in symptoms and patient satisfaction when indicated [114]. A complete history and physical examination with selective imaging studies should lead to an accurate diagnosis of patellofemoral instability [114].

Stiffness / Arthrofibrosis: All indications for revision total knee arthroplasty except severe stiffness had a similar clinical outcome which was maintained up to 7.5-year follow-up [23].

Nerve palsy: The provided evidence does not contain specific data regarding nerve palsies, risk factors, or management strategies.

Wound complications: The provided evidence does not contain specific data regarding wound complications, risk factors, or management strategies.

Polyethylene wear: The provided evidence does not contain specific data regarding polyethylene wear rates, risk factors, or management strategies.

Other Considerations: Early and accurate diagnosis of tumors and tumor-like conditions of the spine in children is often possible based on clinical history, physical examination, and plain radiographic imaging [1]. Evidence regarding long-term functional outcomes of bone grafting in distal radius fractures is largely inconclusive, with most controlled series showing only short-term or radiographic benefits [2]. Noninvasive imaging technologies, particularly MRI, provide objective measures to better understand the natural history and mechanisms of diseases, optimize treatment, and assess the integrity of joint tissues [3]. Long-term follow-up studies are required to validate the predictive validity of noninvasive imaging technologies for clinical outcomes [3]. Long-term functional follow-up is not available for bipolar osteoarticular reconstruction of the radioscaphoid joint [11]. Longer-term clinical follow-up is needed to understand the clinical impact of decreased meniscal extrusion at 1 year follow-up when arthroscopic capsulodesis is combined with transtibial repair of posteromedial root lesions [19]. Further research is required in anatomic and biomechanic studies, experience in inflammatory arthropathy, and long-term survivorship to improve outcomes of total wrist arthroplasty [20]. Clinical and radiological follow-up showed good short-term results after meniscus repair in a prospective short-term MRI controlled investigation [21]. The natural history of Kienbock's disease is not fully known, though it is generally considered a progressive condition that can end in Stage IV changes [24]. Treatment strategies for Kienbock's disease focus on biomechanical unloading, vascularized bone grafts, or salvage procedures depending on the stage [24]. Improved understanding of the natural history of spine deformity, combined with advances in imaging, surgical technology, radiation therapy, and chemotherapeutic regimens, has improved survival rates and decreased rates of local recurrence in malignant osseous tumors of the pediatric spine [25]. Femoroacetabular impingement (FAI) is defined as a pathologic mechanical process involving morphologic abnormalities and vigorous motion that damages soft-tissue structures [107]. FAI morphology is common in young adults and predisposes to later osteoarthritis [107]. More long-term data are needed to define the natural history of pincer deformities and FAI in younger cohorts [107]. Correlation of the clinical history, physical examination, and imaging findings is fundamental for determining if relief from intra-articular anesthetic injection predicts outcome after hip arthroscopy [111]. Women and patients with a 3- to 10-year history of anterior cruciate ligament reconstruction (ACLR) demonstrated vertical drop jump (VDJ) biomechanics that may be associated with knee motion control challenges [112]. Clinical decision making should carefully analyze the association of patient history and physical examination with radiographic imaging findings of femoroacetabular impingement in asymptomatic volunteers [113]. Muscle imaging can help for recognition of atypical clinical presentations of Pompe disease, for understanding the natural history of the disease, and for determining patients suited for treatment [115]. Gender, age, years of experience, type of imaging modality, and employment status were the most common associated risk factors for developing work-related musculoskeletal symptoms among radiologists [116]. Careful history-taking, physical examination, electrodiagnostic study, and imaging are necessary for an accurate diagnosis of deep gluteal syndrome as a cause of posterior hip pain and sciatica-like pain [117]. Conservative treatment is recommended initially for deep gluteal syndrome, with surgical decompression reserved for persistent or recurrent symptoms [117].

Recovery

Light activity (weeks): Early reconstruction of malunited distal radius fractures is technically easier and reduces the overall period of disability for patients with radiographic characteristics predictive of persistent functional limitation [121]. Patients undergoing ulnar shortening osteotomy for ulnar impaction syndrome experience satisfactory results at greater than 5 years, though asymptomatic radiographic degenerative changes may occur [122].

Full activity (months): Current evidence suggests kinematic alignment provides better functional outcomes and faster recovery than mechanical alignment at two-year follow-up, though its true value remains to be determined [13]. Early follow-up of trochleoplasty for patellar instability in patients with severe trochlear dysplasia demonstrates improved radiographic parameters coupled with excellent clinical outcomes and no recurrent instability [4].

Complete recovery / outcome plateau (months): Long-term functional outcomes of bone grafting in distal radius fractures are largely inconclusive, with most controlled series showing only short-term or radiographic benefits [2]. Long-term functional follow-up is not available for bipolar osteoarticular reconstruction of the radioscaphoid joint [11]. More biomechanical and clinical analysis is needed to assess longer-term outcomes of cement-in-cement revision for selected Vancouver Type B1 femoral periprosthetic fractures [18]. Longer-term clinical follow-up is needed to understand the clinical impact of decreased meniscal extrusion at 1 year follow-up when arthroscopic capsulodesis is combined with transtibial repair of posteromedial root lesions [19]. Further research is required in anatomic and biomechanic studies, experience in inflammatory arthropathy, and long-term survivorship to improve outcomes of total wrist arthroplasty [20].

Rehabilitation protocol: Clinical and radiological follow-up showed good short-term results after meniscus repair in a prospective short-term MRI controlled investigation [21].

Functional milestones: Long-term outcomes of lower extremity injuries are profoundly affected by demographic, social, and economic factors rather than traditional orthopaedic variables [78].

Other Considerations: Noninvasive imaging technologies, particularly MRI, provide objective measures to better understand the natural history and mechanisms of diseases, optimize treatment, and assess the integrity of joint tissues [3]. Long-term follow-up studies are required to validate the predictive validity of noninvasive imaging technologies for clinical outcomes [3]. The natural history of Kienböck's disease is not fully known, though it is generally considered a progressive condition that can end in Stage IV changes [24]. Treatment strategies for Kienböck's disease focus on biomechanical unloading, vascularized bone grafts, or salvage procedures depending on the stage [24]. Radiographic progression of Kienböck's disease over 1 year or more seems slight on average regardless of treatment [123]. Long-term clinical and radiographic follow-up is necessary to determine the natural history of asymptomatic talar bone marrow edema in professional ballet dancers [120]. In a study of perilunate dislocation and fracture dislocation of the wrist with a mean follow-up time of 9.9 years, 79% of patients showed radiographic signs of osteoarthritis [119]. Future clinical trials investigating the natural history and treatment of femoroacetabular impingement will require multimodal staging systems for hip osteoarthritis because the optimal system will differ based on the size of the study population, the specific objective in question, and the time frame in which the investigator expects to see the specified end point [118].

Key Evidence

• [L5] Early and accurate diagnosis is often possible based on clinical history, physical examination, and plain radiographic imaging. (10.5435/00124635-200510000-00002)
• [L4] Evidence is largely inconclusive regarding long-term functional outcomes, with most controlled series showing only short-term or radiographic benefits. (10.1016/j.jhsa.2010.10.006)
• [L5] Noninvasive imaging technologies, particularly MRI, provide objective measures to better understand the natural history and mechanisms of diseases, optimize treatment, and assess the integrity of joint tissues, though long-term follow-up studies are required to validate their predictive validity for clinical outcomes. (10.1177/0363546518817315)
• [L4] Early follow up demonstrates improved radiographic parameters coupled with excellent clinical outcomes and no recurrent instability. (10.1177/2325967117s00389)
• [L4] The developed kinematics protocol provides objective, quantified data to supplement clinical evaluation and compare results before and after treatment. (10.1016/j.otsr.2009.04.012)
• [L1] It recommends against using specific physical signs, history topics, and certain diagnostic tools like MRI or ultrasound as independent maneuvers for diagnosis. (10.2106/jbjs.16.00719)
• [L5] Diagnosis requires a thorough history, physical examination, and appropriate imaging, while treatment ranges from non-operative management to operative fixation depending on the specific injury pattern. (10.1016/j.hcl.2009.05.002)
• [L2] In-office diagnostic imaging can provide a more detailed and accurate diagnostic assessment of intra-articular knee pathology than MRI. (10.1016/j.arthro.2018.03.010)
• [L5] Imaging techniques allow better understanding of conditions that affect the shoulder. (10.1197/j.jht.2007.02.002)
• [Paper] Early diagnosis and proper management are crucial to ensure preservation of the wrist function and kinematics. (10.1016/j.hcl.2019.03.002)
• [L4] Long-term functional follow-up is not available. (10.1177/1753193418802559)
• [L5] Proper understanding of anatomy, biomechanics, indications, and contraindications can help guide patient selection for surgery. (10.5435/00124635-200701000-00004)
• [L4] The true value of kinematic alignment remains to be determined, though current evidence suggests it provides better functional outcomes and faster recovery than mechanical alignment at two-year follow-up. (10.1302/2058-5241.3.170022)
• [L5] Advances in 3-dimensional MRI techniques create the opportunity to improve understanding of articular morphology and joint biomechanics, with the potential to enhance preoperative planning and the effectiveness of arthroscopic techniques. (10.1016/j.arthro.2019.06.001)
• [L5] MRI is evolving as a complete answer to cartilage-imaging requirements for lesion description, treatment planning, and outcome measurement, serving as a noninvasive tool that overcomes the shortcomings of radiography by detecting preclinical disease and subtle early abnormalities. (10.2106/jbjs.rvw.15.00093)
• [L4] More studies are needed to determine the biomechanical and clinical efficacy of this reconstruction. (10.1016/j.jhsa.2015.08.019)
• [L5] Additional biomechanical and larger long-term clinical studies are needed to further evaluate the efficacy of this technique. (10.1177/23259671251325752)
• [L5] However, more biomechanical and clinical analysis is needed to assess longer-term outcomes. (10.1016/j.arth.2012.08.016)
• [L2] Longer-term clinical follow-up is needed to understand the clinical impact of this radiological finding. (10.1016/j.jisako.2023.03.251)
• [L5] Further research is required in anatomic and biomechanic studies, experience in inflammatory arthropathy, and long-term survivorship to improve outcomes. (10.1177/17531934231209638)
• [L4] Clinical and radiological follow-up showed good short-term results after meniscus repair. (10.1177/2325967117s00146)
• [L5] Further biomechanical and clinical investigation is indicated. (10.1177/2325967123s00028)
• [L3] All indications except severe stiffness had a similar clinical outcome which was maintained up to 7.5-year follow-up. (10.1016/j.arth.2020.01.053)
• [L5] The natural history of Kienbock's disease is not fully known, though it is generally considered a progressive condition that can end in Stage IV changes; treatment strategies focus on biomechanical unloading, vascularized bone grafts, or salvage procedures depending on the stage. (10.1016/j.hcl.2006.07.003)
• [L4] Improved understanding of the natural history of spine deformity, combined with advances in imaging, surgical technology, radiation therapy, and chemotherapeutic regimens, has improved survival rates and decreased rates of local recurrence. (10.5435/00124635-201210000-00004)
• [L5] Diagnosis of DRUJ instability is made clinically and corroborated by imaging studies, with a thorough history and physical examination serving as the foundation. (10.1016/j.hcl.2020.07.004)
• [L4] Effective diagnosis and management require a thorough understanding of golf swing biomechanics and forces. (10.5435/jaaos-d-15-00433)
• [L2] Presentation factors that increase the likelihood of a diagnostic X-ray included pain for longer than 6 months, the presence of medial or diffuse pain, and mechanical symptoms. (10.1007/s00167-014-3003-8)
• [L5] It emphasizes the need for further clinical and biomechanical verification to establish a scientific approach for diagnosis and management. (10.1016/j.jhsa.2005.12.014)
• [L5] Careful clinical and radiographic evaluation, coupled with a thorough understanding of the anatomy and biomechanics of the foot, will allow accurate evaluation and appropriate treatment. (10.5435/00124635-199509000-00005)
• [L2] Both surgical groups demonstrated decreased wrist kinematic motion and functional performance compared with individuals with normal wrists. (10.1016/j.jhsa.2015.04.035)
• [L5] Determining the etiology of ulnar-sided wrist pain is often challenging due to overlapping history and physical examination findings; a detailed history, systematic physical examination with provocative maneuvers, and appropriate diagnostic imaging are essential for diagnosis. (10.5435/jaaos-d-16-00407)
• [L4] The authors propose a new four-part classification system to aid in the comparison of results and better understanding of implant biomechanics. (10.1302/2058-5241.5.190034)
• [L5] Diagnostic imaging is essential to differentiate between injuries with common clinical presentations, determine the degree of injury, estimate time to return to activity, and document healing. (10.1016/j.csm.2011.09.006)
• [L4] This proposed classification system is anatomically based and considers the deforming forces from ligaments and tendons. (10.1016/j.jse.2023.12.021)
• [L5] The diagnosis of iliotibial band syndrome is typically made based on a characteristic patient history and physical examination, with imaging studies reserved for cases of recalcitrant disease. (10.5435/00124635-201112000-00003)
• [L4] The diagnosis of femoroacetabular impingement (FAI) syndrome is made based on a combination of clinical symptoms, physical examination findings, and imaging studies, as no single pathognomonic finding exists for FAI. (10.5435/00124635-201300001-00005)
• [L5] Diagnosis of compressive neuropathies relies on a combination of clinical presentation, physical examination findings, and use of imaging modalities and electrodiagnostic studies, as there is no true diagnostic gold standard for most conditions. (10.1016/j.jhsg.2022.10.010)
• [L5] This study demonstrates that forearm orientation affects contact mechanics and end-range carpal kinematics. (10.1016/j.jhsa.2020.10.017)
• [L4] The techniques presented provide a detailed description of forearm kinematics. (10.1177/17531934221142520)
• [L2] The efficacy of both ACI and microfracture was demonstrated with respect to both functional outcomes and morphological repair. (10.1177/2325967119854442)
• [L4] Systematic clinical examination, proper radiographs, and histology are essential for diagnosis. (10.1007/s00402-007-0478-5)
• [L3] Functional kinematic and kinetic biomechanical strategies at the hip and knee were associated with patellar tendon abnormality identified on imaging and symptomatic limbs. (10.1177/23259671241242008)
• [L4] Acute distal radioulnar joint instability is primarily a clinical diagnosis, and physical examination remains a mainstay of diagnosis. (10.2106/jbjs.rvw.m.00110)
• [Paper] Despite many studies attempting to explain carpal mechanics over the past hundred years, no unanimous theory or model fully explains wrist anatomy and function. (10.1016/j.hcl.2006.08.001)
• [L4] Knee arthroscopy is effective in treating patients with symptomatic osteoarthritis and mechanical symptoms, with 76% reporting good and excellent results. (10.1016/j.arthro.2011.03.031)
• [L5] Wrist kinematic coupling parameters are task specific in healthy individuals. (10.1016/j.jhsa.2013.12.031)
• [L5] This additional knowledge helps provide further understanding of wrist kinematics, the function of individual ligaments, and their roles in joint motion, stability, and injuries. (10.1016/j.hcl.2006.08.003)
• [L1] Inconsistent agreement using the current common radiographic classification system suggests a need for better radiographic tools to quantify disease severity. (10.1007/s11999-013-3208-z)
• [L5] Wrist positions significantly influence the biomechanical behavior of the radiocapitellar joint during elbow extension. (10.1016/j.jse.2025.02.040)
• [L5] Surgical repair is the preferred choice over conservative treatment to mitigate osteoarthritis progression by reinstating optimal joint contact pressures and kinematics. (10.1177/2325967124s00381)
• [L5] Wrist biomechanics were significantly altered following trapeziectomy, and of the reconstructions tested, LRTI most closely resembled the intact biomechanics in this cadaveric model. (10.1016/j.jhsa.2019.10.003)
• [L1] No current MRI classification system has been shown to correlate with clinical outcomes after all types of cartilage repair surgery. (10.1177/0363546513485931)
• [L5] With appropriate treatment practices, excellent results with good functional outcomes are to be expected. (10.1007/s11552-014-9706-y)
• [L3] No classification system is universally accepted, and every classification system is subject to interobserver variability, ultimately raising questions about the suitability of its use in a research as well as in a clinical context. (10.1016/j.jse.2014.10.025)
• [L5] Anatomic and biomechanical research of the wrist has yielded a substantial amount of information that improves our basic knowledge of carpal morphology and function of the wrist and provides information to better assess and improve treatment(s) for various problems of the wrist joint. (10.1016/j.jhsa.2009.07.019)
• [L4] The new four-category, 7-point classification system demonstrated interobserver reproducibility and correlation with joint function equivalent to the Pettersson et al. system, while being easier to apply and more sensitive in discriminating advanced arthropathy than the Arnold and Hilgartner system. (10.2106/00004623-198971020-00010)
• [L3] The 3D classification system using combined humeroscapular alignment and glenoid erosion can be applied to describe the disease comprehensively. (10.1177/23259671221110512)
• [L5] It provides a robust platform for exploring forearm biomechanics and guiding clinical applications. (10.1186/s12891-026-09672-6)
• [L4] Twenty-six different criteria described by multiple classification systems have been identified for the magnetic resonance assessment of rotator cuff after repair. (10.1007/s00167-014-3486-3)
• [L5] This study describes the effect of lunate morphology on 3-dimensional carpal kinematics during wrist flexion and extension. (10.1016/j.jhsa.2014.09.019)
• [Commentary] The study is just one small piece in the enormous puzzle that constitutes wrist biomechanics, and the information gleaned from this study is not enough at this point to carry over into clinical practice. (10.1016/j.jhsa.2015.08.017)
• [Paper] Proper indication relies on identifying and simultaneously correcting malalignment and/or traumatic changes in affected joints. (10.1016/j.injury.2008.01.041)
• [L5] The study presents a forward kinematic analysis of the carpus that provides the basis for the development of a unifying kinetic theory of wrist motion based on isometric constraints and rules-based motion. (10.1177/1753193413505407)
• [L4] The proposed PIP-Kellgren functional-radiological classification system may help stratify surgical candidates and standardize severity assessment. (10.1016/j.jhsg.2025.100911)
• [L5] Large distal radius forces and moments can occur during pushup and active wrist motions. (10.1016/j.jhsa.2018.05.020)
• [L5] Despite complex carpal bone anatomy and kinematics, computed fiber elongations were found to vary linearly with wrist position. (10.1016/j.jhsa.2012.04.025)
• [L5] Existing classification systems for complex extremity fractures are inadequate and lack therapeutic recommendations. (10.1016/j.injury.2009.10.039)
• [L4] Conservative treatment or non-anatomical repair results in significant loss of supination strength and variable loss of flexion strength. (10.2106/00004623-198567030-00011)
• [L4] The authors present a validated classification system for acetabular bone loss that guides treatment and prognosticates outcomes. (10.1016/j.arth.2007.05.020)
• [L4] A comprehensive classification system integrating historical and newer descriptions of rotator cuff lesions may help to guide treatment further. (10.1302/2058-5241.1.160005)
• [Paper] Existing classification systems for ballistic fractures are inadequate because they fail to account for soft-tissue injury, anatomical location, and joint involvement. (10.1016/j.injury.2004.10.023)
• [L4] The study established a radiological classification system identifying three types of glenoid fossa shape changes and six total deformity types when including upward humeral head migration. (10.1155/2011/239894)
• [L5] All plate constructs met the anticipated demands given their biomechanical properties and the loads transmitted across the native wrist. (10.1016/j.jhsa.2012.03.021)
• [L4] Eight studies followed International Society of Biomechanics standards for quantifying upper body kinematics. (10.1016/j.jelekin.2018.02.011)
• [L5] Four-dimensional computed tomography (4DCT) is a promising, non-invasive, and affordable method to assess and quantify wrist kinematics, extending conventional CT by incorporating the temporal dimension. (10.1177/17531934251326028)
• [L4] Long-term outcomes are profoundly affected by demographic, social, and economic factors rather than traditional orthopaedic variables. (10.1016/j.injury.2006.07.016)
• [L1] Nonanatomic and anatomic techniques exceeded the minimum acceptable threshold of stability and failure loads in controlled biomechanical testing. (10.1016/j.asmr.2020.12.007)
• [Paper] MRI review by musculoskeletal-specialized radiologists is likely to lead to more correct diagnoses. (10.1055/a-1328-3142)
• [L4] Advanced microfracture techniques showed promise, but indications and variability in techniques need to be elucidated in higher-level studies. (10.1177/23259671231153422)
• [L1] These biomechanical findings must be interpreted in the context of clinical outcomes data as well as the differing complication profiles of the two techniques to best inform the surgical decision-making process. (10.1016/j.jisako.2023.03.027)
• [L2] Radiographic criteria explained 49% of the variation in treatment recommendations, while surgeon and patient factors explained only 1%. (10.1177/1753193414555284)
• [L5] Recent advances in noninvasive musculoskeletal imaging, particularly MRI sequences detecting biochemical changes, may offer a great advance in the diagnosis and treatment of osteoarthritis by identifying the disease at a stage when it is potentially reversible. (10.1302/0301-620x.95b6.31414)
• [L5] Recognition of the indications and applications of the principles of modern implants and techniques is fundamental in achieving optimal outcomes. (10.5435/00124635-201010000-00003)
• [L3] The difference between imaging modalities correlated with the degree of knee flexion during image acquisition. (10.1177/23259671241304754)
• [L3] An analysis of the imaging features of such fractures and evaluation of the diagnostic value of various methods can provide imaging basics for the development of accurate and appropriate treatment options. (10.1186/s12891-018-1982-1)
• [L5] Compositional MRI techniques may allow for an earlier diagnosis of cartilage injury before morphologic changes manifest. (10.1016/j.csm.2017.02.002)
• [L5] All imaging modalities (radiograph, CT, and MRI) demonstrated excellent inter-rater agreement with no significant difference in bias from the true variance when compared to each other. (10.1016/s0363-5023(11)60022-1)
• [L4] More recent long-term data have allowed refinement of the indications and on the acetabular side, and it should be used with caution in association with severe defects. (10.1016/j.arth.2017.02.045)
• [L4] Mechanical loosening has not occurred to date, but a much longer follow-up period is necessary for full assessment of the long-term benefit of this procedure and device. (10.2106/00004623-199274040-00003)
• [L2] CT is the preferred imaging modality for detail, but radiographs remain the appropriate initial investigation. (10.1177/17531934231184130)
• [L4] Functional MRI techniques improve tissue characterisation and staging of bone and soft-tissue tumours compared to structural imaging but have limitations with overlap between benign and malignant tumours. (10.1016/j.otsr.2012.12.005)
• [L5] Non-operative treatment is preferable, but for carefully selected patients, specific joint stabilization and nerve decompression procedures can provide symptomatic relief when conservative measures fail. (10.1002/ajmg.c.31551)
• [L2] Non-invasive imaging modalities and mechanical testing techniques, as well as the assessment of bone composition, need to complement each other to provide comprehensive and ideal information on the bone quality of human bone specimens. (10.1186/s13018-022-03041-4)
• [L3] However, by constructing predictive models, MRI could significantly improve diagnostic validity compared with radiography. (10.1186/s42836-024-00262-2)
• [L4] In particular, symptomatic cases with inconspicuous conventional MRI imaging, additional MRI imaging only in the axial plane in a 20° of knee flexion could be beneficial and useful in clinical daily routine. (10.1186/s12891-021-04733-4)
• [L5] The anatomic and radiographic locations of the POL and its biomechanical properties were successfully recorded. (10.1177/23259671231174857)
• [L5] Plain radiographic evaluation remains the initial diagnostic modality, while three-dimensional imaging such as MRI and CT is often obtained for the evaluation of labral and cartilage pathology, definition of bony anatomy, and surgical planning. (10.5435/00124635-201300001-00006)
• [L2] The results suggest that nonoperative treatment should be performed early for optimal outcomes. (10.1177/2325967118788531)
• [L4] Nonoperative treatment may be appropriate for minimally displaced cases. (10.1177/23259671251365974)
• [L4] For selected fractures, nonoperative management can lead to good clinical and radiographic outcomes. (10.1016/j.jse.2016.02.025)
• [L5] Nonoperative management is recommended initially, while operative treatment is indicated after nonoperative management has failed. (10.1302/2058-5241.4.180025)
• [L4] Non-operative management is favoured for first-time dislocators, particularly those with multi-directional instability, soft-tissue laxity, older patients, or younger patients not engaged in overhead activities. (10.1302/2058-5241.2.160018)
• [L5] There is a paucity of literature and persistent controversy regarding the best treatment algorithm, though nonoperative management is frequently preferred for stable fractures. (10.1007/s11552-013-9562-1)
• [L5] FAI is defined as a pathologic mechanical process involving morphologic abnormalities and vigorous motion that damages soft-tissue structures; while FAI morphology is common in young adults and predisposes to later OA, more long-term data are needed to define the natural history of pincer deformities and FAI in younger cohorts. (10.5435/00124635-201300001-00004)
• [L5] Nonoperative treatment is almost always initiated although surgical treatment may be indicated in cases refractory to conservative management. (10.1155/2013/473259)
• [L5] Current non-surgical managements for osteoarthritis do not change the clinical course or arrest disease progression, while joint replacement is indicated for end-stage disease. (10.1530/eor-2025-0050)
• [L5] Non-operative treatment cannot correct the deformity but can help control symptoms. (10.1302/2058-5241.1.000005)
• [L3] Correlation of the clinical history, physical examination, and imaging findings are fundamental. (10.1177/2325967115s00018)
• [L3] Women and patients with a 3- to 10-year history of ACLR demonstrated VDJ biomechanics that may be associated with knee motion control challenges. (10.1177/23259671211058105)
• [L4] Clinical decision making should carefully analyze the association of patient history and physical examination with radiographic imaging. (10.1016/j.arthro.2014.11.042)
• [L5] A complete history and physical examination with selective imaging studies should lead to an accurate diagnosis, and while nonoperative treatment often provides good results, surgical treatment can yield substantial improvement in symptoms and patient satisfaction when indicated. (10.5435/00124635-199701000-00006)
• [L5] Muscle imaging can help for recognition of atypical clinical presentations, for understanding the natural history of the disease, and for determining patients suited for treatment. (10.1186/1471-2474-14-s2-o2)
• [L4] Gender, age, years of experience, type of imaging modality, and employment status were the most common associated risk factors for developing musculoskeletal symptoms. (10.1186/s12891-023-06596-3)
• [L4] Careful history-taking, physical examination, electrodiagnostic study, and imaging are necessary for an accurate diagnosis, with conservative treatment recommended initially and surgical decompression reserved for persistent or recurrent symptoms. (10.1302/0301-620x.102b5.bjj-2019-1212.r1)
• [L5] Future clinical trials investigating the natural history and treatment of femoroacetabular impingement will require multimodal staging systems for hip osteoarthritis because the optimal system will differ based on the size of the study population, the specific objective in question, and the time frame in which the investigator expects to see the specified end point. (10.5435/00124635-201300001-00008)
• [L4] The mean follow-up time was 9.9 years, with 79% of patients showing radiographic signs of osteoarthritis. (10.1016/j.otsr.2022.103332)
• [L4] Long-term clinical and radiographic follow-up is necessary to determine the natural history of these lesions. (10.1177/23259671231159910)
• [L3] Early reconstruction is technically easier and reduces the overall period of disability for patients with radiographic characteristics predictive of persistent functional limitation. (10.2106/00004623-199605000-00014)
• [L4] Patients experience satisfactory results at greater than 5 years, though asymptomatic radiographic degenerative changes may occur. (10.1016/j.jhsa.2012.07.019)
• [L4] Radiographic progression of Kienböck over 1 year or more seems slight on average regardless of treatment. (10.1016/j.jhsa.2016.02.016)

See Also

• Kienböck's Disease

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