Textbook Joint Preservation in The Adult Knee 1St Edition E Carlos Rodriguez Merchan Ebook All Chapter PDF

Joint Preservation in the Adult Knee 1st
Edition E. Carlos Rodríguez-Merchán

Visit to download the full and correct content document:
https://textbookfull.com/product/joint-preservation-in-the-adult-knee-1st-edition-e-carlo
s-rodriguez-merchan/
More products digital (pdf, epub, mobi) instant
download maybe you interests ...
Hip Joint Restoration Worldwide Advances in Arthroscopy

Arthroplasty Osteotomy and Joint Preservation Surgery
1st Edition Joseph C. Mccarthy
https://textbookfull.com/product/hip-joint-restoration-worldwide-
advances-in-arthroscopy-arthroplasty-osteotomy-and-joint-
preservation-surgery-1st-edition-joseph-c-mccarthy/
Regenerative Strategies for the Treatment of Knee Joint

Disabilities 1st Edition Joaquim Miguel Oliveira
https://textbookfull.com/product/regenerative-strategies-for-the-
treatment-of-knee-joint-disabilities-1st-edition-joaquim-miguel-
oliveira/
Foundations and Adult Health Nursing E-Book Eighth

Edition / Cooper
https://textbookfull.com/product/foundations-and-adult-health-
nursing-e-book-eighth-edition-cooper/
Preservation 1st Edition Christina Ward
https://textbookfull.com/product/preservation-1st-edition-
christina-ward/
Moss Adams Heart Disease in infants Children and
Adolescents Including the Fetus and Young Adult Robert
E. Shaddy
https://textbookfull.com/product/moss-adams-heart-disease-in-
infants-children-and-adolescents-including-the-fetus-and-young-
adult-robert-e-shaddy/
The hip joint 1st Edition Iyer
https://textbookfull.com/product/the-hip-joint-1st-edition-iyer/
Cardiac Surgery in the Adult 5th Edition Lawrence H.

Cohn
https://textbookfull.com/product/cardiac-surgery-in-the-
adult-5th-edition-lawrence-h-cohn/
The Complete Guide to Male Fertility Preservation 1st

Edition Ahmad Majzoub
https://textbookfull.com/product/the-complete-guide-to-male-
fertility-preservation-1st-edition-ahmad-majzoub/
The Knee Injury Bible Everything You Need to Know about

Knee Injuries How to Treat Them and How They Affect
Your Life 1st Edition Robert F. Laprade
https://textbookfull.com/product/the-knee-injury-bible-
everything-you-need-to-know-about-knee-injuries-how-to-treat-
them-and-how-they-affect-your-life-1st-edition-robert-f-laprade/
E. Carlos Rodríguez-Merchán
Alexander D. Liddle
Editors
Joint Preservation
in the Adult Knee
123
Joint Preservation in the Adult Knee
Alexander D. Liddle
Editors
Joint Preservation in the

Adult Knee
Editors
E. Carlos Rodríguez-Merchán Alexander D. Liddle
Department of Orthopaedic Surgery University College London
La Paz University Hospital-IdiPaz Institute of Orthopaedics and
Madrid Musculoskeletal Science
Spain London
United Kingdom
ISBN 978-3-319-41807-0 ISBN 978-3-319-41808-7 (eBook)

DOI 10.1007/978-3-319-41808-7
Library of Congress Control Number: 2016956096
© Springer International Publishing Switzerland 2017

This work is subject to copyright. All rights are reserved by the Publisher, whether the whole or
part of the material is concerned, specifically the rights of translation, reprinting, reuse of
illustrations, recitation, broadcasting, reproduction on microfilms or in any other physical way,
and transmission or information storage and retrieval, electronic adaptation, computer software,
or by similar or dissimilar methodology now known or hereafter developed.
The use of general descriptive names, registered names, trademarks, service marks, etc. in this
publication does not imply, even in the absence of a specific statement, that such names are
exempt from the relevant protective laws and regulations and therefore free for general use.
The publisher, the authors and the editors are safe to assume that the advice and information in
this book are believed to be true and accurate at the date of publication. Neither the publisher nor
the authors or the editors give a warranty, express or implied, with respect to the material
contained herein or for any errors or omissions that may have been made.
Printed on acid-free paper
This Springer imprint is published by Springer Nature

The registered company is Springer International Publishing AG
The registered company address is Gewerbestrasse 11, 6330 Cham, Switzerland
Preface
The orthopaedic surgeon of today has access to an unprecedented selection of

interventions to reconstruct knees damaged through trauma, infection,
tumours or arthritis. Reconstructive treatments which were considered exper-
imental within recent memory have now become commonplace; likewise,
patients who may in the relatively recent past have had no alternative to
arthroplasty now have access to treatments which allow the preservation of
their native joint. Rapid progress has been made in terms of the development
of new techniques, instruments and implants, through collaboration between
orthopaedic surgeons, scientists and industry.
The rapid pace of innovation within orthopaedic surgery has been
accompanied by a marked improvement in the quality of evidence avail-
able for the interventions that we use. Those wishing to introduce new
interventions now have to demonstrate a sound evidence-base in terms of
preclinical testing and post-market surveillance. Interventions that have
been introduced are scrutinised to a much greater extent as evidenced by
the rise in the standard of scientific methodology displayed within the
major orthopaedic journals. Increasingly, interventions in widespread use
are having their indications refined on the basis of high-quality ran-
domised trials. The use of ‘big data’ within orthopaedics, with increased
use and more sophisticated interpretation of institutional and national
databases, has provided an additional source of information as to how our
interventions are working in the real world.
These developments, both in terms of the introduction of new interven-
tions and the growth of evidence-based practice within orthopaedics, repre-
sent a challenge to orthopaedic surgeons. Whilst we aim to provide our
patients with the best and newest treatments, we are unable to change our
practice without robust evidence that the new treatment is better than those
already in use. Likewise, surgeons may be faced with evidence that what they
currently consider to be best practice is in fact inferior to other surgical or
non-surgical treatments.
The aim of this book is to help surgeons to negotiate this challenge. We
have assembled a group of authors who between them have huge experience
and knowledge on the practice and science of joint-preserving knee surgery.
v
vi Preface
Between them, they provide an overview of the state of the art of joint-
preserving surgery of the knee, using the latest evidence together with insights
from their practice. We hope that it will be of use to surgeons looking to
develop and refine their practice to provide the best care for their patients.
E. Carlos Rodríguez-Merchán Madrid, Spain

Alexander D. Liddle London, UK
Contents
1 Examination of the Knee . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

Quen O. Tang and Chinmay M. Gupte
2 Imaging Assessment of the Knee . . . . . . . . . . . . . . . . . . . . . . . . . . 13
Antony J.R. Palmer, Sion Glyn-Jones, and Dimitri Amiras
3 Intra-articular Corticosteroids and Hyaluronic
Acid in the Knee Joint . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
Carlos Kalbakdij-Sánchez and Enrique Gómez-Barrena
4 Injection Therapy: Intra-articular Platelet-Rich
Plasma and Stem Cell Therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . 29
Yusuf H. Mirza and Sam Oussedik
5 The Patellofemoral Joint . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43
Farhad Iranpour, Arash Aframian, and Justin P. Cobb
6 Tendon Injuries of the Knee . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55
Alexander D. Liddle and E. Carlos Rodríguez-Merchán
7 The Meniscus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65
Luke D. Jones and Sean O’Leary
8 The Anterior Cruciate Ligament . . . . . . . . . . . . . . . . . . . . . . . . . . 75
Alexander D. Liddle and E. Carlos Rodríguez-Merchán
9 Posterior Cruciate Ligament, Posterolateral
Corner and Multiligament Knee Injuries . . . . . . . . . . . . . . . . . . . 91
Jonathan J. Negus and Fares S. Haddad
10 Synovitis: Hemophilia and Pigmented
Villonodular Synovitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 113
11 Cartilage Injuries of the Knee . . . . . . . . . . . . . . . . . . . . . . . . . . . 127
Alfonso Vaquero-Picado and E. Carlos Rodríguez-Merchán
12 Septic Arthritis of the Knee . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 143
Simon D.S. Newman and Charles E.R. Gibbons
vii
viii Contents
13 Bone Tumors Around the Knee . . . . . . . . . . . . . . . . . . . . . . . . . . 153

Manuel Peleteiro-Pensado, Irene Barrientos-Ruiz, and
Eduardo J. Ortiz-Cruz
14 Osteotomies About the Knee . . . . . . . . . . . . . . . . . . . . . . . . . . . . 175
Jonathan Palmer and Andrew J. Price
Examination of the Knee
1
Quen O. Tang and Chinmay M. Gupte
Abstract
The art of clinical examination is often forgotten with the advent of
increasingly precise imaging modalities but in fact remains the most pow-
erful tool in the surgeon’s armamentarium and is at the heart of the patient–
clinician relationship. A clear examination sequence forms a fundamental
tool for the diagnosis and correct treatment of knee pathology. Whilst this
is important, the advanced examiner together with the history will tailor a
specific exam series depending on the suspected pathology. In general,
there are three broad series: one for patellofemoral/extensor mechanism
pathologies; one for meniscal and chondral (articular) lesions; and one for
instability. This chapter will provide an overview of advanced physical
examination of the knee and outlines the most commonly used tests.
Images and detailed descriptions will provide the reader with a thorough
understanding of hand positions and identifying a positive sign.
Keywords
Knee • Clinical examination • Static assessment • Dynamic assessment
Assessment of gait
1.1 Introduction
Electronic supplementary material The online version The knee is amongst the most commonly injured
of this chapter (doi:10.1007/978-3-319-41808-7_1) con- large joint in the body [1], primarily because the
tains supplementary material, which is available to autho-
rized users. tibiofemoral and patellofemoral articulations are
inherently unstable and also due to the large loads
Q.O. Tang • C.M. Gupte (*) that are transmitted through the joint when bear-
The Musculoskeletal Surgery Group, Department of ing weight.
Surgery and Cancer, Imperial College London,
The art of examining the knee should there-
London, UK
e-mail: quentang@gmail.com; c.gupte00@imperial. fore involve consideration of the interplay
ac.uk between stabilising factors of the knee (muscles
© Springer International Publishing Switzerland 2017 1

E.C. Rodríguez-Merchán, A.D. Liddle (eds.), Joint Preservation in the Adult Knee,
DOI 10.1007/978-3-319-41808-7_1
2 Q.O. Tang and C.M. Gupte
and ligaments) and the overall biomechanics of performed in the case of patellofemoral instabil-
the lower limbs. ity using the “Staheli profile” technique with the
Whilst the examiner should have a logical and patient seated [3].
repeatable sequence of examination for each
knee, the advanced examiner will develop the
ability to adapt this protocol and add further tests Sagittal plane (Fig. 1.2) The patient is examined
to the specific knee condition suspected. For from the side assessing for flexed posture, and
example, the tests employed to assess for patel- anterior tibial or femoral bowing.
lofemoral instability in a young patient (tracking,
apprehension, Q angle) may differ from the 1.2.1.2 Assessment of Gait
assessment of an elderly patient with medial Full gait assessment is beyond the scope of this
osteoarthritis. chapter. However, specifically with regards to
The general sequence of examination should orthopaedic knee examination, gait should again
be as follows: be assessed in coronal (frontal) and sagittal
planes:
(a) Look
(b) Feel (with knee in extension and 90° Coronal
flexion) Assess varus thrust for lateral collateral and pos-
(c) Move terolateral corner injury. Valgus thrust indicates
(d) Special tests medial collateral injury.
This chapter is arranged according to the

above sequence.
1.2 Look
1.2.1 Alignment
Alignment should be assessed in the static

(patient standing) and dynamic (patient walking)
modes and in all three planes (coronal, sagittal
and axial).
1.2.1.1 Patient Standing

Coronal plane (Fig. 1.1) Examination with the
patient facing the examiner: assessing for varus
or valgus posture and the presence of tibial bow-
ing. Further coronal assessment can be performed
from behind, whilst assessing for popliteal
masses or scars. Varus and valgus deformities are
often more obvious from behind.
Axial plane This can also be assessed with the

patient facing the examiner. Specific findings
include a “squinting” (inward-tilting) patella [2],
femoral anteversion or retroversion. Further Fig. 1.1 Assessing coronal plane. Note the physiological
assessment of axial (rotational) alignment can be valgus attitude of the lower limb
1 Examination of the Knee 3
Sagittal (a) The extensor mechanism.

From the side, assess for flexed knee gait (sug- (b) Patellar tracking (Video 1.1): The arc of
gesting fixed flexion of the knee or hamstring interest is mainly between 70° of flexion and
tightness) or back knee gait (suggesting hyperex- full extension.
tension of the knee).
Pathology most commonly detected includes:
1.2.2 Examination of Knee • “Inverse J sign” – lateral subluxation of the

with Patient Sitting on Couch, patella between 30° of flexion and full
Legs Suspended from Side extension.
of Couch (Fig. 1.3) • Frank lateral dislocation of the patella. This
most commonly occurs in chronic recurrent
It is the senior author’s practice to examine patel- patellar dislocation in near extension.
lofemoral tracking before laying the patient However, it can occur with the knee flexed.
supine to order to avoid “forgetting” the patello-
femoral joint.
The patient is asked to sit on the side of the 1.2.3 Examination Supine (Fig. 1.4)
couch with legs hanging down but not touching
the floor. The examiner then faces the patient and The patient is laid on the couch. Convention dic-
asks the patient to slowly flex and extend each tates that the patient should be fully supine in
knee in turn. This allows assessment of: order to examine the hip joint first. However,
a b
Fig. 1.2 (a) Assessing left lateral sagittal plane. (b) Assessing right lateral sagittal plane
Fig. 1.3 Examination of knee with patient sitting on Fig. 1.4 Assessing whilst supine on a couch. Note the
couch, legs suspended from side of couch valgus attitude is more obvious whilst supine
examination of the knee is more comfortable 1.3 Feel

with the patient in the semi-supine position
(approximately 45° flexed at waist). The key to 1.3.1 Warmth
supine examination is to ensure patient relax-
ation, by avoiding causing unexpected pain. The Warmth is best palpated with the back of the
best way to assess for pain is to consistently look examiner’s hand. If there is warmth, is there a
at the patient’s eyes. focus e.g. prepatellar bursa, tibial or femoral
Alignment should be checked again from the component of a total knee replacement?
end of the bed.
1.3.1.1 Effusion
Muscle wasting The quadriceps group, in particu- There are three grades of effusion:
lar vastus medialis obliqus (VMO). VMO wasting
is often best detected by palpation of the muscle • Grade 1: Small effusion: Best assessed by the
belly whilst asking the patient to contract the “sweep” test. Fluid is gently moved from the
quads group. “Push your knee down into the bed”. lateral gutter by “sweeping” the hand over the
Objectively, the quads can be assessed by measur- gutter, into the medial gutter. The medial gut-
ing circumference of the thigh from a fixed bony ter is then pressed and the fluid is displaced
point (e.g. 10 cm proximal to the tibial tubercle). back into the lateral gutter in a positive test.
• Grade 2: Patellar tap: A moderate sized effu- there is a weakness of the quadriceps, known as
sion will lead to the patella floating up towards extensor lag (Video 1.2). If the knee stays flexed,
the skin. The patella can then be “tapped” then there is fixed flexion.
against the femoral trochlea. Once this is performed, the patient is asked
• Grade 3: Cross fluctuance: A very large effu- to flex the knee – “pull your heel towards your
sion will lead to a fluid thrill demonstrated by buttock”. Active flexion is assessed first. If
cross fluctuance of the fluid when pressed. there is full active flexion, then no passive
assessment is required. If there is any deficit,
1.3.1.2 Joint Palpation the heel can be gently held and the knee flexed
The joint line is best palpated with the knee further always watching the patient’s face for
flexed to 80°. The examiner should visualise pain.
the anatomy being palpated through the skin It is important to note that full extension is
and sequence of palpation should be termed as “zero degrees flexion”, a right angle is
consistent: “90° flexion” and full flexion will depend on the
body habitus of the patient and can vary from
1. Medial joint line: medial meniscus, medial 120° in a patient with large thighs to 160° in a
femoral condyle, and tibial and femoral very thin patient. Another way to quantifying
insertions of the medial collateral ligament flexion deficit between knees is to determine the
(MCL). If a thickened medial plica is sus- “heel to buttock” distance.
pected, this can be palpated over the medial It is best to assess flexion of both knees one
femoral condyle with the knee at 30°. More after the other.
distally, the pes anserinus bursa should be
palpated for tenderness typical of pes
bursitis. 1.5 Special Tests
2. Lateral joint line: lateral meniscus, lateral
femoral condyle, and lateral collateral liga- These can be divided into:
ment. The fibula can also be palpated for ten-
derness and the superior tibiofibular joint can (a) Cruciate ligaments
be balloted if instability is suspected. (b) Collateral ligaments
3. Popliteal fossa for popliteal cyst, and to (c) Meniscal tests
exclude popliteal aneurysm. (d) Patellofemoral tests
As previously mentioned, not all tests have to

1.4 Move be performed in every knee and the examination
should be tailored to the pathology suspected.
With the knee extended, the patient is asked to Grades of laxity vary between authors and tes-
dorsiflex the ankle and lift the leg up straight. If ters [4]. It is best to state the estimated:
there is any flexion when this is done, there are
two possibilities: (a) Distance (mm) of translation of the joint
(b) The degree of difference between sides
(a) Fixed flexion deficit due to joint contracture (c) The “end point”. The firmness of resistance
(b) Quadriceps weakness/extensor lag towards the extreme of the test. A less firm
“end point” indicates a more severe injury
In order to distinguish between the two, the and damage to secondary restraints.
patient is asked to rest the leg relaxed into the
examiner’s hand. If full extension occurs, then If grades are used, the general convention is:
• Grade 1: 0–5 mm side to side difference with the knee in the same position as for a Lachman’s.
good end point Often the subtlest sign of laxity is a soft end point.
• Grade 2: 5–10 mm difference with soft end More obvious laxity is demonstrated by more than
point 2 mm side to side difference.
• Grade 3: gross laxity beyond 10 mm
difference 1.5.1.2 Tests with Knee at 80°
of Flexion
It is important to note that the knee should be
1.5.1 Cruciate Ligaments between 80° and 90° of flexion for the following
tests as higher angles of flexion can lead to false
1.5.1.1 Tests with Knee at 30° Relaxed negative results.
Over the Examiner’s Thigh Posterior sag and medial step off (for poste-
Lachman´s test (for anterior cruciate ligament rior cruciate ligament (PCL) injury):
(ACL) injury) Best performed with the knee
relaxed over the examiner’s contralateral thigh, Posterior sag The knees are flexed together to
with the point of contact between the two 80°. The examiner inspects from the side so that
approximately 5 cm proximal to the popliteal a tangential view of the tibiofemoral joint is
fossa. The thigh is stabilised anteriorly with the obtained in the sagittal plane. A posterior sag is
examiner’s contralateral hand and the tibia is observed if there is “dip” in the tibiofemoral
gently translated anteriorly with the ipsilateral articulation. This is often confirmed using a pen
hand placed cupping the tibial tubercle (Fig. 1.5 with a straight edge on the area.
and Video 1.3).
Posterior Lachman’s (for posterolateral capsular Medial step off In a PCL injured knee, there is
injury) This is a subtle sign that indicates poste- loss of the normal medial step off. Normally the
rior capsule laxity in the case of posterolateral cor- anterior aspect of the medial tibial condyle pro-
ner injury. The tibia is translated posteriorly with trudes 3–5 mm anterior to the medial femoral
Fig. 1.5 Position of hands whilst performing Lachman’s test

condyle. PCL injury results in loss of this protru- drawer” when the tibia is brought back into its
sion, whereby the tibia sags posteriorly: grade 1 normal position.
is fewer steps off than the normal side, grade 2 is
tibia level with the femoral condyle and grade 3 1.5.1.3 Other Tests
is tibia posterior to the femoral condyle. Pivot shift test (for ACL injury) This test should
only be performed if ACL insufficiency is sus-
Anterior drawer (for ACL deficiency), poste- pected and only in the most comfortable of
rior drawer (for PCL deficiency) and dial test patients. If the patient is in significant discom-
(for PLC insufficiency): fort, the pivot shift test should be reserved for
examination under anaesthetic.
Anterior drawer It is essential to ensure relaxation
of the hamstring tendons with the examiner’s mid- In the comfortable, relaxed patient, the pivot
dle fingers whilst performing this test. Otherwise, a shift test should be performed as follows:
false negative result is obtained. The examiner
places their hands with the thumbs just below the (a) Knee fully extended.
joint line and middle finger behind the knee palpat- (b) Ipsilateral hand cupping the sole of the foot
ing the relaxed hamstring tendons on either side. rotating the tibia into internal rotation.
The tibia is then brought forward. Again, it is best (c) Contralateral hand holding lower leg at neck
to assess for the number of millimetres of side-to- of fibula, again rotating the tibia into internal
side difference and end point rather than grades of rotation. This will sublux the lateral tibia
laxity (Fig. 1.6 and Video 1.4). anteriorly, with the iliotibial band acting as
an extensor of the knee. The medial tibia will
Posterior drawer The posterior drawer can be remain in position.
assessed in the same manoeuvre as the anterior (d) Flexing the knee from full extension into 30°
drawer but by pushing the tibia posteriorly. It is flexion. Will convert the iliotibial band (ITB)
important to assess for posterior cruciate defi- into a flexor of the knee and the lateral tibial
ciency as well as anterior cruciate as a posteriorly condyle will reduce back into the joint from
sagged tibia will lead to a “pseudo anterior its anteriorly subluxed position.
Fig. 1.6 Position of the hands whilst performing anterior drawer test. Note the examiners thumbs are just below the
joint line
Quadriceps active test (for PCL injury) The examiner on one side with an assistant on the
patient is asked to rest the knee on the couch with other side. This has since been adapted so that the
the knee in 80° flexion. The tibia will sag posteri- examiner can assess both sides together by plac-
orly in the PCL deficient knee. The examiner then ing the patient prone. The patient is asked to
holds the foot on the couch and the patient is inform the examiner of pain as they are prone as
asked to kick the foot away (eliciting quadriceps the face cannot be inspected.
contraction) against the examiner’s resistance.
The resulting quads contraction will lead the pos- The test is performed ensuring:
teriorly subluxed tibia back into joint.
(a) The knees are together and in neutral
rotation.
Test for anterolateral and anteromedial instabil- (b) The ankles are fully dorsiflexed.
ity These tests, which are modifications of the (c) The examiner is directly looking over both feet.
anterior drawer test, are for the advanced exam-
iner. For anteromedial instability (ACL and/or The dial test is performed initially with the
MCL) the tibia is rotated internally and then an knee at 30°. A 10° to 15° difference in external
anterior drawer is applied. The medial tibial pla- rotation indicates damage to the posterolateral
teau will sublux more anteriorly than the lateral corner. Excess rotation is caused by posterior
in a positive test. For anterolateral instability, the translation of the lateral tibial due to lack of pos-
opposite applies (Fig. 1.7 and Video 1.5). terolateral restraint.
If the test is positive when also performed at
Dial test The dial test was originally described 90°, this indicates a combined PCL and postero-
with the patient in a supine position and the lateral corner injury.
a b
Fig. 1.7 (a) Internal rotation of tibia allows assessment of anteromedial instability. (b) External rotation of tibia allows
assessment of anterolateral instability
NB. False positive dial test The difference between full extension and 20°
The dial test can be positive if the posterome- is that in full extension the posterior capsular
dial corner is injured. In this case it is the medial structures act as secondary restraints to the col-
tibia translating anteriorly and the lateral tibia lateral ligaments, whereas in 20° only the collat-
staying in position. This also causes the excess eral ligaments resist the stress. Thus, a knee that
external rotation. is lax in full extension and 20° flexion may indi-
cate more damage to the posterior capsular struc-
tures than a knee that is only lax at 20° flexion.
1.5.2 Collateral Ligaments
The most reliable method of achieving muscle 1.5.3 Meniscal Tests

relaxation is to cradle the leg with the examiner’s
arms just beneath the examiner’s axilla. It is help- Thessaly test [5] A weight bearing meniscal
ful to place the examiner’s four fingers on the test performed by the examiner supporting the
medial and lateral joint lines in order to assess the patient and asking the patient to swivel to the left
degree of joint opening. and right side whilst rising from crouching posi-
tion (Fig. 1.8 and Video 1.6).
MCL (medial collateral ligament) – Valgus stress
applied in full extension and 20° flexion. McMurray’s test This should be performed
LCL (lateral collateral ligament) – Varus stress only in the most comfortable of patients, and is of
applied in full extension and 20° flexion. limited sensitivity and specificity [6]. This is best
a b
Fig. 1.8 (a) Swivelling to the left during Thessaly test. (b) Swivelling to the right during Thessaly test
performed with the thumb on the joint line and supposed to represent the resultant lateral
the tibia externally rotated (posterior horn medial pull of the patella tendon and the quadriceps
meniscus) and then internally rotated (posterior tendon on the patella. A normal value is
horn lateral meniscus). 12–15°, with the angle slightly greater in
women than men.
Increase in Q angle is associated with:
1.5.4 Patellofemoral Tests • Femoral anteversion
• External tibial torsion
Patellofemoral joint (PFJ) tracking and assess- • Laterally displaced tibial tubercle
ment of lateral tilt and tightness is mentioned • Genu valgum: increases the obliquity of
above. the femur and concomitantly, the obliquity
Other tests include: of the pull of the quadriceps
2. Patellar apprehension. In this test, the exam-
1. The clinical Q angle (Fig. 1.9). This is the iner applies gentle pressure on the medial side
angle subtended between: (a) a straight line of the patella displacing it laterally as the knee
from the anterior superior iliac spine and cen- flexes from full extension. The patient will
tre of the patella and (b) a line from the centre contract their quadriceps as a reflex in order to
of the patella to the tibial tubercle. This is avoid flexion and lateral displacement if the
test is positive.
3. Clarke’s test (Video 1.7) [7]. This, as classi-
cally described, is a painful test and should
not be performed. However, a modified
Clarke’s test for irritability of the PFJ can be
performed with the knee relaxed and flexed to
20° over the examiner’s contralateral thigh
much like the position for Lachman’s test. The
patella is then gently glided medially and lat-
erally: significant pain or crepitus indicates
PFJ irritability and chondral wear of the patel-
lofemoral surface.
Conclusion
Clinical examination of the knee is an art that
requires a combination of biomechanical
thinking, static and dynamic assessment and
delicate handling of the patient.
References
1. Schraeder TL, Terek RM, Smith CC (2010) Clinical
evaluation of the knee. N Engl J Med 363:e5
2. Haim A, Yaniv M, Dekel S, Amir H (2006)
Patellofemoral pain syndrome: validity of clinical and
Fig. 1.9 The clinical Q angle. A line from the anterior radiological features. Clin Orthop Relat Res
superior iliac spine to the superior pole of the patella inter- 451:223–228
secting a line from the inferior pole of the patella to the 3. Staheli LT, Engel GM (1972) Tibial torsion: a method
tibial tubercle. The patella, joint line and the tibial tuber- of assessment and a survey of normal children. Clin
cle are all marked in red Orthop Relat Res 86:183–186
4. Duggan NP, Ross JC (1991) Intertester reliabil- 6. Hegedus EJ, Cook C, Hasselblad V, Goode A,
ity of the modified anterior drawer (Lachman) test for McCrory DC (2007) Physical examination tests for
anterior cruciate ligament laxity. Aust J Physiother assessing a torn meniscus in the knee: a systematic
37:163–168 review with meta-analysis. J Orthop Sports Phys Ther
5. Karachalios T, Hantes M, Zibis AH, Zachos V, 37:541–550
Karantanas AH, Malizos KN (2005) Diagnostic accu- 7. Doberstein ST, Romeyn RL, Reineke DM (2008)
racy of a new clinical test (the Thessaly test) for early The diagnostic value of the Clarke sign in assessing
detection of meniscal tears. J Bone Joint Surg Am chondromalacia patella. J Athletic Train
87:955–962 43:190–196
Imaging Assessment of the Knee
2
Antony J.R. Palmer, Sion Glyn-Jones,
and Dimitri Amiras
Abstract
Many imaging modalities and techniques are helpful for the diagnosis
and prognostication of disorders within the knee. Plain radiographs
remain the first line of investigation, however, MRI now plays an increas-
ing role for imaging the knee in the setting of joint-preservation strate-
gies. Whilst the imaging findings for specific conditions are discussed in
each chapter of this book, this chapter aims to give an overview of the
imaging modalities available and to discuss in detail the use of imaging
techniques for the visualisation and assessment of early osteoarthritis
within the knee joint.
Keywords
Knee • Imaging • Assessment
2.1 Introduction
The advance has not been the ‘correct’ use of

imaging modalities. There have been scientific
advances in imaging techniques. It would be
A.J.R. Palmer (*) • S. Glyn-Jones more accurate to state that there have been
Nuffield Department of Orthopaedics, Rheumatology ‘advances in the field of imaging’. The wide-
and Musculoskeletal Sciences, University of Oxford,
Botnar Research Centre, Windmill Road, spread availability of MRI, and the increasing
Oxford OX3 7LD, UK quality of the images that it produces, has allowed
e-mail: Antony.palmer@ndorms.ox.ac.uk; sion. better visualisation of pathology in the knee joint.
glyn-jones@ndorms.ox.ac.uk Alongside the diagnosis of acute joint injury,
D. Amiras advances in imaging have facilitated the shift in
Imperial College Healthcare NHS Trust, St Mary’s focus toward disease prevention and the treat-
Hospital, Praed Street, Paddington,
London W2 1NY, UK ment of early osteoarthritis (OA) [1]. The devel-
e-mail: Dimitri.amiras@imperial.nhs.uk opment of joint-preserving strategies requires the

DOI 10.1007/978-3-319-41808-7_2
14 A.J.R. Palmer et al.
ability to diagnose early joint degeneration prior ogy in most instances. It is readily available and
to the onset of irreversible structural damage. It is relatively inexpensive and facilitates early identi-
at this early stage of disease when patients are fication of cases that are not amenable to joint
most likely to benefit from intervention. preservation procedures.
The aim of this chapter is to describe the
imaging tools available and their optimal use in
the knee. Individual imaging modalities and their 2.2.1 Joint Space Width
findings relevant to specific pathologies will be
covered in detail in the chapters relating to each Joint space width measurements are dependent
pathology. In this chapter, we will concentrate on on the radiographic protocol [7] and radiographs
imaging protocols for specific knee tissues, as may be performed weight-bearing or non-weight-
well as describing the current state of the art bearing, with the knee flexed or extended, and
imaging of early osteoarthritis. positioned under fluoroscopic or non-fluoroscopic
guidance. Radiographs that are non-weight-
bearing or acquired with the knee extended are
2.2 Radiography inferior to weight-bearing flexed-knee protocols
for the assessment of joint space width [8]. Knee
Radiography is the first line of imaging in all flexion aims to ensure joint space width on the
pathologies of the knee. Whole-limb radiographic radiograph corresponds to the site of load trans-
studies allow the assessment of malalignment and mission across the joint when the medial femoral
weight-bearing studies can demonstrate osteo- condyle is located in a central position on the
chondral lesions, as well as demonstrating sec- articular surface of the tibia. Radio-anatomic
ondary changes resulting from ligamentous alignment of the anterior and posterior margins
insufficiency (see Chaps. 8 and 9). Plain radio- of the medial tibial plateau is critical for joint
graphs allow visualisation of ossified structures space width measurements [5], and is aided by
and features of degenerative change. In OA, fluoroscopic guidance [9].
osteophyte formation is often the earliest sign on Several semi-flexed radiographic protocols
plain radiographs with narrowing of the joint are available, and two frequently adopted are the
space width, sclerosis of subchondral bone, and posteroanterior fixed-flexion (FF) protocol and
development of subchondral cysts Osteophyte its fluoroscopically guided equivalent, the Lyon
formation is often the earliest sign of osteoarthri- Schuss (LS) protocol. FF images are acquired
tis, followed by narrowing of the joint space with patients standing with their patellae and
width, sclerosis of subchondral bone, and devel- thighs against a radiograph cassette in line with
opment of subchondral cysts. Kellgren-Lawrence the tip of their great toes. This results in a fixed-
[2] and Osteoarthritis Research Society flexion of approximately 20–30°. The X-ray
International (OARSI) [3] grades can be used to beam is then directed caudally 10° to bring it par-
score the severity of these features, but measure- allel with the medial tibial plateau. LS images are
ment of joint space width provides a more sensi- acquired with the same positioning is as for FF
tive and reliable assessment of degenerative views, but rather than directing the beam 10° cau-
change [4]. Joint space width reflects cartilage dally, the beam is aligned fluoroscopically to
thickness and meniscal integrity [5], but is not ensure the anterior and posterior aspects of the
sensitive to localised cartilage lesions. MRI can medial tibial plateau are superimposed. Although
detect chondropathy that is not evident on radio- LS radiographs are more sensitive to change in
graphs [6], as well as offering three-dimensional joint space width, both techniques offer similar
assessment of subchondral bone, meniscus, liga- reproducibility [9], and the non-fluoroscopic FF
ments and synovium. However, radiography technique is better suited to routine clinical prac-
remains the first line investigation for knee pathol- tice. Posteroanterior views are combined with a
2 Imaging Assessment of the Knee 15
lateral view to permit assessment of tibial transla- ing the special considerations for different tissue
tion and patella height, in addition to features of types and pathologies.
osteoarthritis. Assessment of the patellofemoral
joint is best assessed with a skyline axial view.
2.3.1 Imaging Protocols
2.2.2 Limb Alignment 2.3.1.1 Sequences

Pulse sequences are the sets of pre-determined
Varus or valgus knee malalignment of the knee is radiofrequency and gradient pulses which pro-
a risk factor for ligamentous injury and for the duce the final MRI image [14]. Different pulse
development and progression of knee osteoarthri- sequences produce images of different character-
tis [10]. Accurate assessment of the mechanical istics which allow the examination of different
axis therefore provides value information on prog- structures and pathologies. The selection of
nosis and potential treatment options. Full limb sequences for imaging of the knee must be a bal-
weight-bearing radiographs are considered opti- ance between time and the quality of images
mal and the mechanical axis is measured with a required. Standard sequences include T1, T2 and
line passing through the centre of the femoral head Proton Density (PD) [15].
to the centre of the tibiotalar joint, and usually T1 weighted images have short repetition and
passes just medial to the tibial spine. It is further echo times (TR and TE) and the resultant image
subdivided into the mechanical axis of the femur produced as a function of relaxation time demon-
and tibia to determine the hip-knee-ankle angle, strates tissue contrast where fat is bright and cor-
which is a measurement of overall lower limb tical bone, ligaments and tendons are dark; this is
mechanical alignment [11]. However, full limb traditionally been considered to be the best view
radiographs are more technically demanding and for assessing anatomy. T2 weighted images have
expensive and deliver greater ionising radiation a long TR and TE and demonstrate both fat and
than short limb radiographs centred on the knee. water to have high signal intensities. PD
Therefore, authors have explored the value of sequences have a short TE and a long TR to pro-
measuring the anatomical axis on anteroposterior duce an image which represents the concentra-
knee radiographs as a surrogate for the mechanical tion of protons in each tissue; this is largely used
axis. The anatomical axis passes along the centre for the imaging of both fibrocartilage and articu-
of the femoral and tibial diaphysis, and anatomical lar cartilage [15].
alignment is the angle subtended by these two Fluid sensitive techniques are used to increase
lines. Studies have reported variable agreement the available tissue contrast to demonstrate areas
between mechanical and anatomical alignment, of oedema or abnormal tissue. These techniques
and the method of performing short limb radio- are varied and include fat suppression, inversion
graphs is likely to be of importance [12]. recovery and newer techniques such as Dixon
imaging. Fat suppression can be applied to T1,
T2 and PD sequences and they each have their
2.3 Morphological MRI own benefits with fat suppression usually provid-
ing the better spatial resolution.
Morphological MRI studies have become the
mainstay of diagnosis of soft tissue pathologies 2.3.1.2 Coils and Magnets
within the knee, and are being used increasingly The quality of the image produced relies upon
in the diagnosis and prognostication of early many factors; however, the adequacy of B0, or
osteoarthritis [13]. In this section, we will main field strength and the use of appropriate
describe the choices in terms of equipment and coils are very important [16]. The standard field
protocols for imaging of the knee, before describ- strength for most MRI machines is now 1.5 T;
this field strength is adequate for most applica-

tions within the knee. Magnets of higher field
strength have a higher signal to noise ratio and
may be more sensitive for imaging cartilage in
the context of early OA [16]. Direct comparisons
of the ability of radiologists to diagnose chondral
lesions in 1.5 and 3 T scanners have been under-
taken with both animal and human subjects.
Whilst the sensitivity of the two are similar, 3 T
scanners have a higher specificity and accuracy
for diagnosing chondral lesions [16]. Open MRI
scanners are useful for claustrophobic patients
and have been used in the research setting to
study the knee during weight-bearing. However,
the field strength is significantly lower than that
of conventional closed scanners (around 0.5 T)
and the quality of the images produced is signifi-
cantly poorer. Ultra-high field strength (7 T) MRI Fig. 2.1 Coronal T2 weighted fat-suppressed image
is in use in the research setting and has the poten- demonstrating anterolateral bone bruising following rup-
ture of the anterior cruciate ligament
tial to deliver even higher quality images [17].
Image quality is also improved by the use of
specific coils. Coils with higher numbers of chan-
nels and coils with more homogenous radiofre-
quency signals produce better images. Flexible
coils, which may be necessary for larger patients,
usually produce poorer quality images.
2.3.2 Bone
The medullary portion of bone is mainly com-

Fig. 2.2 Coronal T2 weighted fat-suppressed image
posed of fat cells. This is best imaged on T1 demonstrating bony oedema secondary to trauma result-
weighted images. The assessment of bone mar- ing in posterolateral corner injury
row lesions can be difficult especially around
the meta-diaphysis where there are commonly
areas of haematopoiesis which leads to a 2.3.3 Cartilage
marked reduction in fat cell content. Given
this, it is important to compare the T1 signal to In current practice, proton density imaging is the
the adjacent muscle. If the signal is compara- mainstay of morphological assessment of articu-
ble to muscle, there is concern of a mass and lar cartilage. Accurate assessment of articular
further investigation is recommended. Newer cartilage is achieved through adequate spatial
techniques involve the automatic estimation of resolution, contrast resolution and orthogonal
fat content using “in and out of phase” tech- image acquisition, which allow for a fuller appre-
niques using a region of interest [18]. T2 fat ciation of curved articular surfaces. Assessment
suppressed images allow visualisation of bone for bone marrow oedema subjacent to areas of
marrow oedema related to tumours or trauma cartilage irregularity is important to help recog-
(Figs. 2.1 and 2.2). nise areas of full thickness fissure. As interest
increases in the use of MRI for OA, new

sequences are being employed including mor-
phological and compositional techniques which
are covered in more detail below [19].
2.3.4 Meniscus
The meniscus is rich in proteoglycans; this

makes the inherent signal characteristics of the
meniscus low on all sequences. PD and T2 Fig. 2.3 Sagittal image demonstrating intrasubstance
sequences make for excellent tissue contrast high signal following partial rupture of the ACL
with the adjacent joint fluid and articular carti-
lage and the addition of fluid sensitive tech-
niques such as fat suppression makes the there may be some fibres which retain their nor-
appreciation of tears better. The meniscus is mal signal (Fig. 2.3) [20].
depicted in two planes, coronal and sagittal,
and although the orientation of the collagen
fibres cannot be demonstrated on MRI, the 2.3.6 Whole Joint Imaging (Semi-
type of meniscal tear can be. The stability of quantitative Scores)
meniscal tears can be assessed in order to
ascertain the requirement for surgical interven- Osteoarthritis is a disease of the whole joint.
tion. The findings of these on MRI include Whilst a broad understanding of the degree of
tears greater in size than 1 cm and displace- joint involvement is possible using systems such
ment of meniscal tissue. as that of Kellgren and Lawrence, elements of the
A three-dimensional appreciation of the disease such as synovitis and degree of meniscal
meniscus is key to understanding the tear config- involvement are only visualised using MRI. Whilst
uration and how this appears on MRI. Challenging the degree of cartilaginous damage is predicted
areas include visualisation of the meniscal root, using joint space width on plain radiographs, it is
which can be easily overlooked, and the assess- only possible to directly measure it using
ment of previously repaired menisci. In the case MRI. Likewise, the ability to predict disease pro-
of diagnostic difficulty, the use of an arthro- gression is higher when there is co-localised non-
graphic study can aid diagnosis. cartilaginous pathology, such as bone marrow
lesions and meniscal pathology [21].
A number of scoring systems have been
2.3.5 Ligament devised to categorise the degree of damage to the
joint on MRI [22]. These systems are important
The assessment of ligament injury is one of the in the research setting as they allow standardisa-
main indications for MRI examinations. The lig- tion of MRI findings in epidemiological and
amentous anatomy is usually best assessed by interventional studies in OA. They may have
fluid sensitive proton density or T2 images, in at clinical relevance as predictors of progression,
least two planes. Sagittal images can be taken but as MRI is not in widespread use for the moni-
obliquely, to be oriented along the course of the toring of OA, their direct clinical relevance is
ligament in question, to avoid averaging artefacts limited. Such systems include the Whole-Organ
which may produce false-positive findings for MRI Score (WORMS), the Knee Osteoarthritis
ligamentous injury. High intrasubstance signal in Scoring System (KOSS), the Boston-Leeds
T2 images suggests injury but in partial ruptures osteoarthritis Knee Score (BLOKS) and the MRI
Osteoarthritis Knee Score (MOAKS) [23–26]. In scan times. These include T2 mapping, T1rho,
all these systems, scores are attributed to a num- T2* mapping and diffusions protocols [30].
ber of cartilage, synovial, subchondral, ligamen- These sequences are responsive to a range of car-
tous and meniscal findings, subdivided by the tilage properties including glycosaminoglycan
area of the joint affected. All have excellent inter- content, collagen fibre orientation and cartilage
and intra-rater reliability. Such scores have been hydration. T2 mapping and T1rho are increas-
used in randomised controlled trials and epide- ingly used in clinical studies, and like dGEM-
miological studies of OA. They also appear to be RIC, values correlate with histological
clinically relevant, with the degree of bone mar- degeneration [31] and baseline values are able to
row change and synovitis being related to the predict progressive osteoarthritis in the knee [32].
degree of pain in OA. They also appear to be of T2 mapping is more sensitive than morphological
use in predicting progression of disease. MRI for the identification of early cartilage
degeneration [33], and T2 mapping has been fre-
quently employed to monitor the outcomes of
2.4 Compositional MRI cartilage repair procedures [34]. Compositional
MRI may therefore offer diagnostic and prognos-
2.4.1 Imaging Protocols tic capabilities, as well as providing a measure of
intervention efficacy.
Compositional MRI aims to assay the biochemi-
cal composition of tissues in order to detect early
osteoarthritis prior to when it is evident on mor- 2.4.3 Non-cartilaginous Structures
phological MRI, at which point cartilage damage
is likely irreversible. Potential applications Compositional MRI has also been adopted for
include the identification of individuals who may the evaluation of meniscus. There appears to be
benefit from early intervention, as well as an out- concomitant degeneration of the articular carti-
come measure to evaluate the efficacy of novel lage and meniscus in early osteoarthritis, sup-
interventions within a short timeframe. ported by delayed Gadolinium Enhanced MRI of
Meniscus (dGEMRIM) [35]. Meniscal T1rho
and T2 mapping values also correlate with the
2.4.2 Cartilage severity of knee osteoarthritis [36]. Given the
critical role played by the meniscus, addressing
A plethora of MRI sequences are available that any associated meniscal pathology may be a criti-
appear responsive to different cartilage properties cal step in delaying or preventing the develop-
[27]. The best validated compositional sequence ment of osteoarthritis. Compositional MRI of
is delayed Gadolinium Enhanced MRI of non-cartilaginous structures is likely to represent
Cartilage (dGEMRIC), which provides a mea- an area for future development.
sure of cartilage glycosaminoglycan content.
Several studies show that dGEMRIC correlates
well with the histological severity of osteoarthri- 2.5 Computerised
tis [28] and may predict future knee osteoarthritis Tomography (CT)
[29], however, clinical applicability is limited by
a long scanning protocol and requirement for CT has a limited but potentially valuable appli-
potentially nephrotoxic contrast agent. There are cation for imaging early osteoarthritis. It offers
a number of sequences with potentially greater excellent three-dimensional assessment of
clinical value that do not require contrast agent or bone morphology, and bone shape is increas-
specialist hardware, and that have acceptable ingly thought to have predictive value for the
Fig. 2.4 Axial section of knee in 32 year old healthy vol-

unteer – true fast imaging with steady-state free preces-
sion at 7 tesla MRI (Courtesy of Dr Daniel Park and Prof
Neal Bangerter, University of Oxford)
Fig. 2.5 Sagittal section of knee in 32 year old healthy
volunteer – true fast imaging with steady-state free pre-
cession at 7 tesla MRI (Courtesy of Dr Daniel Park and
development and progression of osteoarthritis. Prof Neal Bangerter, University of Oxford)
CT arthrography can be employed to both
identify cartilage defects and estimate carti- range of associated technical challenges that
lage glycosaminoglycan content [37]. However, must be overcome. The ability to diagnose early
MRI has several advantages in that it permits osteoarthritis is enhanced by the greater spatial
the imaging of all joint structures alongside resolution of images (Figs. 2.4 and 2.5), but also
non-invasive compositional assessment. because additional compositional sequences are
Combined single photon emission CT and con- feasible at ultra-high field strength. These
ventional CT (SPECT/CT) may have a poten- include sodium scanning and chemical exchange
tial role in assessing loading of compartments saturation transfer imaging of glycosamynogli-
in relation to leg alignment [38]. SPECT/CT cans (gagCEST), both of which assay glycos-
tracer uptake in the medial and lateral compart- aminoglycan content [40]. Currently, 7 Tesla
ment correlates with varus or valgus alignment, MRI is confined to the research setting, however,
respectively. these platforms are likely to eventually enter
clinical practice, and in the meantime, it may be
possible to reverse engineer research findings
2.6 Future Advances onto current clinical MRI platforms.
Current clinical MRI platforms have field Conclusions

strengths of 1.5 Tesla or 3 Tesla, however, Radiography continues to play an integral
research is underway on 7 Tesla platforms (ultra- role in the assessment of knee pathology,
high field strength). Increasing the field strength however, MRI is now central in the assess-
allows improved image resolution and faster ment of joint injury and early osteoarthritis.
image acquisition [39], although there are also a Morphological MRI allows high-resolution
three-dimensional imaging of all joint struc- 9. Le Graverand MP, Vignon EP, Brandt KD et al (2008)
tures. Compositional MRI offers great Head-to-head comparison of the Lyon Schuss and
fixed flexion radiographic techniques. Long-term
promise for the biochemical assessment of reproducibility in normal knees and sensitivity to
tissues, but does require further validation. change in osteoarthritic knees. Ann Rheum Dis
There remains a lack of standardisation 67:1562–1566
10. Sharma L, Chmiel JS, Almagor O et al (2013) The
between compositional MRI protocols and
role of varus and valgus alignment in the initial devel-
this limits any comparison between studies. It opment of knee cartilage damage by MRI: the MOST
may be this that explains the different conclu- study. Ann Rheum Dis 72:235–240
sions reached as to which tissue property a 11. Luo CF (2004) Reference axes for reconstruction of
the knee. Knee 11:251–257
compositional sequence is responsive. The
12. Felson DT, Cooke TD, Niu J et al (2009) Can ana-
influence of activity levels on compositional tomic alignment measured from a knee radiograph
MRI readings is also poorly characterised and substitute for mechanical alignment from full limb
it is important to be able to differentiate adap- films? Osteoarthritis Cartilage 17:1448–1452
13. Kijowski R, Roemer F, Englund M et al (2014)
tive from pathological signal [39]. Finally,
Imaging following acute knee trauma. Osteoarthritis
post-processing remains very time intensive Cartilage 22:1429–1443
and automated tools will be required in order 14. Brown MA, Semelka RC (1999) MR imaging abbre-
for these sequences to be used in routine clini- viations, definitions, and descriptions: a review.
Radiology 213:647–662
cal practice.
15. Hartley KG, Damon BM, Paterson GT, Long JH, Holt
GE (2012) MRI techniques: a review and update for
the orthopaedic surgeon. J Am Acad Orthop Surg
20:775–787
16. Link TM (2009) MR imaging in osteoarthritis: hard-
References ware, coils and sequences. Radiol Clin N Am
47:617–632
1. Glyn-Jones S, Palmer AJ, Agricola R et al (2015) 17. Regatte RR, Schweitzer ME (2007) Ultra-high-field
Osteoarthritis. Lancet 386(9991):376–387 MRI of the musculoskeletal system at 7.0T. J Mag
2. Kellgren JH, Lawrence JS (1957) Radiological assess- Res Imaging 25:262–269
ment of osteo-arthrosis. Ann Rheum Dis 16:494–502 18. Erly WK, Oh ES, Outwater EK (2006) The utility of
3. Altman RD, Gold GE (2007) Atlas of individual in-phase/opposed-phase imaging in differentiating
radiographic features in osteoarthritis, revised. malignancy from acute benign compression fractures
Osteoarthritis Cartilage 15:A1–A56 of the spine. AJNR Am J Neuroradiol 27:1183–1188
4. Gossec L, Jordan JM, Mazzuca SA et al (2008) 19. Eckstein F, Cicuttini F, Raynauld J-P, Waterton JC,
Comparative evaluation of three semi-quantitative Peterfy C (2006) Magnetic resonance imaging (MRI)
radiographic grading techniques for knee osteoarthri- of articular cartilage in knee osteoarthritis (OA): mor-
tis in terms of validity and reproducibility in 1759 phological assessment. Osteoarthritis Cartilage
X-rays: report of the OARSI-OMERACT task force. 14:A46–A75
Osteoarthritis Cartilage 16:742–748 20. Bining J, Andrews G, Forster BB (2009) The ABCs of
5. Hunter DJ, Zhang YQ, Tu X et al (2006) Change in the anterior cruciate ligament: a primer for magnetic
joint space width: hyaline articular cartilage loss or resonance imaging assessment of the normal, injured
alteration in meniscus? Arthritis Rheum and surgically repaired anterior cruciate ligament. Br
54:2488–2495 J Sports Med 43:856–862
6. Guermazi A, Niu J, Hayashi D et al (2012) Prevalence 21. Roemer FW, Felson DT, Wang K et al (2013)
of abnormalities in knees detected by MRI in adults Co-localisation of non-cartilaginous articular pathol-
without knee osteoarthritis: population based obser- ogy increases risk of cartilage loss in the tibiofemoral
vational study (Framingham Osteoarthritis Study). joint--the MOST study. Ann Rheum Dis 72:942–948
BMJ 345, e5339 22. Guermazi A, Roemer FW, Haugen IK, Crema MD,
7. Piperno M, Hellio Le Graverand MP et al (1998) Hayashi D (2013) MRI-based semiquantitative scor-
Quantitative evaluation of joint space width in femo- ing of joint pathology in osteoarthritis. Nat Rev
rotibial osteoarthritis: comparison of three radio- Rheumatol 9:236–251
graphic views. Osteoarthritis Cartilage 6:252–259 23. Hunter DJ, Lo GH, Gale D et al (2008) The reliability
8. Roux CH, Mazieres B, Verrouil E et al (2016) of a new scoring system for knee osteoarthritis MRI
Femoro-tibial knee osteoarthritis: one or two X-rays? and the validity of bone marrow lesion assessment:
Results from a population-based study. Joint Bone BLOKS (Boston–Leeds Osteoarthritis Knee Score).
Spine 83:37–42 Ann Rheum Dis 67:206–211
24. Kornatt PR, Ceulemans RYT, Kroon HM et al (2005) cartilage of the knee joint: value of adding a T2 map-
MRI assessment of knee osteoarthritis: Knee ping sequence to a routine MR imaging protocol.
Osteoarthritis Scoring System (KOSS)—inter-observer Radiology 267:503–513
and intra-observer reproducibility of a compartment- 34. Baum T, Joseph GB, Karampinos DC, Jungmann PM,
based scoring system. Skeletal Radiol 34:95–102 Link TM, Bauer JS (2013) Cartilage and meniscal T2
25. Hunter DJ, Guermazi A, Lo GH et al (2011) Evolution relaxation time as non-invasive biomarker for knee
of semi-quantitative whole joint assessment of knee osteoarthritis and cartilage repair procedures.
OA: MOAKS (MRI Osteoarthritis Knee Score). Osteoarthritis Cartilage 21:1474–1484
Osteoarthritis Cartilage 19:990–1002 35. van Tiel J, Kotek G, Reijman M et al (2014) Delayed
26. Peterfy CG, Guermazi A, Zaim S et al (2004) Whole- gadolinium-enhanced MRI of the meniscus (dGEM-
Organ Magnetic Resonance Imaging Score (WORMS) RIM) in patients with knee osteoarthritis: relation
of the knee in osteoarthritis. Osteoarthritis Cartilage with meniscal degeneration on conventional MRI,
12:177–190 reproducibility, and correlation with dGEMRIC. Eur
27. Palmer AJ, Brown CP, McNally EG et al (2013) Non- Radiol 24:2261–2270
invasive imaging of cartilage in early osteoarthritis. 36. Rauscher I, Stahl R, Cheng J et al (2008) Meniscal
Bone Joint J 95-B:738–746 measurements of T1rho and T2 at MR imaging in
28. Zilkens C, Miese F, Herten M et al (2013) Validity of healthy subjects and patients with osteoarthritis.
gradient-echo three-dimensional delayed gadolinium- Radiology 249:591–600
enhanced magnetic resonance imaging of hip joint 37. van Tiel J, Siebelt M, Reijman M et al (2016)
cartilage: a histologically controlled study. Eur Quantitative in vivo CT arthrography of the human
J Radiol 82:e81–e86 osteoarthritic knee to estimate cartilage sulphated gly-
29. Owman H, Tiderius CJ, Neuman P, Nyquist F, cosaminoglycan content: correlation with ex-vivo ref-
Dahlberg LE (2008) Association between findings on erence standards. Osteoarthritis Cartilage
delayed gadolinium-enhanced magnetic resonance 24:1012–1020
imaging of cartilage and future knee osteoarthritis. 38. Hirschmann MT, Schon S, Afifi FK et al (2013)
Arthritis Rheum 58:1727–1730 Assessment of loading history of compartments in the
30. Guermazi A, Alizai H, Crema MD, Trattnig S, Regatte knee using bone SPECT/CT: a study combining align-
RR, Roemer FW (2015) Compositional MRI tech- ment and 99mTc-HDP tracer uptake/distribution pat-
niques for evaluation of cartilage degeneration in terns. J Orthop Res 31:268–274
osteoarthritis. Osteoarthritis Cartilage 23:1639–1653 39. Welsch GH, Juras V, Szomolanyi P et al (2012)
31. Nishioka H, Hirose J, Nakamura E et al (2012) T1rho Magnetic resonance imaging of the knee at 3 and 7
and T2 mapping reveal the in vivo extracellular matrix tesla: a comparison using dedicated multi-channel
of articular cartilage. J Magn Reson Imaging coils and optimised 2D and 3D protocols. Eur Radiol
35:147–155 22:1852–1859
32. Prasad AP, Nardo L, Schooler J, Joseph GB, Link TM 40. Hovis KK, Stehling C, Souza RB et al (2011)
(2013) T(1)rho and T(2) relaxation times predict pro- Physical activity is associated with magnetic reso-
gression of knee osteoarthritis. Osteoarthritis nance imaging-based knee cartilage T2 measure-
Cartilage 21:69–76 ments in asymptomatic subjects with and those
33. Kijowski R, Blankenbaker DG, Munoz Del Rio A, without osteoarthritis risk factors. Arthritis Rheum
Baer GS, Graf BK (2013) Evaluation of the articular 63:2248–2256
Intra-articular Corticosteroids
and Hyaluronic Acid in the Knee
3
Joint
Carlos Kalbakdij-Sánchez
and Enrique Gómez-Barrena
Abstract
Degenerative knee osteoarthritis (OA) affects 35 % of the population older
than 65 years. Before surgical treatment (total knee arthroplasty, TKA),
there are many conservative strategies that may offer good clinical out-
comes. The aim of this chapter is to describe the mechanism of action of
corticosteroids and hyaluronic acid joint injections in knee’s osteoarthritis
physiopathology. The authors hope to improve reader’s understanding on
the role of corticosteroids and hyaluronic acid joint injections and how it
can improve the quality of life of these patients, and eventually delay total
knee arthroplasty.
Keywords
Knee • Injections • Corticosteroids • Hyaluronic acid
3.1 Introduction There is no therapeutic agent proven to mod-

ify disease progression in OA. Instead, there are
Knee osteoarthritis (OA) is characterized by car- many options which have uncertain effective-
tilage degeneration, pain and loss of function. ness in the treatment of knee OA. However,
OA leads to progressive loss of function, affect- pharmacologic therapies, non-steroidal anti-
ing the individual’s capability to perform daily inflammatory drugs (NSAIDs) and intra-articu-
activities. Knee OA also leads to impaired work lar (IA) corticosteroid injections are commonly
performance and early retirement, which has prescribed to control the symptoms of
socioeconomic implications [1]. OA. NSAIDs and IA corticosteroid injections
have inherent limitations: NSAIDs have poten-
tially serious adverse events associated with
C. Kalbakdij-Sánchez • E. Gómez-Barrena (*) their use; and corticosteroid injections often
Department of Orthopedic Surgery, “La Paz” provide a relatively short period of effective
University Hospital-IdiPaz, Paseo de la Castellana 261, pain relief. Although corticosteroid injections
Madrid 28046, Spain
e-mail: carloskalbakdij@hotmail.com; generally have a positive safety profile, they
egomezbarrena@gmail.com have been shown to cause a transient increase in

DOI 10.1007/978-3-319-41808-7_3
Another random document with
no related content on Scribd:
supervision of the Secretary of State of the United States,
and was to continue in existence for a period of ten years,
and, if found profitable to the nations participating in its
advantages, it was to be maintained for successive periods of
ten years indefinitely. At the first session of the
Fifty-first Congress of the United States, that body, in an
'Act making appropriations for the support of the Diplomatic
and Consular Service, etc.,' approved July 14, 1890, gave the
President authority to carry into effect the recommendations
of the Conference so far as he should deem them expedient, and
appropriated $36,000 for the organization and establishment of
the Bureau, which amount it had been stipulated by the
delegates in the Conference assembled should not be exceeded,
and should be annually advanced by the United States and
shared by the several Republics in proportion to their
population. … The Conference had defined the purpose of the
Bureau to be the preparation and publication of bulletins
concerning the commerce and resources of the American
Republics, and to furnish information of interest to
manufacturers, merchants, and shippers, which should be at all
times available to persons desirous of obtaining particulars
regarding their customs tariffs and regulations, as well as
commerce and navigation."
Bulletin of the Bureau of American Republics,

June, 1898.
A plan of government for the International Union, by an

executive committee composed of representatives of the
American nations constituting the Union, was adopted in 1896,
but modified at a conference held in Washington, March 18,
1899. As then adopted, the plan of government is as follows:
"The Bureau of the American Republics will be governed under

the supervision of the Secretary of State of the United
States, with the cooperation and advice of four
representatives of the other Republics composing the
International Union, the five persons indicated to constitute
an Executive Committee, of which the Secretary of State is to
be ex-officio Chairman, or, in his absence, the Acting
Secretary of State. The other four members of the Executive
Committee shall be called to serve in turn, in the
alphabetical order of the official names of their nations in
one of the four languages of the Union, previously selected by
lot at a meeting of the representatives of the Union. At the
end of each year the first of these four members shall retire,
giving place to another representative of the Union, in the
same alphabetical order already explained, and so on until the
next period of succession."
{11}
"The interest taken by the various States forming the

International Union of American Republics in the work of its
organic bureau is evidenced by the fact that for the first
time since its creation in 1890 all the republics of South and
Central America are now [1899] represented in it. The unanimous
recommendation of the International American Conference,
providing for the International Union of American Republics,
stated that it should continue in force during a term of ten
years from the date of its organization, and no country
becoming a member of the union should cease to be a member
until the end of said period of ten years, and unless twelve
months before the expiration of said period a majority of the
members of the union had given to the Secretary of State of
the United States official notice of their wish to terminate
the union at the end of its first period, that the union
should continue to be maintained for another period of ten
years, and thereafter, under the same conditions, for
successive periods of ten years each. The period for
notification expired on July 14, 1899, without any of the
members having given the necessary notice of withdrawal. Its
maintenance is therefore assured for the next ten years."
Message of the President of the United States.

December 5, 1899.
AMERICANISM:
Pope Leo XIII. on opinions so called.
See (in this volume)

PAPACY: A. D. 1899 (JANUARY).
AMNESTY BILL, The French.

FRANCE: A. D. 1900 (DECEMBER).
ANARCHIST CRIMES:
Assassination of Canovas del Castillo.

SPAIN: A. D. 1897 (AUGUST-OCTOBER).
Assassination of the Empress of Austria.

AUSTRIA-HUNGARY: A. D. 1898 (SEPTEMBER).
Assassination of King Humbert.

ITALY: A. D. 1899-1900;
and 1900 (JULY-SEPTEMBER).
ANATOLIAN RAILWAY, The.

TURKEY: A. D. 1899 (NOVEMBER).
ANCON, The Treaty of.

CHILE: A. D. 1894-1900.
ANDERSON, General Thomas M.:

Correspondence with Aguinaldo.

UNITED STATES OF AMERICA:
A. D. 1898 (JULY-AUGUST: PHILIPPINES).
ANDRÉE, Salamon August:

Arctic balloon voyage.

POLAR EXPLORATION, 1897, 1898, 1899, 1900-.
ANGLO-AMERICAN POPULATION.

NINETEENTH CENTURY: EXPANSION.
ANGONI-ZULUS, The.

BRITISH CENTRAL AFRICA PROTECTORATE.
ANTARCTIC EXPLORATION.

POLAR EXPLORATION.
ANTEMNÆ, Excavations at.

ARCHÆOLOGICAL RESEARCH: ITALY.
ANTIGUA: Industrial condition.

WEST INDIES, THE BRITISH: A. D. 1897.
ANTITOXINE, Discovery of.

SCIENCE, RECENT: MEDICAL AND SURGICAL.
ANTI-IMPERIALISTS, The League of American.

UNITED STATES OF AMERICA:
A. D. 1900 (MAY-NOVEMBER).
ANTI-REVOLUTIONARY BILL, The German.

GERMANY: A. D. 1894-1895.
ANTI-SEMITIC AGITATIONS.

AUSTRIA-HUNGARY: A. D. 1895-1896, and after;
and FRANCE: A. D. 1897-1899, and after.
ANTI-SEMITIC LEAGUE, Treasonable conspiracy of the.

FRANCE: A. D. 1899-1900 (AUGUST-JANUARY).
APPORTIONMENT ACT.

UNITED STATES OF AMERICA: A. D. 1901 (JANUARY).
ARBITRATION, Industrial:
In New Zealand.

NEW ZEALAND: A. D. 1891-1900.
ARBITRATION, Industrial:
In the United States between employees and employers
engaged in inter-state commerce.

UNITED STATES OF AMERICA: A. D. 1898 (JUNE).
ARBITRATION, International: A. D. 1896-1900.

Boundary dispute between Colombia and Costa Rica.

COLOMBIA: A. D. 1893-1900.
ARBITRATION, International: A. D. 1897.

Nicaragua and Costa Rica.

CENTRAL AMERICA (NICARAGUA-COSTA RICA): A. D. 1897.
ARBITRATION, International: A. D. 1897-1899.

Venezuela and Great Britain.
Guiana boundary.

VENEZUELA: A. D. 1896-1899.

Argentine Republic and Chile.

ARGENTINE REPUBLIC: A. D. 1898.

Treaty between Italy and the Argentine Republic.

ARGENTINE REPUBLIC: A. D. 1898.

The Treaty for the Pacific Settlement of International
Disputes concluded at the Peace Conference at the Hague (Text).
The Permanent Court created.

PEACE CONFERENCE.

Brazil and French Guiana boundary dispute.

BRAZIL: A. D. 1900.

Compulsory arbitration voted for at Spanish-American Congress.

SPAIN: A. D. 1900 (NOVEMBER).
ARBITRATION TREATY, Great Britain and the United States.

Its defeat.

UNITED STATES OF AMERICA: A. D. 1897 (JANUARY-MAY).
----------ARCHÆOLOGICAL RESEARCH: Start--------
ARCHÆOLOGICAL RESEARCH:
The Oriental Field.
Recent achievements and future prospects.
"Three successive years have just added to the realm of

Egyptian archaeology, not only the period of the first two
dynasties, hitherto absolutely unrecognized from contemporary
remains, but also a long prehistoric period. Assyriology
likewise has lately been pushed back into antiquity with
almost equal rapidity. Though the subjects will probably
always have their limitations, yet the insight of scholars and
explorers is opening up new vistas on all sides. … Our
prospect for the future is bright. Egypt itself seems
inexhaustible. Few of the cities of Babylonia and Assyria have
yet been excavated, and each of them had its library and
record office of clay-tablets as well as monuments in stone
and bronze. In Northern Mesopotamia are countless sites still
untouched; in Elam and in Armenia monuments are only less
plentiful.
{12}
In Arabia inscriptions are now being read which may perhaps
date from 1000 B. C. The so-called Hittite hieroglyphs still
baffle the decipherer; but as more of the documents become
known these will in all likelihood prove a fruitful source for
the history of North Syria, of Cappadocia, and of Asia Minor
throughout. Occasionally, too, though it is but rarely, an
inscription in the Phaenician type of alphabet yields up
important historical facts. When all is done, there is but
scant hope that we shall be able to construct a consecutive
history of persons and events in the ancient world. All that
we can be confident of securing, at any rate in Egypt, is the
broad outline of development and change, chronologically
graduated and varied by occasional pictures of extraordinary
minuteness and brilliancy."
F. LL. Griffith,
Authority and Archaeology Sacred and Profane,
part 2, pages. 218-219
(New York: Charles Scribner's Sons).
ARCHÆOLOGICAL RESEARCH: In Bible Lands:

General results as affecting our knowledge
of the ancient Hebrews.
"The general result of the archaeological and anthropological

researches of the past half-century has been to take the
Hebrews out of the isolated position which, as a nation, they
seemed previously to hold, and to demonstrate their affinities
with, and often their dependence upon, the civilizations by
which they were surrounded. Tribes more or less closely akin
to themselves in both language and race were their neighbours
alike on the north, on the east, and on the south; in addition
to this, on each side there towered above them an ancient and
imposing civilization,—that of Babylonia, from the earliest
times active, enterprising, and full of life, and that of
Egypt, hardly, if at all, less remarkable than that of
Babylonia, though more self-contained and less expansive. The
civilization which, in spite of the long residence of the
Israelites in Egypt, left its mark, however, most distinctly
upon the culture and literature of the Hebrews was that of
Babylonia. It was in the East that the Hebrew traditions
placed both the cradle of humanity and the more immediate home
of their own ancestors; and it was Babylonia which, as we now
know, exerted during many centuries an influence, once
unsuspected, over Palestine itself.
"It is true, the facts thus disclosed, do not in any degree

detract from that religious pre-eminence which has always been
deemed the inalienable characteristic of the Hebrew race: the
spiritual intuitions and experiences of its great teachers
retain still their uniqueness; but the secular institutions of
the nation, and even the material elements upon which the
religious system of the Israelites was itself constructed, are
seen now to have been in many cases common to them with their
neighbours. Thus their beliefs about the origin and early
history of the world, their social usages, their code of civil
and criminal law, their religious institutions, can no longer
be viewed, as was once possible, as differing in kind from
those of other nations, and determined in every feature by a
direct revelation from Heaven; all, it is now known, have
substantial analogies among other peoples, the distinctive
character which they exhibit among the Hebrews consisting in
the spirit with which they are infused and the higher
principles of which they are made the exponent. …
"What is called the 'witness of the monuments' is often

strangely misunderstood. The monuments witness to nothing
which any reasonable critic has ever doubted. No one, for
instance, has ever doubted that there were kings of Israel (or
Judah) named Ahab and Jehu and Pekah and Ahaz and Hezekiah, or
that Tiglath-Pileser and Sennacherib led expeditions into
Palestine; the mention of these (and such like) persons and
events in the Assyrian annals has brought to light many
additional facts about them which it is an extreme
satisfaction to know: but it has only 'confirmed' what no
critic had questioned. On the other hand, the Assyrian annals
have shewn that the chronology of the Books of Kings is, in
certain places, incorrect: they have thus confirmed the
conclusion which critics had reached independently upon
internal evidence, that the parts of these books to which the
chronology belongs are of much later origin than the more
strictly historical parts, and consequently do not possess
equal value.
"The inscriptions, especially those of Babylonia, Assyria, and

Egypt, have revealed to us an immense amount of information
respecting the antiquities and history of these nations, and
also, in some cases, respecting the peoples with whom, whether
by commerce or war, they came into contact: but (with the
exception of the statement on the stele of Merenptah that
'Israel is desolated') the first event connected with Israel
or its ancestors which they mention or attest is Shishak's
invasion of Judah in the reign of Rehoboam; the first
Israelites whom they specify by name are Omri and his son
Ahab. There is also indirect illustration of statements in the
Old Testament relating to the period earlier than this; but
the monuments supply no 'confirmation' of any single fact
recorded in it, prior to Shishak's invasion."
S. R. Driver,
Authority and Archaeology Sacred and Profane,
part 1, pages 150-151
(New York: Charles Scribner's Sons).
ARCHÆOLOGICAL RESEARCH: Babylonia:

Earlier explorations in.
For some account of the earlier archæological explorations in

Babylonia and their results,
See (in volume 1) BABYLONIA, PRIMITIVE;

and (in volume 4) SEMITES.

American exploration of the ruins of ancient Nippur.
[Footnote: Quotations in this account from Professor

Hilprecht's copyrighted reports in the "Sunday School Times"
are used with permission from the publishers of that journal.]
"In the summer of 1888, the University of Pennsylvania fully

equipped and sent out the first American expedition to the
northern half of the plains of Babylonia to effect a thorough
exploration of the ruins of Nippur—the modern Niffer, or, more
correctly, Nuffar—on the border of the unwholesome swamps of
the Affej, and to undertake extensive excavations. A few
intelligent citizens of Philadelphia had met in the house of
Ex-Provost Dr. William Pepper, and formed 'The Babylonian
Exploration Fund,' a short time before this with the purpose
of effecting a systematic exploration of ancient Babylonia.
What science owes to this unselfish undertaking can be
adequately estimated only by posterity. … Two professors,
Peters and Hilprecht, were entrusted with the management of
the expedition, Dr. Peters as director, and Dr. Hilprecht as
Assyriologist."
H. V. Hilprecht, editor,
Recent Research in Bible Lands,
page 47.
{13}
Professor Hilprecht, who conducts for the "Sunday School

Times" a most interesting and important department, in which
the proceedings and principal results of archæological
exploration in Bible Lands have been currently chronicled
during several years past, gave, in that journal of December
I, 1900, the following description of the scene and the
historical importance of the ruins in which the excavations
above mentioned have been carried on: "Nuffar is the modern
Arabic name of an old Babylonian ruin situated about half-way
between the Euphrates and Tigris, at the northeastern boundary
of the great Affej swamps, which are formed by the regular
annual inundations of the Euphrates. In a straight line, it is
nearly eighty miles to the southeast from Baghdad. A large
canal, now dry, and often for miles entirely filled with
rubbish and sand, divides the ruins into two almost equal
parts. On an average about fifty or sixty feet high, these
ruins are torn up by frequent gulleys and furrows into a
number of spurs and ridges, from the distance not unlike a
rugged mountain range on the bank of the upper Tigris. In the
Babylonian language, the city buried here was called Nippur.
According to Jewish tradition, strongly supported by arguments
drawn from cuneiform texts and archaeological objects found at
the ruins themselves, Nippur was identical with the Biblical
Calneh, mentioned in Genesis 10: 10, as one of the four great
cities of the kingdom of Nimrod. It was therefore natural that
the public in general should take a warm interest in our
excavations at Nuffar. This interest grew considerably in
religious circles when, a few years ago, I announced my
discovery of the name of the 'river Chebar' in two cuneiform
texts from the archives of Nippur. It became then evident that
this 'river Chebar,' which hitherto could not be located, was
one of the four or five large canals once bringing life and
fertility to the fields of Nippur; that, furthermore, a large
number of the Jewish captives carried away by Nebuchadrezzar
after the destruction of Jerusalem were settled in the plains
around this city; and that even Ezekiel himself, while
admonishing and comforting his people, and holding out to them
Jehovah's mercy and never-failing promise of a brighter
future, stood in the very shadow of Babylonia's ancient
national sanctuary, the crumbling walls of the great temple of
Bêl at Nippur. The beginning and end of Old Testament history
thus point to Nippur as the background and theater for the
first and final acts in the great drama of divine selection
and human rejection in which Israel played the leading role."
In the same article, Professor Hilprecht indicated in a few

words what was done at Nuffar by the first three of the four
expeditions sent out from Philadelphia since 1888. "It was
comparatively easy," he said, "to get a clear idea of the
extent of the city and the life in its streets during the last
six centuries preceding our era. Each of the four expeditions
to Nuffar contributed its peculiar share to a better knowledge
of this latest period of Babylonian history, particularly,
however, the third and the present campaigns. But it was of
greater importance to follow up the traces of a very early
civilization, which, accidentally, we had met during our first
brief campaign in 1889. By means of a few deep trenches, the
second expedition, in the following year, had brought to light
new evidence that a considerable number of ancient monuments
still existed in the lower strata of the temple mound. The
third expedition showed that the monuments, while numerous,
are mostly very fragmentary, thereby offering considerable
difficulties to the decipherer and historian. But it also
showed that a number of platforms running through the temple
mound, and made of baked bricks, frequently bearing
inscriptions, enable us to fix the age of the different strata
of this mound with great accuracy. The two lowest of these
platforms found were the work of kings and patesis
(priest-kings) of 4000-3800 B. C., but, to our great
astonishment, they did not represent the earliest trace of
human life at Nippur. There were not less than about thirty
feet of rubbish below them, revealing an even earlier
civilization, the beginning and development of which lie
considerably before the times of Sargon the Great (3800 B. C.)
and Narâm-Sin, who had been generally regarded as
half-mythical persons of the first chapter of Babylonian
history."
Of the results of the work of those three expeditions of the

University of Pennsylvania, and of the studies for which they
furnished materials to Professor Hilprecht, Professor Sayce
wrote with much enthusiasm in the "Contemporary Review" of
January, 1897, as follows: "In my Hibbert Lectures on the
'Religion of the Ancient Babylonians' I had been led by a
study of the religious texts of Babylonia to the conclusion
that Nippur had been a centre from which Babylonian culture
was disseminated in what we then regarded as prehistoric
times. Thanks to the American excavations, what were
prehistoric times when my Hibbert Lectures were written have
now become historic, and my conclusion has proved to be
correct. … For the first time in Babylonia they have
systematically carried their shafts through the various strata
of historical remains which occupy the site, carefully noting
the objects found in each, and wherever possible clearing each
stag away when once it had been thoroughly examined. The work
began in 1888, about two hundred Arabs being employed as
labourers. … The excavations at Nippur were carried deeply and
widely enough not only to reveal the history of the city
itself but also to open up a new vista in the forgotten
history of civilised man. The history of civilisation has been
taken back into ages which a short while since were still
undreamed of. Professor Hilprecht, the historian of the
expedition, upon whom has fallen the work of copying,
publishing, and translating the multitudinous texts discovered
in the course of it, declares that we can no longer 'hesitate
to date the founding of the temple of Bel and the first
settlements in Nippur somewhere between 6000 and 7000 B. C.,
possibly even earlier.' At any rate the oldest monuments which
have been disinterred there belong to the fifth or sixth
millennium before the Christian era. Hitherto we have been
accustomed to regard Egypt as the land which has preserved for
us the earliest written monuments of mankind, but Babylonia
now bids fair to outrival Egypt. The earliest fixed date in
Babylonian history is that of Sargon of Akkael and his son
Naram-Sin. It has been fixed for us by Nabonidos, the royal
antiquarian of Babylonia. In one of his inscriptions he
describes the excavations he made in order to discover the
memorial cylinders of Naram-Sin, who had lived '3200 years'
before his own time. In my Hibbert Lectures I gave reasons for
accepting this date as approximately correct. The recent
discoveries at Niffer, Telloh, and other places have shown
that my conclusion was justified. …
{14}
"Assyriologists have long had in their possession a cuneiform

text which contains the annals of the reign of Sargon, and of
the first three years of the reign of his son. It is a late
copy of the original text, and was made for the library of
Nineveh. Our 'critical' friends have been particularly merry
over the credulity of the Assyriologists in accepting these
annals as authentic. … So far from being unhistorical, Sargon
and Naram-Sin prove to have come at the end of a
long-preceding historical period, and the annals themselves
have been verified by contemporaneous documents. The empire of
Sargon, which extended from the Persian Gulf to the
Mediterranean, was not even the first that had arisen in
Western Asia. And the art that flourished under his rule, like
the art which flourished in Egypt in the age of the Old
Empire, was higher and more perfect than any that succeeded it
in Babylonia. … Henceforward, Sargon and Naram-Sin, instead of
belonging to 'the grey dawn of time,' must be regarded as
representatives of 'the golden age of Babylonian history.'
That they should have undertaken military expeditions to the
distant West, and annexed Palestine and the Sinaitic Peninsula
to the empire they created need no longer be a matter of
astonishment. Such campaigns had already been undertaken by
Babylonian kings long before; the way was well known which led
from one extremity of Western Asia to the other. …
"It is Mr. Haynes [Director of the explorations from 1893] who

tells us that we are henceforth to look upon Sargon of Akkad
as a representative of 'the golden age of Babylonian history,'
and his assertion is endorsed by Professor Hilprecht. In fact,
the conclusion is forced upon both the excavator and the
palæographist. Professor Hilprecht, who, thanks to the
abundant materials at his disposal, has been able to found the
science of Babylonian palæography, tracing the development of
the cuneiform characters from one stage of development to
another, and determining the age of each successive form of
writing, has made it clear to all students of Assyriology that
many of the inscriptions found at Niffer and Telloh belong to
a much older period than those of the age of Sargon. The
palæographic evidence has been supplemented by the results of
excavation. … As far back as we can penetrate, we still find
inscribed monuments and other evidences of civilisation. It is
true that the characters are rude and hardly yet lifted above
their pictorial forms. They have, however, ceased to be
pictures, and have already become that cursive script which we
call cuneiform. For the beginnings of Babylonian writing we
have still to search among the relics of centuries that lie
far behind the foundation of the temple of Nippur.
"The first king whom the excavations there have brought to

light is a certain En-sag(sak)-ana who calls himself 'lord of
Kengi' and conqueror of Kis 'the wicked.' Kengi—'the land of
canals and reeds,' as Professor Hilprecht interprets the
word—was the oldest name of Babylonia, given to it in days
when it was still wholly occupied by its Sumerian population,
and when as yet no Semitic stranger had ventured within it.
The city of Kis (now El-Hy-mar) lay outside its borders to the
north, and between Kis and Kengi there seems to have been
constant war. … Nippur was the religious centre of Kengi, and
Mul-lil, the god of Nippur, was the supreme object of Sumerian
worship. … A king of Kis made himself master of Nippur and its
sanctuary, and the old kingdom of Kengi passed away. The final
blow was dealt by the son of the Sumerian high priest of the
'Land of the Bow.' Lugal-zaggi-si was the chieftain who
descended from the north upon Babylonia and made it part of
his empire. … Lugal-zaggi-si lived centuries before Sargon of
Akkad in days which, only a year ago, we still believed to lie
far beyond the horizon of history and culture. We little
dreamed that in that hoar antiquity the great cities and
sanctuaries of Babylonia were already old, and that the
culture and script of Babylonia had already extended far
beyond the boundaries of their motherland. The inscriptions of
Lugal-zaggi-si are in the Sumerian language, and his name,
like that of his father, is Sumerian also. … The empire of
Lugal-zaggi-si seems to have passed away with his death, and
at no long period subsequently a new dynasty arose at Ur. …
According to Professor Hilprecht, this would have been about
4000 B. C. How long the first dynasty of Ur lasted we cannot
tell. It had to keep up a perpetual warfare with the Semitic
tribes of northern Arabia, Ki-sarra, 'the land of the hordes,'
as it was termed by the Sumerians. Meanwhile a new state was
growing up on the eastern side of the Euphrates in a small
provincial city called Lagas, whose ruins are now known as
Telloh. Its proximity to Eridu, the seaport and trading depot
of early Babylonia, had doubtless much to do with its rise to
power. At all events the kings of Telloh, whose monuments have
been brought to light by M. de Sarzec, became continually
stronger, and the dynasty of Lagas took the place of the
dynasty of Ur. One of these kings, E-Anna-gin, at length
defeated the Semitic oppressors of northern Chaldæa in a
decisive battle and overthrew the 'people of the Land of the
Bow.' …
"The kings of Lagas represent the closing days of Sumerian

supremacy. With Sargon and his empire the Semitic age begins.
The culture of Chaldæa is still Sumerian, the educated classes
are for the most part of Sumerian origin, and the literature of
the country is Sumerian also. But the king and his court are
Semites, and the older culture which they borrow and adopt
becomes Semitised in the process. … For many generations
Sumerians and Semites lived side by side, each borrowing from
the other, and mutually adapting and modifying their own forms
of expression. … Sumerian continued to be the language of
religion and law—the two most conservative branches of human
study—down to the age of Abraham. … The new facts that have
been disinterred from the grave of the past furnish a striking
confirmation of Professor Hommel's theory, which connects the
culture of primitive Egypt with that of primitive Chaldæa, and
derives the language of the Egyptians, at all events in part,
from a mixed Babylonian language in which Semitic and Sumerian
elements alike claimed a share. We now know that such a mixed
language did once exist, and we also know that this language
and the written characters by which it was expressed were
brought to the shores of the Mediterranean and the frontiers
of Egypt in the earliest age of Egyptian history."
A. H. Sayce,
Recent Discoveries in Babylonia
(Contemporary Review, January, 1897).
{15}
The third of the Pennsylvania expeditions closed its work at

Nippur in February, 1896. There was then an interval of three
years before a fourth expedition resumed work at the ruins in
February, 1899. In the "Sunday School Times" of April 29 and
May 27, 1899, Professor Hilprecht (who did not go personally
to Nuffar until later in the year) gave the following account
of the friendly reception of the exploring party by the Arabs
of the district, from whom there had been formerly much
experience of trouble: "The Affej tribes, in whose territory
the large mounds are situated, had carefully guarded the
expedition's stronghold,—a mud castle half-way between the
ruins and the marshes, which had been sealed and entrusted to
their care before we quitted the field some years ago. They
now gave to the expedition a hearty welcome, accompanied by
shooting, shouting, dancing, and singing, and were evidently
greatly delighted to have the Americans once more in their
midst. In the presence of Haji Tarfa, their
commander-in-chief, who was surrounded by his minor shaykhs
and other dignitaries of the El-Hamza tribes, the former
arrangements with the two shaykhs Hamid el-Birjud and Abud
el-Hamid were ratified, and new pledges given for the security
and welfare of the little party of explorers, the question of
guards and water being especially emphasized. In accordance
with the Oriental custom, the expedition showed its
appreciation of the warm reception by preparing for their
hosts in return a great feast, at which plenty of mutton and
boiled rice were eaten by some fifty Arabs, and the old bond
of friendship was cemented anew with 'bread and salt.'" …
"Doubtless all the advantages resulting for the Affej Bed'ween

and their allies from the presence of the Americans were
carefully calculated by them in the three years (February,
1896-1899) that we had withdrawn our expedition from their
territory. They have apparently found out that the
comparatively large amount of money brought into their country
through the wages paid to many Arabs employed as workmen, and
through the purchase of milk, eggs, chicken, mutton, and all
the other material supplied by the surrounding tribes for our
camp, with its about two hundred and fifty persons, has done
much to improve their general condition. The conviction has
been growing with them that we have not come to rob them of
anything to which they attach great value themselves, nor to
establish a new military station for the Turkish government in
order to gather taxes and unpaid debts. Every Arab engaged by
the Expedition has been fairly treated, and help and
assistance have always been given cheerfully and gratis to the
many sick people who apply daily for medicine, suffering more
or less during the whole year from pulmonary diseases, typhoid
and malarial fevers, easily contracted in the midst of the
extended marshes which they inhabit."
In the "Sunday School Times" of August 5, in the same year,

Professor Hilprecht reported: "The mounds of Nippur seem to
conceal an almost inexhaustible treasure of inscribed
cuneiform tablets, by means of which we are enabled to restore
the chronology, history, religion, and the high degree of
civilization, obtained at a very early date by the ancient
inhabitants between the lower Euphrates and Tigris. More than
33,000 of these precious documents were found during the
previous campaigns. Not less than 4,776 tablets have been
rescued from February 6 to June 10 this year, averaging,
therefore, nearly 1,200 'manuscripts in clay,' as we may style
them, per month. About the fourth part of these tablets is in
perfect condition, while a very large proportion of the
remaining ones are good-sized fragments or tablets so
fortunately broken that their general contents and many
important details can be ascertained by the patient
decipherer."
In November, 1899, Professor Hilprecht started for the field,

to superintend the explorations in person, and on the way he
wrote to the "S. S. Times" (published December 13): "The
deeper the trenches of the Babylonian Expedition of the
University of Pennsylvania descend into the lower strata of
Nippur, the probable site of the biblical Calneh, the more
important and interesting become the results obtained. The
work of clearing the northeastern wall of the high-towering
temple of Bel was continued with success during the summer
months. Particularly numerous were the inscribed vase
fragments brought to light, and almost exclusively belonging
to the pre-Sargonic period,—3800 B. C. and before. As I showed
in the second part of Volume I of our official University
publication, this fragmentary condition of the vases is due to
the wilful destruction of the temple property by the
victorious Elamitic hordes, who, towards the end of the third
pre-Christian millennium, ransacked the Babylonian cities,
extending their conquest and devastation even as far as the
shores of the Mediterranean Sea (comp. Gen. 14). From the
earliest historical period down to about 2200 B. C., when this
national calamity befell Babylonia, the large temple
storehouse, with its precious statues, votive slabs and vases,
memorial stones, bronze figures, and other gifts from powerful
monarchs and governors, had practically remained intact. What,
therefore, is left of the demolished and scattered contents of
this ancient chamber as a rule is found above the platform of
Ur-Ninib (about 2500 B. C.), in a layer several feet thick and
about twenty-five feet wide, surrounding the front and the two
side walls of the temple. The systematic clearing and
examination of this layer, and of the huge mass of ruins lying
above it, occupied the attention of the expedition
considerably in the past years, and was continued with new
energy during the past six months." At the end of January,
1900, Professor Hilprecht arrived in Babylonia, and wrote some
weeks later to the "Sunday School Times" (May 3): "As early as
eleven years ago, the present writer pointed out that the
extensive group of hills to the southwest of the temple of Bel
must be regarded as the probable site of the temple library of
ancient Nippur. About twenty-five hundred tablets were rescued
from the trenches in this hill during our first campaign.
Later excavations increased the number of tablets taken from
these mounds to about fifteen thousand. But it was only within
the last six weeks that my old theory could be established
beyond any reasonable doubt.
{16}
During this brief period a series of rooms was exposed which
furnished not less than over sixteen thousand cuneiform
documents, forming part of the temple library during the
latter half of the third millennium B. C. In long rows the
tablets were lying on ledges of unbaked clay, serving as
shelves for these imperishable Old Babylonian records. The
total number of tablets rescued from different parts of the
ruins during the present campaign amounts even now to more
than twenty-one thousand, and is rapidly increased by new
finds every day. The contents of this extraordinary library
are as varied as possible. Lists of Sumerian words and
cuneiform signs, arranged according to different principles,
and of fundamental value for our knowledge of the early
non-Semitic language of the country, figure prominently in the
new 'find.' As regards portable antiquities of every
description, and their archeological value, the American
expedition stands readily first among the three expeditions at
present engaged in the exploration of Ancient Babylonia and
the restoration of its past history."
Three weeks later he added: "The Temple Library, as indicated

in the writer's last report, has been definitely located at
the precise spot which, in 1889, the present writer pointed
out as its most probable site. Nearly eighteen thousand
cuneiform documents have been rescued this year from the
shelves of a series of rooms in its southeastern and
northwestern wings. The total number of tablets (mostly of a
didactic character) obtained from the library up to date is
from twenty-five thousand to twenty-six thousand tablets
(whole and broken). In view, however, of more important other
duties to be executed by this expedition before we can leave
Nippur this year, and in consideration of the enormous amount
of time and labor required for a methodical exploration of the
whole mound in which it is concealed, I have recently ordered
all the gangs of Arabic workmen to be withdrawn from this
section of ancient Nippur, and to be set at work at the
eastern fortification line of the city, close to the
temple-complex proper. According to a fair estimate based upon
actual finds, the unique history of the temple, and
topographical indications, there must be hidden at least from
a hundred thousand to a hundred and fifty thousand tablets
more in this ancient library, which was destroyed by the
invading Elamites about the time of Abraham's emigration from
Ur of the Chaldees. Only about the twentieth part of this
library (all of Dr. Haynes's previous work included) has so
far been examined and excavated."
In the same letter the Professor described the uncovering of

one façade of a large pre-Sargonic palace—"the chief
discovery," in his opinion, "of this whole campaign." "A
thorough excavation of this large palace," he wrote, "will
form one of the chief tasks of a future expedition, after its
character, age, and extent have been successfully determined
by the present one. Important art treasures of the Tello type,
and literary documents, may reasonably be expected to be
unearthed from the floor-level of its many chambers. It has
become evident, from the large number of pre-Sargonic
buildings, walls, and other antiquities discovered on both
sides of the Shatt-en-Nil, that the pre-Sargonic Nippur was of
by far greater extent than had been anticipated. This
discovery, however, is only in strict accord with what we know
from the cuneiform documents as to the important historical
rôle which the temple of Bel ('the father of the gods'), as
the central national sanctuary of ancient Babylonia, played at
the earliest period, long before Babylon, the capital of the
later empire, achieved any prominence."
The work at Nippur was suspended for the season about the
middle of May, 1900, and Professor Hilprecht, after his return
to Philadelphia, wrote of the general fruits of the campaign,
in the "Sunday School Times" of December 1: "As the task of
the fourth and most recent expedition, just completed, I had
mapped out, long before its organization, the following work.
It was to determine the probable extent of the earliest
pre-Sargonic settlement at ancient Nippur; to discover the
precise form and character of the famous temple of Bêl at this
earliest period; to define the exact boundaries of the city
proper; if possible, to find one or more of the great city
gates frequently mentioned in the inscriptions; to locate the
great temple library and educational quarters of Nippur; to
study the different modes of burial in use in ancient
Babylonia; and to study all types and forms of pottery, with a
view to finding laws for the classification and determination
of the ages of vases, always excavated in large numbers at
Nuffar. The work set before us has been accomplished. The task
was great,—almost too great for the limited time at our
disposal. … But the number of Arab workmen, busy with pickax,
scraper, and basket in the trenches for ten to fourteen hours
every day, gradually increased to the full force of four
hundred. … In the course of time, when the nearly twenty-five
thousand cuneiform texts which form one of the most
conspicuous prizes of the present expedition have been fully
deciphered and interpreted; when the still hidden larger mass
of tablets from that great educational institution, the temple
library of Calneh-Nippur, discovered at the very spot which I
had marked for its site twelve years ago, has been brought to
light,—a great civilization will loom up from past
millenniums before our astonished eyes. For four thousand
years the documents which contain this precious information
have disappeared from sight, forgotten in the destroyed rooms
of ancient Nippur. Abraham was about leaving his ancestral
home at Ur when the great building in which so much learning
had been stored up by previous generations collapsed under the
ruthless acts of the Elamite hordes. But the light which
begins to flash forth from the new trenches in this lonely
mound in the desert of Iraq will soon illuminate the world
again. And it will be no small satisfaction to know that it
was rekindled by the hands of American explorers."
{17}

German exploration of the ruins of Babylon.
An expedition to explore the ruins of Babylon was sent out by

the German Orient Society, in 1899, under the direction of Dr.
Koldewey, an eminent architect and archæologist, who had been
connected with previous works of excavation done in Babylonia
and northern Syria. In announcing the project, in the "Sunday
School Times" of January 28, 1899, Professor Hilprecht
remarked: "These extended ruins will require at least fifty
years of labor if they are to be excavated as thoroughly and
systematically as the work is done by the American expedition
at Nippur, which has employed in its trenches never less than
sixty, but frequently from two hundred to four hundred, Arabic
workmen at the same time during the last ten years. Certain
parts of the ruins of Babylon have been previously explored
and excavated by Layard, Rawlinson, and the French expedition
under Fresnel and Oppert, to which we owe the first accurate
details of the topography of this ancient city." Writing
somewhat more than a year later from Nippur, after having
visited the German party at Babylon, Professor Hilprecht said
of its work: "The chief work of the expedition during the past
year was the exploration of the great ruin heap called
El-Kasr, under which are hidden the remains of the palace of
Nebuchadrezzar, where Alexander the Great died after his
famous campaign against India. Among the few important
antiquities so far obtained from this imposing mound of
Ancient Babylon is a new Hittite inscription and a
neo-Babylonian slab with an interesting cuneiform legend. Very
recently, Dr. Koldewey, whose excellent topographical surveys
form a conspicuous part of the results of the first year, has
found the temple of the goddess Nin-Makh, so often mentioned
in the building inscriptions of the neo-Babylonian rulers, and
a little terra-cotta statue of the goddess. The systematic
examination of the enormous mass of ruins covering Ancient
Babylon will require several decenniums of continued hard
labor. To facilitate this great task, a bill has been
submitted to the German Reichstag requesting a yearly
government appropriation of over fifteen thousand dollars,
while at the same time application has been made by the German
Orient Committee to the Ottoman Government for another firman
to carry on excavations at Warka, the biblical Erech, whose
temple archive was badly pillaged by the invading Elamites at
about 2280 B. C."
Some account of results from the uncovering of the palace of

Nebuchadrezzar are quoted from "Die Illustrirte Zeitung" in
the "Scientific American Supplement," December 16, 1899, as
follows: "According to early Babylonian records,
Nebuchadnezzar completed the fortifications of the city, begun
by his father Narbolpolassar, consisting of a double inclosure
of strong walls, the inner called Imgur-Bel ('Bel is
gracious'), the outer Nemitti-Bel ('foundation of Bel'). The
circumference of the latter according to Herodotus was 480
stades (55 miles), its height 340 feet, and its thickness 85
feet. At the inner and outer peripheries, one-story houses
were built, between which was room enough for a chariot drawn
by four horses harnessed abreast. When Koldewey cut through
the eastern front of Al Kasr, he came upon a wall which was
undoubtedly that described by Herodotus. The outer eastern
shell was composed of burnt brick and asphalt, 24 feet in
thickness; then came a filling of sand and broken stone 70½
feet in thickness, which was followed by an inner western
shell of 43 feet thickness. The total thickness was,
therefore, 137.5 feet. By dint of hard work this wall was cut
through and the entrance to Nebuchadnezzar's palace laid bare.
Koldewey and his men were enabled to verify the description
given by Diodorus of the polychromatic reliefs which graced
the walls of the royal towers and palaces. It still remains to
be seen how trustworthy are the statements of other ancient
historians. The city itself, as previous investigators have
found, was adorned with many temples, chief among them Esaglia
('the high towering house'), temple of the city, and the national
god Marduk (Merodach) and his spouse Zirpanit. Sloping toward
the river were the Hanging Gardens, one of the world's seven
wonders, located in the northern mound of the ruins of Babel.
The temple described by Herodotus is that of Nebo, in
Borsippa, not far from Babylon, which Herodotus included under
Babylon and which the cuneiform inscriptions term 'Babylon the
Second.' This temple, which in the mound of Birs Nimrûd is the
most imposing ruin of Babylon, is called the 'eternal house'
in the inscriptions; it was restored by Nebuchadnezzar with
great splendor. In form, it is a pyramid built in seven
stages, for which reason it is sometimes referred to as the
'Temple of the Seven Spheres of Heaven and Earth.' The Tower
of Babel, described in Genesis x., is perhaps the same
structure. It remains for the German expedition to continue
its excavations in Nebuchadnezzar's palace."

Discovery of an inscription of Nabonidos,
the last of the Babylonian kings.
"A discovery of the greatest importance has just been made by

Father Scheil, who has for some time been exploring in
Babylonia. In the Mujelibeh mound, one of the principal heaps
of ruins in the 'enciente' of Babylon, he has discovered a
long inscription of Nabonidos, the last of the Babylonian
Kings (B. C. 555-538), which contains a mass of historical and
other data which will be of greatest value to students of this
important period of Babylonian history. The monument in
question is a small 'stela' of diorite, the upper part of
which is broken, inscribed with eleven columns of writing, and
which appears to have been erected early in the King's reign.
It resembles in some measure the celebrated India-House
inscription of Nebuchadnezzar, but is much more full of
historical matter. Its value may be estimated when it is
stated that it contains a record of the war of revenge
conducted by the Babylonians and their Mandian allies against
Assyria, for the destruction of the city by Sennacherib, in B.
C. 698; an account of the election and coronation of Nabonidos
in B. C. 555, and the wonderful dream in which Nebuchadnezzar
appeared to him; as well as an account of the restoration of
the temple of the Moon god at Kharran, accompanied by a
chronological record which enables us to fix the date of the
so-called Scythian invasion. There is also a valuable
reference to the murder of Sennacherib by his son in Tebet, B.
C. 681."
American Journal of Archœology,

January-March, 1896.
ARCHÆOLOGICAL RESEARCH: Persia:

French exploration of the ruins of Susa,
the capital of ancient Elam.
"In 1897 an arrangement was completed between the French

Government and the Shah of Persia by which the former obtained
the exclusive right of archeological explorations in the
latter's empire, coupled with certain privileges for the
exportation of different kinds of antiquities that might be
unearthed. Soon afterwards, M. J. de Morgan, late director of
excavations in Egypt, who had made archeological researches in
the regions east of the Tigris before, was placed at the head
of a French expedition to Susa, the ancient capital of Elam,
the upper strata of which had been successfully explored by M.
Dieulafoy.
{18}
In the Babylonian cuneiform inscriptions Elam appears as the
most terrible foe of the Babylonian empire from the earliest
time: and the name of its capital, Susa, or Shâsha, was
discovered by the present editor several years ago on a small
votive object in agate, originally manufactured and inscribed
in southern Babylonia, in the first half of the third
pre-christian millennium, several hundred years afterwards
carried away as part of their spoil by the invading Elamites,
and in the middle of the fourteenth century B. C. recaptured,
reinscribed, and presented to the temple of Nippur by King
Kurigalzu, after his conquest of Susa. It was therefore
evident that, if the same method of excavating was applied to
the ruins of Susa as had been applied so successfully by the
University of Pennsylvania's expedition in Nippur, remarkable
results would soon be obtained, and amply repay all labor and
money expended. M. de Morgan, accompanied by some engineers
and architects, set hopefully to work, cutting his trenches
more than fifty feet below the ruins of the Achæmenian
dynasty. The first campaign, 1897-98, was so successful, in
the discovery of buildings and inscribed antiquities, that in
October of last year the French government despatched the
Assyriologist Professor Scheil, in order to decipher the new
cuneiform documents, and to report on their historical
bearings.
"Among the more important finds so far made, but not yet
published, maybe mentioned over a thousand cuneiform tablets
of the earlier period, a beautifully preserved obelisk more
than five feet high, and covered with twelve hundred lines of
Old Babylonian cuneiform writing. It was inscribed and set up
by King Manishtusu, who left inscribed vases in Nippur and
other Babylonian cities. A stele of somewhat smaller size,
representing a battle in the mountains, testifies to the high
development of art at that remote period. On the one end it
bears a mutilated inscription of Narâm-Sin, son of Sargon the
Great (3800 B. C.); on the other, the name of Shimti-Shilkhak,
a well-known Elamitic king, and grandfather of the biblical
Ariokh (Genesis 14). These two monuments were either left in
Susa by the two Babylonian kings whose names they bear, after
successful operations against Elam, or they were carried off
as booty at the time of the great Elamitic invasion, which
proved so disastrous to the treasure-houses and archives of
Babylonian cities and temples [see above: BABYLONIA]. The
latter is more probable to the present writer, who in 1896
('Old Babylonian Inscriptions,' Part II, page 33) pointed out,
in connection with his discussion of the reasons of the
lamentable condition of Babylonian temple archives, that on
the whole we shall look in vain for well-preserved large
monuments in most Babylonian ruins, because about 2280 B. C.
'that which in the eyes of the national enemies of Babylonia
appeared most valuable was carried to Susa and other places:
what did not find favor with them was smashed and scattered on
Babylonian temple courts.'"
Prof. H. V. Hilprecht,
Oriental Research
(Sunday School Times, January 28, 1809).
ARCHÆOLOGICAL RESEARCH: Egypt:

Earlier explorations.
For some account of earlier archæological explorations in

Egypt,
See, in volume 1,
EGYPT.
ARCHÆOLOGICAL RESEARCH: Egypt:

Results of recent exploration.
The opening up of prehistoric Egypt.
The tomb of Mena.
The funeral temple of Merenptah.
Single mention of the people of Israel.
"During all this century in which Egyptian history has been

studied at first hand, it has been accepted as a sort of axiom
that the beginnings of things were quite unknown. In the
epitome of the history which was drawn up under the Greeks to
make Egypt intelligible to the rest of the world, there were
three dynasties of kings stated before the time of the great
pyramid builders; and yet of those it has been commonly said
that no trace remained. Hence it has been usual to pass them
by with just a mention as being half fabulous, and then to
begin real history with Senefern or Khufu (Cheops), the kings
who stand at the beginning of the fourth dynasty, at about
4000 B. C. The first discovery to break up this habit of
thought was when the prehistoric colossal statues of Min, the
god of the city of Koptos, were found in my excavations in his
temple. These had carvings in relief upon them wholly
different from anything known as yet in Egypt, and the
circumstances pointed to their being earlier than any carvings

Textbook Joint Preservation in The Adult Knee 1St Edition E Carlos Rodriguez Merchan Ebook All Chapter PDF

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Textbook Joint Preservation in The Adult Knee 1St Edition E Carlos Rodriguez Merchan Ebook All Chapter PDF

Uploaded by

Copyright:

Available Formats

Joint Preservation in the Adult Knee 1st

Edition E. Carlos Rodríguez-Merchán

Hip Joint Restoration Worldwide Advances in Arthroscopy

Regenerative Strategies for the Treatment of Knee Joint

Foundations and Adult Health Nursing E-Book Eighth

Preservation 1st Edition Christina Ward

The hip joint 1st Edition Iyer

Cardiac Surgery in the Adult 5th Edition Lawrence H.

The Complete Guide to Male Fertility Preservation 1st

The Knee Injury Bible Everything You Need to Know about

Joint Preservation in the

ISBN 978-3-319-41807-0 ISBN 978-3-319-41808-7 (eBook)

Library of Congress Control Number: 2016956096

© Springer International Publishing Switzerland 2017

Printed on acid-free paper

This Springer imprint is published by Springer Nature

The orthopaedic surgeon of today has access to an unprecedented selection of

E. Carlos Rodríguez-Merchán Madrid, Spain

1 Examination of the Knee . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

13 Bone Tumors Around the Knee . . . . . . . . . . . . . . . . . . . . . . . . . . 153

© Springer International Publishing Switzerland 2017 1

This chapter is arranged according to the

Alignment should be assessed in the static

1.2.1.1 Patient Standing

Axial plane This can also be assessed with the

Sagittal (a) The extensor mechanism.

1.2.2 Examination of Knee • “Inverse J sign” – lateral subluxation of the

examination of the knee is more comfortable 1.3 Feel

As previously mentioned, not all tests have to

Fig. 1.5 Position of hands whilst performing Lachman’s test

The most reliable method of achieving muscle 1.5.3 Meniscal Tests

The advance has not been the ‘correct’ use of

© Springer International Publishing Switzerland 2017 13

2.2.2 Limb Alignment 2.3.1.1 Sequences

this field strength is adequate for most applica-

The medullary portion of bone is mainly com-

increases in the use of MRI for OA, new

The meniscus is rich in proteoglycans; this

Fig. 2.4 Axial section of knee in 32 year old healthy vol-

Current clinical MRI platforms have field Conclusions

3.1 Introduction There is no therapeutic agent proven to mod-

© Springer International Publishing Switzerland 2017 23

Bulletin of the Bureau of American Republics,

A plan of government for the International Union, by an

"The Bureau of the American Republics will be governed under

"The interest taken by the various States forming the

Message of the President of the United States.

See (in this volume)

AMNESTY BILL, The French.

See (in this volume)

See (in this volume)

Assassination of the Empress of Austria.

See (in this volume)

Assassination of King Humbert.

See (in this volume)

ANATOLIAN RAILWAY, The.

See (in this volume)

ANCON, The Treaty of.

ANDERSON, General Thomas M.:

See (in this volume)

ANDRÉE, Salamon August:

See (in this volume)

See (in this volume)