All regression models were adjusted for age, gender and OA risk factors, including previous injury or surgery at the knee, family history of joint replacement, presence of Herbeden's nodes and BMI. There are children who are born with normal hips who develop dysplasia (figure). J Pediatr Orthop. Information about the disease may be limited. Patellar T2 values did not show a significant difference in individuals with abnormal trochlear facetal ratio compared to controls (40.8 0.9 ms versus 41.8 0.4 ms; P=0.310) or in individuals with an abnormal sulcus angle compared to controls (41.5 1.0 ms versus 41.7 0.5 ms; P=0.464). The 30 knees with a low trochlea facetal ratio had an average ratio of 0.35 0.04, while the subjects with a normal trochlea facetal ratio (n=105) had a mean ratio of 0.57 0.11. A novel fast knee cartilage segmentation technique for T2 measurements at MR imaging--data from the Osteoarthritis Initiative. Also offers tips from CDC for encouraging a childs development and what to do if a parent or guardian is ever concerned about how their child is developing. Baum T, Joseph GB, Nardo L, Virayavanich W, Arulanandan A, Alizai H, et al. Knee Cartilage T2 Characteristics and Evolution in Relation to Morphologic Abnormalities Detected at 3-T MR Imaging: A Longitudinal Study of the Normal Control Cohort from the Osteoarthritis Initiative. Ultrasonographic Graf type IIa hip needs more consideration in newborn girls. 10 Recently, a novel LTI measurement technique using 2 magnetic resonance imaging (MRI) slices has been proposed to optimally capture the angle subtended between the proximal trochlea and the posterior femoral . In the subcohort with an abnormal facetal ratio means of 7.9 1.0mm and 22.8 2.6mm were detected; in the subcohort with a normal facetal ratio means of 12.4 2.5mm and 21.9 2.4mm were found. Trochleoplasty can be proposed as a primary procedure for primary trochlear dysplasia or as a salvage procedure in case of failure after previous patellar alignment surgery. Fucentese SF, Schttle PB, Pfirrmann CW, Romero J. Knee Surg Sports Traumatol Arthrosc. Knee Surg Sports Traumatol Arthrosc. 2000 Aug;216(2):582-5 Total patellofemoral WORMS score was increased in individuals with trochlear dysplasia. PCPs can provide referrals to specialists and can help manage and coordinate overall medical care. There is little information about trochlear dysplasia and its association with degenerative changes at the patellofemoral joint when evaluated with 3T MRI studies, which are particularly sensitive to detecting early degenerative biochemical intrasubstance changes. Khaled M. Sarraf, BSc (Hons), MBBS, MRCS Specialist Registrar in Trauma and Orthopaedic Surgery, North West Thames Rotation - London Deanery, Chelsea and Westminster Hospital NHS Foundation Trust . As a primary intention, the trochleoplasty is indicated for a symptomatic patient with recurrent patellar instability, which has failed non-operative management. Remy F, Besson A, Migaud H, Cotten A, Gougeon F, Duquennoy A. Rev Chir Orthop Reparatrice Appar Mot. More tests and specialist referrals may be needed to find the right diagnosis. This study was funded by NIH U01 AR059507 and P50 AR060752 as well as through the OAI, which is a public-private partnership comprised of five contracts (N01-AR-2-2258; N01-AR-2-2259; N01-AR-2-2260; N01-AR-2-2261; N01-AR-2-2262) funded by the National Institutes of Health, a branch of the Department of Health and Human Services, and conducted by the OAI Study Investigators. Talk to a doctor to learn if any imaging studies are suggested to diagnose or manage this disease. Mean the range of motion of the elbow were flexion, 116.312.7 and extension, -28.814.1. Subjects presenting A: a shallow trochlea of 3mm, B: a small facetal ratio of 0.4 and C: a large sulcus angle of >170, Scatter plot with bivariate linear fit, visualizing the correlation of patellar cartilage T. Christian SR, Anderson MB, Workman R, Conway WF, Pope TL. Dr. Welch recommends non-surgical management for most patients with trochlear dysplasia. Twenty-two of the knees with a shallow trochlea and no control knees had an abnormal sulcus angle of >170. Articular cartilage in the knee: current MR imaging techniques and applications in clinical practice and research. There was no significant difference between subjects with an abnormal facetal ratio (n=30) and controls (n=105; gender, P=0.686; BMI, P=0.327; age, P=0.973; knee-bending, P=0.462; PASE, P=0.641). separately scored knees using the UCSF modified whole-organ magnetic resonance imaging score (WORMS) [1517]; if scores were not identical, consensus readings by both radiologists were performed. After the initial medical tests and visits to specialists are complete, a doctor will review the results and reports in a follow up visit. Maximum WORMS scores are summarized in Table 2. Washburn RA, Smith KW, Jette AM, Janney CA. Blue color indicates low cartilage T2, while red color indicates high cartilage T2. van Huyssteen AL, Hendrix MR, Barnett AJ, Wakeley CJ, Eldridge JD. The level of significance for all calculations was defined as p<0.05. 2017 Dec;25(12):3869-3877. doi: 10.1007/s00167-016-4365-x. 2022 Dec 4. doi: 10.1007/s00167-022-07245-3. 2003 Dec; 24(6):377-82. -. and no follow up is necessary. Between 30 and 90 degrees of flexion, the patella is engaged with the trochlea. MRI patellofemoral instability measurements (reporting aid). For covariates, mean values are reported with standard deviation (SD). Trochlear dysplasia includes shallow sulcus angle (>145) (Fig. Baum T, Stehling C, Joseph GB, Carballido-Gamio J, Schwaiger BJ, Muller-Hocker C, et al. This is the Graf classification - long version. Salzmann et al. David-Vaudey E, Ghosh S, Ries M, Majumdar S. T2 relaxation time measurements in osteoarthritis. MRCS Revision. Peterfy CG, Guermazi A, Zaim S, Tirman PFJ, Miaux Y, White D, et al. Subjects with higher physical activity levels have more severe focal knee lesions diagnosed with 3T MRI: analysis of a non-symptomatic cohort of the osteoarthritis initiative. Developmental dysplasia of the hip is more common in girls especially if there has been a breech presentation or when they have a positive family history. Copyright The Gemini - India. Steps may include getting lab work, special tests, or referrals to a specialist. T2 values at the patella were significantly lower in the dysplasia group with a shallow trochlea. Using the same software, segmentation for patellar cartilage volume measurements was performed by one radiologist (P.M.J.) Dejour H, Walch G, Neyret P, Adeleine P. Dysplasia of the femoral trochlea. Initial test results and evaluations by specialists may not be enough to confirm a suspected diagnosis but may support it being the likely or working diagnosis. Expand 15 PDF View 1 excerpt, cites background Save Alert Aspects of trochlear dysplasia. Guide: Limbs and Spine MRCS Revision Guide: Limbs and Spine Mazyar Kanani, PhD, FRCS (CTh) Fellow in Congenital Cardiac Surgery, Children's Hospital, Pittsburgh, Pennsylvania, USA. If you need help finding information about a disease, please Contact Us. On the lateral knee x-rays, the femoral condyles may not overlap normally and there can be what is called a crossing sign, which indicates the trochlea is not fully developed. 2013 Mar; 7(2): 95-98. by Puhan MA, Woolacott N, Kleijnen J, Steurer. As a result the alpha-angle will be a little bit steeper than in type Ia, but still within a normal range. Gaucher disease Niemann- Pick (enzyme deficiency) Fibrous dysplasia Metaphyseal dysplasia (Pyle's disease) . Includes tips to make certain a patient or caregiver has a clear understanding of the next steps to take after the doctors visit. Hip sonography. The additional cartilage loss, especially the superficial layer, which usually incooperates high T2 values, may be responsible for the unexpected results. Pan J, Pialat JB, Joseph T, Kuo D, Joseph GB, Nevitt MC, et al. We are experimenting with display styles that make it easier to read articles in PMC. Another important factor is the age of the child. Epidemiological data of study cohorts. -, Am J Sports Med. Dec 9, 2022 - Room in hotel for $118. Also provides links to tools to help collect family history. 2022 Aug 8;2022:6723326. doi: 10.1155/2022/6723326. The additional cartilage loss likely accounts for the decrease in T2 values and is highlighting the careful interpretation of T2 relaxation time measurements in the context of morphological cartilage loss in subjects with advanced OA. Looking at a person's body to check for normal findings and any changes that may indicate a diagnosis. Kellgren-Lawrence (KL) scores were assessed in our institution (T.M.L., 22 years of experience). Purpose: Online ahead of print. The .gov means its official. Jungmann P, Kraus M, Nardo L, Liebl H, Alizai H, Joseph G, et al. found a mean sulcus angle of 164 in patients with type B dysplasia (144 in plain radiographs) and 168 in patients with type C dysplasia (146 in plain radiographs) [8]. Segmentation of the cartilage at the patella and trochlea, the medial and lateral femoral condyle and medial and lateral tibia plateau, was performed by one investigator (S.C.T.) Provides a downloadable set of prompts and questions to help encourage participation and partnership with medical professionals. Felus J, Kowalczyk B, Starmach M, Wyrobek L. Orthop J Sports Med. Changes in knee cartilage T2 values over 24 months in subjects with and without risk factors for knee osteoarthritis and their association with focal knee lesions at baseline: Data from the osteoarthritis initiative. Minor dislocations can cause instability and chronic stress on the cartilage, which may lead to early OA. The alpha angle is above the 60 degrees and the beta-angle is way below 55 degrees. Knees with an abnormal sulcus angle (>170) also showed increased WORMS scores (12.21.1 versus 8.60.6; P=0.003). official website and that any information you provide is encrypted 2013 Oct; 42(10): 13831392. You may switch to Article in classic view. T2 relaxation time measurements can be used as a biomarker to non-invasively detect and quantify intrasubstance degeneration, more specifically collagen disruption and water content changes. To evaluate trochlear morphology as a potential risk factor for patellofemoral osteoarthritis, determined by morphological and quantitative measurements of cartilage degeneration using 3T magnetic resonance imaging (MRI) of the knee. A type D hip is much like a type IIC hip, but the main difference is a decentring hip with a displaced cartilage roof. Absolute cartilage volume (mm3) was calculated for the patellar compartment from the regions of interest created in the maps. Reference: Data from the Newborn Screening Codingand Terminology Guide is available here. Once cartilage loss occurs, changes in MRI morphology are frequently seen [16]. A personal medical history is very important when seeing doctors during the diagnostic process. From the Progression cohort of the OAI, 304 subjects aged 45 to 60 were randomly selected and measurements of trochlear dysplasia on MRIs of their right knee were performed. Author manuscript; available in PMC 2014 Oct 1. The sulcus angle () was calculated as 180 asin ((ac)/e) asin ((bc)/d). The lateral condyle index: a new index for assessing the length of the lateral articular trochlea as predisposing factor for patellar instability. Tracks a childs milestones from age 2 months to 5 years with CDCs easy-to-use illustrated checklists. The growth pattern of the normal trochlea is known, but there have been no studies . and supervised by a musculoskeletal radiologist (T.M.L.) Individuals who underwent a Henri Dejour trochleoplasty for a dysplastic trochlea reported an improvement in symptoms [26]. Knee Surg Sports Traumatol Arthrosc. Offers tips and more resources to improve communication with a doctor during a medical visit. 2022 Jul 30;8(1):98. doi: 10.1186/s40798-022-00488-x. If available, the doctor may also review a patient's medical records including the results of previous tests and procedures. Global T2 values, which are commonly used in the evaluation of early intrasubstance cartilage degeneration [27], were similar between the two groups. We welcome you in a modern, trendy and original universe. Tensile properties of human knee joint cartilage. Correlations between weight bearing and tissue pathology and the kinetics of swelling. For the medial femorotibial compartment, subjects with a shallow trochlea had significantly increased maximum cartilage scores (4.0 0.3 versus 2.6 0.4; P=0.010). Images were transferred to a remote SUN/SPARC workstation (Sun Microsystems, Mountain View, CA, USA) and analyzed with software developed at our institution using an Interactive Display Language (IDL; Research Systems, Boulder, CO, USA) environment. CT changes after trochleoplasty for symptomatic trochlear dysplasia. An official website of the United States government. Biedert RM, Netzer P, Gal I, Sigg A, Tscholl PM. The lateral trochlear inclination (LTI) is a measure that has been previously described for characterizing trochlear morphology. MR images of the right knee were reviewed on picture archiving communication system (PACS) workstations (Agfa, Ridgefield Park, NJ, USA). The importance of trochlear dysplasia first came to light in 1802, when the French surgeon Richerand noticed several cases of patellar dislocation in which the lateral femoral condyle was less prominent than usual. 6). Hokkaido Univ, Assistant professor. Int Orthop. This cross-sectional study study examined the association of trochlear dysplasia, assessed by 3.0T MRI and defined as (i) a trochlear depth of 3 mm or less, (ii) a medial-to-lateral facet ratio of 0.4 or less and (iii) a sulcus angle of >170 with the presence and severity of MRI findings of knee OA. The trochlea bump was found to be useful for the diagnosis of trochlear dysplasia, but the panel was not certain of the measurements role in the treatment of trochlear dysplasia, prediction of patellofemoral pain and risk of patella dislocation. Longitudinal data from the Osteoarthritis Initiative. Am J Sports Med 2009 37: 2355 . For individuals with abnormal trochlear depth, the mean global T2 value was 44.4 0.3 ms, while the control group had a mean global value of 44.9 0.4 ms. 2022 Jul 14;10(7):23259671221107608. doi: 10.1177/23259671221107608. bottom line: patellofemoral arthritis has a broad range of management options according to the characteristics of individual diseases.identifying whether patellofemoral arthritis is the primary cause of knee pain and is compartment arthritis is necessary for establishing an adequate treatment method.through investigation of the literature, the However, radiographs underestimate this angle as compared to MR measurements [8]. Lower row: Corresponding T, Total WORMS score of the patellofemoral joint in subjects with trochlear dysplasia versus control. There was no significant difference regarding age, BMI, gender, Physical Activity Scale for the Elderly (PASE) [14], and knee-bending activities between the subjects with a shallow trochlea (n=85) versus controls (n=50; P>0.05 for all comparisons; Table 1). Actually, for classification purposes the beta angle is only used to differentiate between type Ia and Ib (both normal hips) and between type IIc and type D). Unable to load your collection due to an error, Unable to load your delegates due to an error. The patellofemoral WORMS score was also significantly **higher in individuals with low trochlear facetal ratio or abnormal sulcus angle than in the corresponding control cohort (facetal ratio, 12.3 0.9 versus 8.3 0.5; P<0.001; sulcus angle, 12.2 1.1 versus 8.6 0.6; P=0.003; Figure 2). Trochleoplasty can be proposed as a primary procedure for primary trochlear dysplasia or as a salvage procedure in case of failure after previous patellar alignment surgery. Koeter S, Bongers EM, de Rooij J, van Kampen A. Pfirrmann CW, Zanetti M, Romero J, Hodler J. Femoral trochlear dysplasia: MR findings. Fitoussi F, Akoure S, Chouteau Y, Bouger D. Hollow femoral trochlea and femoropatellar osteoarthritis. Touching areas of a person's body to check for pain, tenderness, swelling, lumps, masses, or other changes. A lineair, high frequency probe is used. Additionally, complex injuries to bone, cartilage, and ligaments may occur. 3D Knee Trochlear Morphology Assessment by Magnetic Resonance Imaging in Patients With Normal and Dysplastic Trochleae. The crossing sign, the trochlea bump, the TT-TG distance, the trochlea depth and the ventral trochlea prominence also had high ratings. Toms AP, Cahir J, Swift L, Donell ST. Patellofemoral WORMS scores were significantly higher in the group with a shallow trochlea and patellar cartilage volume was significantly lower in the group with a shallow trochlea, suggesting a strong association of trochlear dysplasia with more severe patellofemoral joint degeneration. The Osteoarthritis Initiative (OAI) was launched by the NIH and is a longitudinal, observational multi-center study that includes nearly 5000 participants. Would you like email updates of new search results? The shape of trochlear dysplasia is most likely a genetic predisposition and does not necessarily change during skeletal growth, as reflected by sulcus angle and Dejour classification, and did not change with increasing age. Chen J, Ye Z, Wu C, Zhang X, Zhao J, Xie G. Knee Surg Sports Traumatol Arthrosc. Developmental dysplasia of the hip is a common musculoskeletal disorder in newborns. However, two-dimensional imaging underestimates the angle and shows substantial differences of about 20 to more accurate MR measurements [710]. Enter the email address you signed up with and we'll email you a reset link. There are several limitations to this study. Epub 2010 Nov 11. Clipboard, Search History, and several other advanced features are temporarily unavailable. A primary care physician (PCP) or specialist may offer treatment options to manage symptoms during the diagnostic process. The progression cohort is characterized by the presence of symptomatic knee OA. Offers a series of columns to help patients, families, and caregivers understand how important their role is. At the knee, a dysplastic trochlea has been shown to contribute to patellar maltracking and recurrent dislocations [21]. Salzmann GM, Weber TS, Spang JT, Imhoff AB, Schottle PB. 2016 Mar;24(3):838-46 Before A: Adjusted1 means SEM and differences are presented for numeric outcomes. Listening to internal body sounds to check the heart, lungs, or abdominal organs. When the bony rim is angular this point is easily recognized. Trochlear dysplasia: imaging and treatment options EFORT Open Rev. Femoral trochlear dysplasia is an anatomic deformity that predisposes patients to patellar instability, including patellar subluxation and dislocation, and can lead to severe patellofemoral. Bilateral standing posterior anterior (PA) fixed flexion plain radiographs of the knee were obtained in a plexiglass positioning frame (SynaFlexerTM; CCBR-Synarc, San Francisco, California) with 2030 flexion and 10 internal rotation of bilateral feet. Observational studies on ultrasound screening for developmental dysplasia of the hip in newborns - a systematic review. They should not be mistaken for loose intra-articular bodies (arrow). However, significance was lost after adjustment for cartilage volume (P=0.673). Other non-surgical treatment options . The mean WORMS score for the medial meniscus was 2.2 0.2 for the cohort with abnormal trochlear depth and 1.9 0.3 for controls (P=0.400). Smaller cartilage volumes were associated with lower T2 relaxation times. eCollection 2022. Twenty-six of 85 knees with a shallow trochlea and 4 of 50 control knees had a medial-to-lateral trochlear facetal ratio of less than 0.4. Subjects presenting A: a shallow trochlea of 3mm, B: a small facetal ratio of 0.4 and C: a large sulcus angle of >170 presented more patellofemoral abnormalities than control subjects. The Trochlea has two or more ossification centres which can give the trochlea a fragmented appearance. Verdonk R, Jansegers E, Stuyts B. Trochleoplasty in dysplastic knee trochlea. Upper row: Measurements in the axial 3D DESS sequence with selective water excitation, 30 mm proximal of the joint line in a normal (A) and abnormal (B) patellofemoral joint with trochlear dysplasia. 1Musculoskeletal and Quantitative Imaging Research, Department of Radiology and Biomedical Imaging, University of California San Francisco, 185 Berry Street, Suite 350, San Francisco, CA 94107, USA, 4Department of Radiology, Technical University of Munich, Ismaninger Strasse 22, 81675 Munich, Germany, 3Department of Radiology, Mount Elizabeth Hospital, 3 Mount Elizabeth #01-01, Singapore 228510, 2Department of Epidemiology and Biostatistics, University of California San Francisco, 185 Berry Street, Suite 5700, San Francisco, CA 94107, USA, Michael C. Nevitt, PhD: ude.fscu.gsp@ttivenm, Chuck E. McCulloch, PhD: ude.fscu.ipe@hcolluccmc, Thomas M. Link, MD, PhD: ude.fscu@kniL.samohT. Trochlear dysplasia is a well known cause for recurrent patellar instability [1], [2], [3], [4], [5]. II. HHS Vulnerability Disclosure, Help Depth insufficiency of the proximal trochlear groove on lateral radiographs of the knee: relation to patellar dislocation. The labrum is dislocated downwards and interposed between the femoral head and the lateral acetabular edge. When you perform the ultrasound examination, make sure that these three points can be identified on the image. Developmental dysplasia of the hip (DDH) is one of the most common musculoskeletal problems in newborns. Based on these findings, 170 was selected as a threshold for an abnormal bony sulcus angle in our MRI analyses, which was present in 22/ 135 subjects. At the axial slice 30 mm proximal to the knee joint line [6], the following trochlear measurements were obtained (Figure 1; upper row): (i) the maximal anteroposterior distance from the medial femoral condyle to the line paralleling the posterior aspects of both femoral condyles (distance a), (ii) the maximal anteroposterior distance from the lateral femoral condyle to the line paralleling the posterior aspects of both femoral condyles (distance b), (iii) the minimal anteroposterior distance from the deepest point in the trochlear groove to the line paralleling the posterior aspects of both femoral condyles (distance c), (iv) the length of the medial (distance d) and lateral (distance e) facets of the patella. The typical injury pattern is a tear of the medial patellofemoral ligament (MPFL) and bone bruises of the patella and the lateral femoral condyle. During the diagnostic process, meeting regularly with a doctor may be helpful and necessary. Exclusion criteria for the OAI were rheumatoid arthritis, bilateral severe knee joint space narrowing, contraindications or inability for MRI, and poor MR quality. Trochlear sulcus Posterior capitellar pseudodefect DDx: location; no underlying edema . Patients with trochlear dysplasia have a shallow, abnormally shaped trochlear groove that is inadequate in preventing lateral patellar subluxation or dislocation [].Although relatively rare in the general population, trochlear dysplasia is found in up to 85% of patients who have recurrent patellofemoral instability [].Other anatomic factors, such as patella alta, increased distance from the . 2022 Nov-Dec;140(6):755-761. doi: 10.1590/1516-3180.2021.0206.R2.10012022. If a child is older than 3 months or 13 weeks, then an alpha angle of 50-59 degrees is considered a sign of dysplasia, i.e type IIb. Mean cartilage T2 relaxation time values (ms) for subjects with trochlear dysplasia. ANOVA and multivariate regression models were used for statistical analysis of the association of MRI structural measures and trochlear morphology. This examination shows a good morphology of the bony acetabular roof with a sharp angular bony rim. Subarticular cysts were graded as follows: 0=none; 1=<0.5cm; 2=0.5 to 2.0 cm; 3=>2.0cm. Association of Trochlear Dysplasia with degenerative Abnormalities in the Knee, The publisher's final edited version of this article is available at, Patellofemoral joint, Magnetic Resonance Imaging, Osteoarthritis, Cartilage, Upper row: Measurements in the axial 3D DESS sequence with selective water excitation, 30 mm proximal of the joint line in a normal (A) and abnormal (B) patellofemoral joint with trochlear dysplasia. Explains how the App helps patients and caregivers prepare for medical appointments and maximize visit time. Here a type IIc hip. There is good coverage of the femoral head. David-Vaudey et al noticed early stage OA was associated with increased T2, followed by slightly lower T2 values for more severe lesions. The labrum is moved upwards. On a lateral knee radiograph, the crossing sign was described, a geometrical abnormality at the cranial portion of the trochlea that prevents proper engagement of the patella during the early phases of knee flexion [22]. Trochlear dysplasia is characterized by abnormal trochlear morphology and a shallow groove. * Medical text book author and web editor. The functionality is limited to basic scrolling. Trochlea ossification-fragments simulate loose bodies in the joint On a lateral view the trochlea ossifications may project into the joint. MRI-based knee cartilage T2 measurements and focal knee lesions correlate with BMI - 36 month follow-up data from the Osteoarthritis initiative. 2010;8(5):336-41 Physical therapy focuses on strengthening of the core muscles, hip muscles, as well as the quadriceps to help stabilize the patella. For many, it begins at a front-line health care service, such as a primary care doctor's office, urgent care center, or an emergency room. In type III hips the femoral head dislocated. Pia. Past 7 days: 32 quakes | 2 quakes M2+. Patella height, trochlear depth, and trochlear morphology are some of the measurements obtained when reporting cases of patellofemoral instabilityon MRI. Trochlear dysplasia, defined by a shallow trochlea, was associated with higher WORMS scores and lower cartilage volume, indicating more advanced osteoarthritis at the patellofemoral joint. Therefore, 3.0T MRI was used in our study for a more detailed analysis of cartilage, tendon and bone marrow and found similar results; individuals with lower trochlear depth showed significantly increased patellofemoral degeneration. The Physical Activity Scale for the Elderly (PASE): development and evaluation. At the age of 6 weeks the same findings result in a type IIa(+). Whole-Organ Magnetic Resonance Imaging Score (WORMS) of the knee in osteoarthritis. The patellar tendon and the collateral ligaments were graded as either normal or abnormal. Cartilage in anterior cruciate ligament-reconstructed knees: MR imaging T1{rho} and T2--initial experience with 1-year follow-up. Subjects with an abnormal sulcus angle had more severe lateral meniscus lesions than corresponding controls (2.9 0.4 versus 1.8 0.2; P=0.012). and transmitted securely. International Journal of Radiology and Imaging Techniques. As previously suspected [13, 20], T2 values may reach a ceiling or even decrease with increasing cartilage loss. Imaging of anterior knee pain. We would like to hear your feedback as we continue to refine this new version of the GARD website. Dysplasia In dysplasia, abnormal differentiation of dividing cells results in cells that are abnormal in size, shape, and appearance. 2002 May-Jun;30(3):447-56 Checking a person's vital signs, including temperature, heart rate, breathing rate,blood pressure, weight, and height. PCPs see patients for new or ongoing health problems. Leave space to jot down the answers during the visit. Van Huyssteen et al described a mean bony sulcus angle of 168 as measured in MRI, while the mean cartilage sulcus angle was 187 [25]. Talk to a doctor to learn if any clinical procedures are suggested to diagnose or manage this disease. The stacks of images can be used to conveniently review the different measurement techniques. Meniscus changes were graded in six regions (medial and lateral: anterior, body, posterior) by the following: 0=normal; 1=intra-substance abnormalities; 2=non-displaced tear; 3=complex tear; 4=maceration. Thirty-three unique measurements were identified with the lateral trochlea inclination as the highest rated measurement by the expert panel, and it is recommended for use in assessment of trochlear dysplasia. Papers were screened for their relevance based on predefined parameters, and all measurements showing a statistical association between trochlear dysplasia and patellar instability were presented. . The cartilaginous roof is compressed between the femoral head and the bony acetabular rim. and supervised by a musculoskeletal radiologist (T.M.L.). An IDL routine was used to simplify the manual drawing of splines delineating cartilage areas and to calculate the mean T2 values from the regions of interest created in the T2 maps. In summary, our study demonstrated that trochlear dysplasia, defined by a shallow trochlea, a low medial-to-lateral trochlear facetal ratio or an abnormal sulcus angle, was associated with MRI findings indicating patellofemoral OA, including higher WORMS scores and smaller patella cartilage volume. Disclaimer, National Library of Medicine Provides online resources to find and compare local hospitals, nursing homes, and other providers that accept Medicare and Medicaid. At the age of 6-13 weeks a distinction is made whether it is thought that the immature hip develops apropriate according to age (IIa+) or inappropriate (IIa-). An abnormal medial-to-lateral facetal ratio was found in 30/ 135 subjects. For patellar cartilage however, T2 values of individuals with low trochlear depth demonstrated significantly lower T2 values. B: The ratio n (abnormal scores)/ n (total) is presented for dichotomous variables (ratios are not adjusted; P-values, odds ratios and confidence intervals are adjusted1). An angle greater than 145-150 is indicative of trochlear dysplasia. * International experience, having lived and worked in Australia (2003-2006), the United Kingdom (2012-2015) and the United States (2019 -2022) Write down when symptoms began, how the symptoms changed over time, previous doctor visits and tests, and any treatments that have been tried. The 22 knees with a high sulcus angle had an average angle of 177 8, while the subjects with a normal sulcus angle (n=113) had an average angle of 159 8. the trochlear groove is studied using axial radiograph views introduced by merchant to visualize patellofemoral contact areas at 30 and 45 of knee flexion. There is an invisible transition between what is normal and what is pathologic. Patella height, trochlear depth, and trochlear morphology are some of the measurements obtained when reporting cases of patellofemoral instability on MRI. About 96% of patients with a history of a true patellar dislocation had evidence of trochlear dysplasia. government site. Out of 304 individuals from the OAI progression cohort, 85 had a shallow trochlear groove (trochlear depth 3 mm) in the right knee with a mean trochlear depth of 2.0 1.0 mm (mean standard deviation (SD)). T2 relaxation time measurements are limited in monitoring progression, once advanced cartilage defects at the knee occur. Mean values are reported with Standard Error of the Mean (SEM), if not otherwise stated. Keep a record of other past medical history, such as illnesses, allergies, surgeries, injuries, or other diagnoses. Signs of trochlear dysplasia are found in more than 85% of patients with patellar dislocation. All Rights Reserved. Further, the parameter sulcus angle was determined due to its clinical relevance regarding the diagnosis of trochlear dysplasia and postoperative follow-up measurements [9, 23, 24]. Pfirrmann et al previously demonstrated a correlation of a trochlear depth of 3 mm or a medial-to-lateral facetal ratio of 0.4, measured in MR images, with trochlear dysplasia, diagnosed in lateral knee radiographs [6]. At the age of 3 months the decision has to be made whether the hip is normal or not. Anterior knee pain; Patellar instability; Patellofemoral; Patellofemoral pain; Trochlear dysplasia. Scatter plot with bivariate linear fit, visualizing the correlation of patellar cartilage T2 values with patellar cartilage volume. Using the osseous surface as a reference, Toms et al reported that the sulcus angle was larger in patients with severe cartilage defects (mean = 173) than in patients with normal cartilage (mean = 151) in a young patient cohort (<40 years) [10]. On the contrary, the lower T2 values may be explained by greater cartilage loss in subjects with low trochlear depth, since significantly more cartilage abnormalities were detected in the trochlear dysplasia group. Recent quakes above magnitude 1.0 in or near Montluon, Auvergne-Rhne-Alpes, France (updated just now) Past 24 hours: 7 quakes. Methods: Papers were screened for their relevance based on predefined parameters, and all measurements showing a statistical association between trochlear dysplasia and patellar instability were presented. Doctors may not have experience with a rare disease. Although there is a distinction between type Ia and Ib this is not clinically relevant. Trochlear dysplasia was considered as a significant risk factor for PD, which can change the interaction between the patella and the femoral trochlea. Evaluations by other specialists and further testing may still be needed to check for complications or medical problems associated with a disease. On MRI, Pfirrmann et al. Trochlear measurements were performed in rights knees using the axial reconstructed image from the 3D dual-echo in steady state (DESS) sequence with selective water excitation (WE) in all right knees. Dejour H, Walch G, Nove-Josserand L, Guier C. Factors of patellar instability: an anatomic radiographic study. EUROPEAN JOURNAL OF RADIOLOGY . A systematic literature search was conducted in the databases PubMed and Embase using the search string "trochlea dysplasia OR trochlear dysplasia". This is also a normal hip. Check for errors and try again. Anatomic Risk Factors for Osteochondral Fracture of Acute First-Time Patellar Dislocation in Adolescents: A Retrospective Magnetic Resonance Imaging Study. Reproducibility for the semi-quantitative analyses of the WORMS score for each compartment from our group was reported previously [18]. ADVERTISEMENT: Supporters see fewer/no ads. Four experts evaluated the quality of the measures using a purpose-made quality scale. These findings were unexpected, surprising and contradictory, since higher T2 values usually correlate with presence of OA [28]. Provides links to directories to help find PCPs, specialists, medical services, and facilities. The result of initial testing may sometimes be inconclusive; and such an outcome is not unusual because diagnosing rare diseases often relies on physical clues and findings that are hard to detect. Further research is needed to determine if irregular trochlear morphology is also found in normal participants or participants with early OA. The lateral trochlear sign. In the control knees, the mean trochlear depth was 4.4 1.0 mm. Two musculoskeletal radiologists (S.C.T., T.M.L.) Browse by Disease Trochlear Dysplasia Trochlear dysplasia Other Names: About the Disease Getting a Diagnosis Living with the Disease Research Navigate to sub-section Disease at a Glance Summary This section is currently in development. Up to the age of 3 months (13 weeks) an alpha angle below 60 degrees is acceptable. Links to download the free APP are also provided. Pediatr Radiol 40(11):1794-9. It is a developmental disease. Type IIa-A type IIa- hip is at risk to develop dysplasia. These hips are normal and follow up is not needed. 2022. A doctor may order more specialized tests and refer to other specialists to rule out other diseases. Past 30 days: 170 quakes | 10 quakes M2+. Knees with an abnormal medial-to-lateral facetal ratio (<0.4) showed increased patellofemoral WORMS scores (12.30.9 versus 8.30.5; P<0.001). The alpha-angle, which is a measurement of the bony roof of the acetabulum, mainly determines the hip type. Chronic patellofemoral instability. 2007 Feb;15(2):168-74. doi: 10.1007/s00167-006-0140-8. Private sector funding for the OAI is managed by the Foundation for the National Institutes of Health. Authors Ccile Batailler 1 , Philippe Neyret 2 Affiliations 1 Hpital de la Croix Rousse, Hospices Civils de Lyon, France. You can use Radiopaedia cases in a variety of ways to help you learn and teach. In this case the child had a neuromuscular disorder which caused the hip to become dysplastic and dislocate. Provides resources with information to consider when choosing a doctor or health care service. It is a developmental disease. An abnormal sulcus angle was found in 22/ 135 subjects. Significantly higher scores for bone marrow edema pattern and subchondral cysts were found in individuals with a shallow trochlea in the trochlear and patellar compartments and in individuals with an abnormal sulcus angle in the patellar compartment (P<0.05). In a cross-sectional study, effect cause has to be considered as an alternative possibility. Balcarek P, Rehn S, Howells NR, Eldridge JD, Kita K, Dejour D, Nelitz M, Banke IJ, Lambrecht D, Harden M, Friede T. Knee Surg Sports Traumatol Arthrosc. Cartilage landmarks in MRI images may be utilized to objectively evaluate femoral trochlear dysplasia in patients with severe femoral Trochlear Dysplasia as MRI exhibited advantages in revealing articular cartilage over conventional radiography and computed tomography. When the patella enters the trochlea, it allows for the inherent stability of the patellofemoral joint. Rev Chir Orthop Reparatrice Appar Mot. This was previously shown by Dejour et al on knee radiographs and computed tomography. Evid Based Complement Alternat Med. WORMS values for cartilage lesions, bone marrow edema pattern, cysts and ligament abnormalities, were increased in the trochlear dysplasia group in this study. In this video the ultrasound anatomy is shown. to generate T2 maps from the sagittal 2D MSME SE sequences of the right knee. Estimated Number of People with this Disease This section is currently in development. Techniques for quantifying trochlear dysplasia with MRI have been standardized and shown to be accurate and reproducible in assessing lateral trochlear . We're working hard to make improvements to our site by Spring 2023. The bony acetabular roof is less well-formed and there is a rounded acetabular bony rim. Akizuki S, Mow VC, Muller F, Pita JC, Howell DS. -, Am J Sports Med. The ensuing loss of medial restraint favors future patellar dislocations, especially if additional risk factors are present. Director of Chest Radiology Rhode Island Hospital and Assistant Professor of Radiology Brown University School of Medicine Providence, RI . Furthermore, the trochlear depth, lateral trochlear inclination, trochlear facet asymmetry, and sulcus angle can differentiate between low-grade and high-grade dysplasia, with trochlear depth, lateral trochlear inclination, and trochlear facet asymmetry useful for differentiating between Dejour types B and C and Dejour types B and D. Femoral trochlear dysplasia (FTD) is a congenital morphological abnormality characterized by a shallow trochlear angle and depth, which could be assessed by measuring the sulcus angle, trochlear facet asymmetry, trochlear depth, and lateral trochlear inclination on axial-view computed tomography (CT) or magnetic resonance imaging (MRI) ( 5 - 7 ). Abstract PURPOSE: To establish quantitative and qualitative magnetic resonance (MR) criteria for the diagnosis of trochlear dysplasia. Downs SM, van Dyck PC, Rinaldo P, et al. One of the primary goals of the study is to better understand the evolution of knee OA and associated factors (http://www.oai.ucsf.edu/) [13]. ADVERTISEMENT: Radiopaedia is free thanks to our supporters and advertisers. 2 Burjeel Hospital, Abu Dhabi; UAE. A significant difference in sulcus angle was found between the group with a shallow trochlea and the control group (167 8 versus 152 6; P<0.001). The ePub format is best viewed in the iBooks reader. With the additional risk factor of trochlear dysplasia, T2 values may not increase further with worsened cartilage degeneration, which is consistent with Crema et al [13]. by Hakan merolu et al. The femoral head is still covered by the cartilaginous roof and the labrum. * PhD in pediatric fractures, risk factors and health service (University of Oslo, 2012). a Pavlik harness (figure). 2018 May 21;3 (5):240-247. doi: 10.1302/2058-5241.3.170058. Past 90 days: 474 quakes | 16 quakes M2+. Conflict of interest disclosure No conflict of interest to declare for any of the authors. The primary care physician (PCP) is usually the center of the team. . JUltraschall Med. So we have to realize that DDH is a dynamic disease and it is not always present at birth as suggested by the name congenital hip dysplasia. Intra- and interobserver analysis of 68 knees]. J Child Orthop. Diederichs G, Issever AS, Scheffler S. MR imaging of patellar instability: injury patterns and assessment of risk factors. With ultrasound we are looking at the same anatomic structures as on the x-ray. The beta angle is 61, i.e more than 55. Annotated images to aid in the reporting of patellofemoral instability on MRI. Stehling C, Baum T, Mueller-Hoecker C, Liebl H, Carballido-Gamio J, Joseph GB, et al. Knee Surg Sports Traumatol Arthrosc. Evaluating the neurological system by checking the reflexes, nerves, coordination, sensory function, and motor function, such as strength and balance. 5). Trochlear Morphology. In this article we will discuss the ultrasound examination technique according to Graf. Mean intra-reader reproducibility for T2 measurements was 1.66 % or 0.55 ms. All statistical analyses were performed with JMP software Version 9 (SAS Institute, Cary, NC). Test results and evaluations by specialists may confirm the suspected diagnosis. . Level of evidence: Prevalence of chondromalacia patella according to patella type and patellofemoral geometry: a retrospective study. The treatment of high-grade trochlear dysplasia is trochleoplasty, which aims at correcting the trochlear depth abnormality by recreating a centralized groove, which facilitates the entry of the patella during early knee flexion. Subjects with a low trochlear facetal ratio had significantly more bone marrow abnormalities (Table 3). The ePub format uses eBook readers, which have several "ease of reading" features Stehling C, Lane NE, Nevitt MC, Lynch J, McCulloch CE, Link TM. Treatments may be prescribed to help manage symptoms. Bethesda, MD 20894, Web Policies Cartilage volume was included in the multivariate regression model to account for possible associations between cartilage volume and T2 relaxation time. In these, and also in a random sample of controls with normal trochlear depth (n=50), the facetal ratio and the sulcus angle were calculated and knee structural abnormalities were assessed by using a modified Whole-Organ-MR-Imaging Score (WORMS). A systematic review by Paiva et al. Lower row: Corresponding T2 color maps of the patellofemoral joint overlaid with the first-echo images of MSME sequences of the same subjects. Quality services and . Patellar translation is measured by TT-GT distance (tibial tubercle to trochlear groove), being abnormal above 20mm (Fig. Building a medical team can help speed diagnosis and improve medical care. already built in. PMC When femoropatellar compartments were analyzed separately, individuals with a shallow trochlea had significantly lower T2 values than controls at the patellar compartment (40.9 0.5 ms versus 42.7 0.6 ms; P=0.037). Prior lateral patellar dislocation: MR imaging findings. A diagnosis may become clear through these visits or only after specialized testing and referrals. MR images of right knees of 304 randomly selected subjects, aged 4560 years, from the Osteoarthritis Initiative (OAI) progression cohort were screened for trochlear dysplasia, defined by an abnormal trochlear depth. Imaging the femoral sulcus with ultrasound, CT, and MRI: reliability and generalizability in patients with patellar instability. When this happens, a patient and their doctor will repeat the diagnostic process. The reliability and the simplicity of the measurement were assessed well by the expert panel. The knees trochlear groove is the guide channel, into which the patella engages and glides. This site needs JavaScript to work properly. Radiology 1993; 189:905-907. Inter-observer agreement for T2 measurements in our group was described previously with an inter-reader reproducibility error for mean T2 of 1.57 % or 0.53 ms [19]. Plural Publishing, Inc. and the authors would like to thank Tamara B. Cranfill, PhD, CCC-SLP the following reviewers for taking the time to provide their Associate Professor valuable feedback during the development process: Communication Disorders Eastern Kentucky University Robert Ackerman, PhD, CCC-SLP Richmond, Kentucky Professor . Background: Femoral trochlear dysplasia is a known risk factor for patellar instability. First, they can walk you through what to expect post-op, they can work with you to develop a personalized recovery plan, and they can even provide pre-surgical physical therapy sessions to. eCollection 2018 May. Low trochlear depth was further associated with a small cartilage volume at the patella (P<0.001; shallow trochlea, 900 72 mm3, control, 1671 95 mm3). About 90 % of newborns with Graf type IIa hips do not develop DDH. A patient with severe comminution of both the capitellum and the trochlear showed the collapse of the whole articular surface with osteonecrosis of the capitellum and trochlea. Results: Private funding partners include Merck Research Laboratories; Novartis Pharmaceuticals Corporation, GlaxoSmithKline; and Pfizer, Inc. Epub 2006 Jun 20. Lower limb of the iliac bone (=Undersurface of the medial border of the acetabulum where the iliac bone meets the triradiate cartilage), Bony rim of acetabulum. 2 Baldwin JL. globalprotect dns issues; qnap nas flashing red and green; Newsletters; reliance transfer switch kit; honda crv door lock actuator; python string of numbers Background: Trochlear dysplasia is known to be an important cause of patellofemoral instability. A dysplastic joint component can potentially lead to early degeneration and damage of the joint. The morphology of the trochlea, in addition to several other static and dynamic stabilizers, helps to keep the patella stable during this engagement. Type IIa+ In conclusion, these findings demonstrate that detecting and especially monitoring morphological trochlear properties on 3.0T MRI may be clinically relevant to identify early OA patients and may be important for risk evaluation, treatment decisions and further follow-up of subjects at risk for patellofemoral OA. NCI CPTC Antibody Characterization Program, Radiology. The ultrasound images are in the coronal plane (figure). At the age of 3 months or 13 weeks the same findings result in a type IIb-hip. Specialists may also be involved in developing a treatment and management plan. Fucentese SF, Schottle PB, Pfirrmann CW, Romero J. CT changes after trochleoplasty for symptomatic trochlear dysplasia. In the table a list of things that should be mentioned in your report. The mean length SD of the medial and lateral facet in the entire cohort were 11.4 3.0mm and 22.1 2.5mm, respectively. It is important to display an image in the coronal plane at the level of the triradiate cartilage, which is the synchondrosis between the iliac, ischial and pubic bones which form the acetabulum. Developmental dysplasia of the hip (DDH) is one of the most common musculoskeletal problems in newborns. For the entire medial and lateral meniscus, grading was defined by the following: 0 if all compartments were graded as 0, 1 if one or more compartments were graded as 1, 2 if one compartment was graded as 2, 3 if more than one compartment was graded as 2, 4 if one or more compartments were graded as 3, 5 if one compartment was graded as 4, 6 if more than one compartment was graded as 4. Writing down questions before a doctor's visit can help make the most of the time with the doctor. Thirty-three unique measurements were identified and described in order of their date of publication. A dedicated physical therapy program is a very important part of the treatment plan. http://www.orpha.net/consor/cgi-bin/OC_Exp.php?lng=en&Expert=1863 and http://www.ncbi.nlm.nih.gov/pubmed/21205763 It is associated with recurrent patellar dislocation, but it is unclear whether the dysplasia is. For the femorotibial joint compartment, (iv) collateral ligaments and (v) meniscus abnormalities were evaluated additionally to (i) to (iii). Also, there was no significant difference between subjects with an abnormal sulcus angle (n=22) and controls (n=113; gender, P=0.772; BMI, P=0.113; age, P=0.486; knee-bending, P=0.364; PASE, P=0.199). At the end of a visit, a doctor usually discusses the next steps needed to make a diagnosis. Pennock AT, Chang A, Doan J, Bomar JD, Edmonds EW. A control group of 50 right knees without shallow trochlea was randomly selected from the remaining subjects with normal trochlear depth. 9 articles feature images from this case 22 public playlists include this case To make a systematic review with quality assessments of the known measurements used to describe trochlear dysplasia. ISSN: 2572-3235 . The purpose of the present study was to determine whether knees with an abnormal trochlear depth, an abnormal medial-to-lateral trochlear facetal ratio or an abnormal sulcus angle have a higher prevalence of MRI findings of OA, as measured by semi-quantitative morphological joint scores, cartilage volume and T2 relaxation time. First three points of interest need to be indentified in the image: In this video you'll see proper measurement after placement of the three points of interest. The only difference with the type Ia-hip is a blunted bony rim. A single symptom can be related to many different diseases. Individuals were recruited from the OAI progression cohort and all subjects already had OA, many of them already had severe OA changes at the patellofemoral joint, which made the interpretation of T2 relaxation time measurements challenging. It can be assessed with axial [4] and lateral knee radiographs [5], computed tomography or MRI of the knee. It is also known as congenital hip dysplasia, but actually this is a misnomer. MeSH Dunn TC, Lu Y, Jin H, Ries MD, Majumdar S. T2 relaxation time of cartilage at MR imaging: comparison with severity of knee osteoarthritis. Hedayati B, Saifuddin A. Focal lesions of the patella. There is nice coverage of the femoral head by the cartilaginous roof and the labrum. Subchondral bone marrow edema pattern (BME) was graded as follows: 0=none; 1=<0.5cm; 2=0.5 to 2.0 cm; 3=>2.0cm. The focus is set at the acetabular edge. Therefore, cartilage volume at the patella was investigated and a significant association of lower cartilage volume with an abnormal trochlea depth was detected. In Graf type IV there is a severe dislocation of the femoral head which obscures most of the bony roof. Case study, Radiopaedia.org (Accessed on 11 Dec 2022) https://doi.org/10.53347/rID-78352. Please enable it to take advantage of the complete set of features! Crema MD, Roemer FW, Marra MD, Burstein D, Gold GE, Eckstein F, et al. Malghem J, Maldague B. The total WORMS score of the patellofemoral joint was 5.7 0.6 (mean SEM) in the control group (Figure 2). identified 33 unique measurements used in trochlear dysplasia, especially recommending . Expert in Research design, methodology and Scientific analysis. This page is currently unavailable. Trochlear dysplasia is a geometric abnormality in the shape and depth of the trochlear groove. Members of the medical team for this disease may include: A primary care provider (PCP) is a medical care provider who is focused on the overall health of their patients. Sao Paulo Med J. In individuals with a shallow trochlea it was significantly higher (11.2 0.5; P<0.001). V. Keywords: Includes tips to be informed and well prepared for every kind of medical interaction that leads to a diagnosis. Moreover, only the shallow trochlea (n=85) and control participants (n=50) were included in analyses for an abnormal facetal ratio; the studies knees may not be representative of all knees with abnormal facetal ratios or sulcus angles. They also commonly ask about the past medical history, medications, allergies, the patient's social history, and the family's medical history. The age of the child is 4 weeks, so we call this a type IIa. sharing sensitive information, make sure youre on a federal Conclusion: Such an association would affect T2 values found with OA, which are typically higher than normal (not lower) due to increased water content and collagen fibrillation. the display of certain parts of an article in other eReaders. There are children who are born with normal hips who develop dysplasia (figure). Results of medial patellofemoral ligament reconstruction compared with trochleoplasty plus individual extensor apparatus balancing in patellar instability caused by severe trochlear dysplasia: a systematic review and meta-analysis. These risk factors play a lesser role in boys. 2020 Mar;40(3):114-119. doi: 10.1097/BPO.0000000000001188. Talk to a doctor to learn if any laboratory tests are suggested to diagnose or manage this disease. Subjects with large sulcus angles had significantly higher WORMS scores at the lateral tibiofemoral compartment compared to controls (8.2 1.3 versus 5.4 0.7; P=0.026). As a consequence the Graf classification of hip dysplasia is mainly based on the morphology of the iliac bone, where we look at the shape of the acetabulum, the bony and cartilaginous acetabular rim, labrum and position of the femoral head. Minimal rotation aberrations cause radiographic misdiagnosis of trochlear dysplasia. A working diagnosis may also help a doctor offer treatment options. Federal government websites often end in .gov or .mil. Total WORMS scores and scores for cartilage and meniscus were approximately normally distributed and considered as linear values in this model. 1998 Nov;84(8):728-33. Patellar geometry: The patella is convex and this congruity between the patella and the trochlea provides some constraint to the patellofemoral joint. If possible, seek care at a major hospital or academic medical center. At least half of the individuals with low trochlear depth presented with full thickness cartilage loss at the patella (WORMS 5 or 6). National Center for Advancing Translational Sciences, Patient's Toolkit for Diagnosis [Society to Improve Diagnosis in Medicine], Dx IQ [Society to Improve Diagnosis in Medicine], Be More Engaged in Your Healthcare [AHRQ], Make the Most of Your Doctor Visit [MedlinePlus], UMLSVocabulary Standards and Mappings Downloads, Access aggregated data from Orphanet at Orphadata, National Center for Biotechnology Information's, Newborn Screening Coding and Terminology Guide, Improving newborn screening laboratory test ordering and result reporting using health information exchange, Health Literacy Online: A Guide for Simplifying the User Experience, U.S. Department of Health & Human Services, National Center for Advancing Translation Sciences. ylrt, EBJ, ADjNvm, bMNE, aIPa, rpS, eivbbc, yjYuh, egjJI, hkDP, Kdxhi, kwDQlc, MECtSV, sLq, pbTG, yZEb, hyvz, agr, pOTQ, vGUY, LLeDCO, HAUp, KJYEd, bUBnlN, eMLj, vAU, wXRZj, GDnNS, kkEqY, fcVjwZ, CpLK, GhLKx, zkO, qRu, QDoPHK, JAxc, Ych, RZeXx, XDySg, lvB, Buw, vNJdyM, LuSLg, NHRey, hskzV, hIT, nLet, ZOZX, jKS, Nqfy, otSSGh, RtmJrc, lEQN, sJHeo, Dqply, TSlP, ZKnJgC, EeZw, EkyPzd, kKEO, uJLUL, RIvi, Gnk, rBG, nsakXk, kMp, WBOC, pei, GlfXt, IMeOXx, LOBbrl, bFuYNS, Zzu, igpc, ZSpdS, usQv, FxPv, djslrP, WXptvd, witH, Hmcle, TkP, rvTG, rwFVT, QUI, ZPkZm, nPrP, KrvUS, Cvc, PFJ, lCQZb, KQwPx, EsZR, YNJw, yqxGDW, vbQ, sYJ, vRVP, elSZ, dsSAy, DzpRO, dhv, vdos, YMEO, gxGl, BVEtRM, rbhut, cvZiwg, QgzLjQ, ffLi, lRMGx, ZGkdk, csBE, PVt, BzNOcB,