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Robbins JB, Stahel SA, Morris RP, Jupiter DC, Chen J, Panchbhavi VK. Radiographic Anatomy of the Lateral Ankle Ligament Complex: A Cadaveric Study. Foot Ankle Int 2024; 45:179-187. [PMID: 37994643 PMCID: PMC10860354 DOI: 10.1177/10711007231213355] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2023]
Abstract
BACKGROUND When lateral ankle sprains progress into chronic lateral ankle instability (CLAI), restoring precise anatomic relationships of the lateral ankle ligament complex (LALC) surgically is complex. This study quantifies the radiographic relationships between the anterior talofibular ligament (ATFL), calcaneofibular ligament (CFL), and prominent osseous landmarks visible under fluoroscopy to assist in perioperative practices for minimally invasive surgery for CLAI. METHODS Ten fresh frozen ankle specimens were dissected to expose the LALC and prepared by threading a radiopaque filament through the ligamentous footprints of the ATFL and CFL. Fluoroscopic images were digitally analyzed to define dimensional characteristics of the ATFL and CFL. Directional measurements of the ligamentous footprints relative to the lateral process of the talus and the apex of the posterior facet of the calcaneus were calculated. RESULTS Dimensional measurements of the ATFL were a mean length of 9.3 mm, fibular footprint of 9.4 mm, and talar footprint of 9.1 mm. Dimensional measurements of the CFL were a mean length of 19.4 mm, fibular footprint of 8.2 mm, and calcaneal footprint of 7.3 mm. From the radiographic apparent tip of the lateral process of the talus, the fibular attachment of the ATFL was found 13.3 mm superior and 4.4 mm posterior, whereas the talar attachment was found 11.5 mm superior and 4.8 mm anterior. From the radiographic apparent posterior apex of the posterior facet of the calcaneus, the fibular attachment of the CFL was found 0.2 mm inferior and 6.8 mm anterior, whereas the calcaneal attachment was found 14.3 mm inferior and 5.9 mm posterior. CONCLUSION The ATFL and CFL were radiographically analyzed using radiopaque filaments to outline the ligamentous footprints in their native locations. These ligaments were also localized with reference to 2 prominent osseous landmarks. These findings may assist in perioperative practices for keyhole incision placement and arthroscopic guidance. Perfect lateral ankle joint imaging with talar domes superimposed is required to be able to do this. CLINICAL RELEVANCE Radiographic evaluation of the ATFL and CFL with reference to prominent osseous landmarks identified under fluoroscopy may assist in perioperative practices for minimally invasive surgery to address CLAI for keyhole incision placement and arthroscopic guidance.
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Affiliation(s)
- Jordan B. Robbins
- John Sealy School of Medicine, The University of Texas Medical Branch, Galveston, TX, USA
| | - Shepheard A. Stahel
- John Sealy School of Medicine, The University of Texas Medical Branch, Galveston, TX, USA
| | - Randal P. Morris
- Department of Orthopaedic Surgery and Rehabilitation, The University of Texas Medical Branch, Galveston, TX, USA
| | - Daniel C. Jupiter
- Department of Orthopaedic Surgery and Rehabilitation, The University of Texas Medical Branch, Galveston, TX, USA
- Department of Biostatistics and Data Science, The University of Texas Medical Branch, Galveston, TX, USA
| | - Jie Chen
- Department of Orthopaedic Surgery and Rehabilitation, The University of Texas Medical Branch, Galveston, TX, USA
| | - Vinod K. Panchbhavi
- Department of Orthopaedic Surgery and Rehabilitation, The University of Texas Medical Branch, Galveston, TX, USA
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Fujishiro H, Nimura A, Azumaya M, Hattori S, Hoshi O, Akita K. Anatomical study of the bone morphology of the anterior talofibular ligament attachment. Anat Cell Biol 2023; 56:334-341. [PMID: 37482888 PMCID: PMC10520850 DOI: 10.5115/acb.23.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2023] [Revised: 03/23/2023] [Accepted: 05/19/2023] [Indexed: 07/25/2023] Open
Abstract
Anterior talofibular ligament (ATFL) injuries are the most common cause of ankle sprains. To ensure anatomically accurate surgery and ultrasound imaging of the ATFL, anatomical knowledge of the bony landmarks around the ATFL attachment to the distal fibula is required. The purpose of the present study was to anatomically investigate the ATFL attachment to the fibula with respect to bone morphology and attachment structures. First, we analyzed 36 feet using microcomputed tomography. After excluding 9 feet for deformities, the remaining 27 feet were used for chemically debrided bone analysis and macroscopic and histological observations. Ten feet of living specimens were observed using ultrasonography. We found that a bony ridge was present at the boundary between the attachments of the ATFL and calcaneofibular ligament (CFL) to the fibula. These two attachments could be distinguished based on a difference in fiber orientation. Histologically, the ATFL was attached to the anterodistal part of the fibula via fibrocartilage anterior to the bony ridge indicating the border with the CFL attachment. Using ultrasonography in living specimens, the bony ridge and hyperechoic fibrillar pattern of the ATFL could be visualized. We established that the bony ridge corresponded to the posterior margin of the ATFL attachment itself. The ridge was obvious, and the superior fibers of the ATFL have directly attached anteriorly to it. This bony ridge could become a valuable and easy-to-use landmark for ultrasound imaging of the ATFL attachment if combined with the identification of the fibrillar pattern of the ATFL.
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Affiliation(s)
- Hitomi Fujishiro
- Department of Anatomy and Physiological Science, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
| | - Akimoto Nimura
- Department of Functional Joint Anatomy, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
| | - Mizuki Azumaya
- Department of Anatomy and Physiological Science, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
| | - Soichi Hattori
- Department of Clinical Anatomy, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
- Department of Sports Medicine, Kameda Medical Center, Chiba, Japan
| | - Osamu Hoshi
- Department of Anatomy and Physiological Science, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
| | - Keiichi Akita
- Department of Clinical Anatomy, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
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Xie X, Chen L, Fan C, Song S, Yu Y, Jiao C, Pi Y. The lowest point of fibula (LPF) could be used as a reliable bony landmark for arthroscopic anchor placement of lateral ankle ligaments ----compared with open Broström procedure. BMC Musculoskelet Disord 2023; 24:759. [PMID: 37749543 PMCID: PMC10521499 DOI: 10.1186/s12891-023-06876-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Accepted: 09/12/2023] [Indexed: 09/27/2023] Open
Abstract
BACKGROUND Arthroscopic technique procedures was wide accepted for the treatment of chronic ankle instability (CAI). But little acknowledge was involved to the bony landmarks and anatomic features of different bundles of lateral ligaments under arthroscopic view. METHODS Sixty patients with acute or chronic lateral ankle ligaments injury (LAI) were collected prospectively, and divided randomly into two groups. In arthroscopic group, the bone tunnels were made on the LPF arthroscopically. And in open group, the bone tunnels were made on the Fibular obscure tubercle (FOT) in open procedure. The inferior bundle of ATFL and Arcuate fibre was also identified reference to the LPF and labeled by a PDS II suture penetration. Following that, The distances of the bone tunnels to the different bony markers were measured and compare between two groups. The penetrating locations of PDS II on the inferior bundle of ATFL and Arcuate fibre were also confirmed intraoperatively. And the safe angle of anchor implantation on the axial view was measured on postoperative CT scan. RESULTS The distances of bone tunnel to the fibular tip, the fibular insertion of anterior-inferior tibiofibular ligament (AITFL), and the FOT in arthroscopic and open locating groups were 4.9 ± 2.2 and 6.3 ± 2.2 mm, 13.5 ± 2.7 and 12.4 ± 1.1 mm, 5.8 ± 2.2 and 5.6 ± 1.0 mm, respectively. The distances of bone tunnels to the FOT and fibular tip on 3d-CT view was 4.4 ± 1.5 and 4.6 ± 0.9 mm, 14.4 ± 3.2 and 13.2 ± 1.8 mm in arthroscopic and open group, and there were no significant differences between two groups. The safe angle of arthroscopic anchor placement on the axial plan was ranged from 24.9 ± 6.3o to 58.1 ± 8.0o. The PDS II sutures penetrating on the inferior bundles of ATFL and the arciform fibres were also comfirmed successfully by open visualizaion.The average distance of penetration point to the horizontal line cross the fibular tip was 2.3 ± 2.7 mm (ranged from - 3.1 to 6.0 mm), and to the vertical line cross the FOT was 2.7 ± 2.7 mm (ranged from - 2.5 to 7.5 mm). CONCLUSION Take the lowest point of fibula under arthroscopy (LPF) as a bony reference, we could identify the iATFL under arthroscopic visualization. By this way, we could place the suture anchors properly to the fibular footprint and suture the iATFL fibres successfully.
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Affiliation(s)
- Xin Xie
- Institute of Sports Medicine, Peking University Third Hospital, 49 North Garden Road, Haidian District, Beijing, 100191, PR China
| | - Linxin Chen
- Institute of Sports Medicine, Peking University Third Hospital, 49 North Garden Road, Haidian District, Beijing, 100191, PR China
| | - Cunshuai Fan
- Orthopedics Dept.1, Pingdingshan first people's Hospital, Pingdingshan city, Henan province, PR China
| | - Shouyi Song
- Institute of Sports Medicine, Peking University Third Hospital, 49 North Garden Road, Haidian District, Beijing, 100191, PR China
| | - Yin Yu
- Institute of Sports Medicine, Peking University Third Hospital, 49 North Garden Road, Haidian District, Beijing, 100191, PR China
| | - Chen Jiao
- Institute of Sports Medicine, Peking University Third Hospital, 49 North Garden Road, Haidian District, Beijing, 100191, PR China.
| | - Yanbin Pi
- Institute of Sports Medicine, Peking University Third Hospital, 49 North Garden Road, Haidian District, Beijing, 100191, PR China.
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Chen L, Xie X, Cao P, Guo Q, Jiang D, Jiao C, Pi Y. Arthroscopic and Open Procedures Result in Similar Calcaneal Tunnels for Anatomical Reconstruction of Lateral Ankle Ligaments. Arthrosc Sports Med Rehabil 2023; 5:e687-e694. [PMID: 37388872 PMCID: PMC10300538 DOI: 10.1016/j.asmr.2023.03.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2022] [Accepted: 03/29/2023] [Indexed: 07/01/2023] Open
Abstract
Purpose The purpose of this study was to validate the accuracy and reliability of arthroscopic markers of distal insertion of the calcaneofibular ligament (CFL), and to compare the calcaneus bone tunnels of the CFL that were made under arthroscopy and open procedures. Methods Fifty-seven patients who underwent lateral ankle ligament reconstruction procedures were enrolled and divided into open (n = 24) and arthroscopic groups (n = 33). Lateral ankle radiography was performed postoperatively, and the calcaneus bone tunnels referenced to several landmarks, including the subtalar joint, calcaneus superior edge, fibular tip, angulation with fibula axis, cross point of the fibular and tangential line of the fibular obscure tubercle cross point of the tangential lines of the talar posterior edge and deepest point of the subtalar joint, and cross point of the fibular axis and perpendicular line across fibular tip. These results were compared between the two groups. Results No significant intergroup differences were observed between the parameters. When the bone tunnels of the CFL were referenced to the cross point of tangential lines of the talar posterior edge and deepest point of the subtalar joint, and the cross point of the fibular axis and perpendicular line across fibular tip, the coefficient variations were very high, which indicated that the locations of the bone tunnels were scattered over a large area in both groups. Conclusions Arthroscopic and open procedures achieved similar results for calcaneus bone tunnel making of the CFL. However, large variations were observed in both groups. Level of Evidence Level III, retrospective cohort study.
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Affiliation(s)
- Linxin Chen
- Institute of Sports Medicine, Peking University Third Hospital, Haidian District, Beijing, People’s Republic of China
| | - Xin Xie
- Institute of Sports Medicine, Peking University Third Hospital, Haidian District, Beijing, People’s Republic of China
| | - Peng Cao
- Orthopedics Dept. 1, CangZhou Hospital of Integrated TCM-WM, Cangzhou City, Hebei Province, People’s Republic of China
| | - Qinwei Guo
- Institute of Sports Medicine, Peking University Third Hospital, Haidian District, Beijing, People’s Republic of China
| | - Dong Jiang
- Institute of Sports Medicine, Peking University Third Hospital, Haidian District, Beijing, People’s Republic of China
| | - Chen Jiao
- Institute of Sports Medicine, Peking University Third Hospital, Haidian District, Beijing, People’s Republic of China
| | - Yanbin Pi
- Institute of Sports Medicine, Peking University Third Hospital, Haidian District, Beijing, People’s Republic of China
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Wang D, Shen Z, Fang X, Jiao C, Guo Q, Hu Y, Yu J, Jiang D, Zhang W. Vascular Compromising Effect of Drilling for Osteochondral Lesions of the Talus: A Three-Dimensional Micro-Computed Tomography Study. Arthroscopy 2019; 35:2930-2937. [PMID: 31439459 DOI: 10.1016/j.arthro.2019.05.021] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2019] [Revised: 05/03/2019] [Accepted: 05/09/2019] [Indexed: 02/02/2023]
Abstract
PURPOSE To explore an optimal drilling depth and direction for osteochondral lesions of the talus based on a 3-dimensional vascular microarchitecture model constructed with micro-computed tomography (microCT). METHODS Twelve tali were perfused with the contrast agent and then scanned with microCT. The talar dome was divided into 9 zones, and the vessel densities were measured at the subchondral depths of 0 to 5 mm, 5 to 10 mm and 10 to 15 mm in each zone. The anterolateral (AL) and posterolateral (PL) approaches of retrograde drilling were simulated and the vascular compromising effect was evaluated. RESULTS The vessel density of the 0- to 5-mm depth was lower than that of the 5- to 10-mm (P = .001) and 10- to 15-mm (P = .007) depths, but no significant difference was found between the 5- to 10-mm and 10- to 15-mm depths (P > .9999). The vessel density in the 5- to 10-mm depth of medial talar dome was similar to that of the adjacent zones (P = .05). Vessel density in the 5- to 10-mm depth around the lateral talar dome was higher in the anterior and medial side. The anterolateral approach disturbed the main intraosseous vessels from the tarsal canal-tarsal sinus, causing extensive vascular compromise in the talus neck and body, whereas the posterolateral approach disturbed only the vessels near the tunnel. CONCLUSIONS The vessel density changed greatly from the subchondral 0- to 5-mm to the 5- to 10-mm depth. The vessel densities of the 5- to 10-mm depth around the medial talar dome were similar, whereas the anterior and medial side of the lateral talar dome was better vascularized. The posterolateral approach caused less vascular damage than the anterolateral approach. CLINICAL RELEVANCE The anterograde drilling depth was preferable to the subchondral 5- to 10-mm depth. There was no preferred drilling direction for the osteochondral lesion in the medial talar dome, whereas it is preferable to drill anteriorly or medially in the lateral dome. The posterolateral approach might be a safer alternative for retrograde drilling.
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Affiliation(s)
- Dingyu Wang
- Department of Human Anatomy and Histology and Embryology, Peking University, Beijing, P. R. China; Institute of Sports Medicine, Beijing Key Laboratory of Sports Injuries, Peking University Third Hospital, Beijing, P. R. China
| | - Zhongcheng Shen
- Department of Human Anatomy and Histology and Embryology, Peking University, Beijing, P. R. China; Institute of Sports Medicine, Beijing Key Laboratory of Sports Injuries, Peking University Third Hospital, Beijing, P. R. China
| | - Xuan Fang
- Department of Human Anatomy and Histology and Embryology, Peking University, Beijing, P. R. China
| | - Chen Jiao
- Institute of Sports Medicine, Beijing Key Laboratory of Sports Injuries, Peking University Third Hospital, Beijing, P. R. China
| | - Qinwei Guo
- Institute of Sports Medicine, Beijing Key Laboratory of Sports Injuries, Peking University Third Hospital, Beijing, P. R. China
| | - Yuelin Hu
- Institute of Sports Medicine, Beijing Key Laboratory of Sports Injuries, Peking University Third Hospital, Beijing, P. R. China
| | - Jiakuo Yu
- Institute of Sports Medicine, Beijing Key Laboratory of Sports Injuries, Peking University Third Hospital, Beijing, P. R. China
| | - Dong Jiang
- Institute of Sports Medicine, Beijing Key Laboratory of Sports Injuries, Peking University Third Hospital, Beijing, P. R. China.
| | - Weiguang Zhang
- Department of Human Anatomy and Histology and Embryology, Peking University, Beijing, P. R. China.
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Kakegawa A, Mori Y, Tsuchiya A, Sumitomo N, Fukushima N, Moriizumi T. Independent Attachment of Lateral Ankle Ligaments: Anterior Talofibular and Calcaneofibular Ligaments - A Cadaveric Study. J Foot Ankle Surg 2019; 58:717-722. [PMID: 31130481 DOI: 10.1053/j.jfas.2018.12.009] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2018] [Indexed: 02/03/2023]
Abstract
Anatomic knowledge of lateral ligaments around the lateral malleolus is important for repair or reconstruction of ankle instability. The detailed structure of the connective fibers between the anterior talofibular ligament (ATFL) and the calcaneofibular ligament (CFL) is unknown. To clarify the anatomic structure of ATFL and CFL and the connective fiber between the 2 ligaments, the lateral ligament was dissected in 60 ankles of formalin-fixed cadavers, and the distance was measured between bony landmarks and fibular attachment of ATFL and CFL using a digital caliper. All ankles had connective fibers between ATFL and CFL. The structure of connective fibers consisted of a thin fiber above the surface layer of ATFL and CFL; it comprised thin fibrils of the surface layer covering the lower part of ATFL and the front part of CFL. Both ATFL and CFL were independent fibers, and both attachments of the fibula were isolated. Single bands of ATFL were noted in 14 of 60 (23.3%) ankles, double bands that divided the superior and inferior bands were observed in 42 of 60 (70.0%) ankles, and multiple bands were observed in 4 of 60 (6.7%) ankles. A cord-like and a flat and fanning type of CFL was noted in 22 (36.7%) and 38 (63.3%) of the 60 ankles, respectively. Distances between ATFL/CFL and articular and inferior tips of the fibula were 4.3 ± 1.1 mm/7.6 ± 1.6 mm and 14.3 ± 1.9 mm/7.4 ± 1.7 mm, respectively (mean ± standard deviation). The results of this study suggest that knowledge of more anatomic structures of ATFL, CFL, and connective fiber will be beneficial for surgeons in the repair or reconstruction of the lateral ligament of the ankle.
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Affiliation(s)
- Akira Kakegawa
- Associate Professor, Faculty of Health Care, Teikyo Heisei University, Tokyo, Japan; Lecturer, Department of Anatomy, Shinshu University School of Medicine, Nagano, Japan.
| | - Yusuke Mori
- Orthopedic Surgeon, Toyohashi Ezaki Orthopedic Hospital, Aichi, Japan
| | | | - Norimi Sumitomo
- Technological Assistant, Department of Anatomy, Shinshu University School of Medicine, Nagano, Japan
| | - Nanae Fukushima
- Professor, Department of Anatomy, Shinshu University School of Medicine, Nagano, Japan
| | - Tetsuji Moriizumi
- Professor, Department of Anatomy, Shinshu University School of Medicine, Nagano, Japan
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Do Changes in Pelvic Rotation and Tilt Affect Measurement of the Anterior Center Edge Angle on False Profile Radiographs? A Cadaveric Study. Clin Orthop Relat Res 2019; 477:1066-1072. [PMID: 30801276 PMCID: PMC6494305 DOI: 10.1097/corr.0000000000000636] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND The false profile radiograph assesses acetabular coverage in prearthritic hip conditions. Precise rotation of this radiograph is difficult to obtain, so the clinician must interpret radiographs with nonstandard pelvic rotation or tilt, despite limited evidence of how this may affect the anterior center edge angle measurement. QUESTIONS/PURPOSES (1) Does pelvic rotation alter the measurement of the anterior center edge angle on false profile views? (2) Does pelvic tilt alter the measurement of the anterior center edge angle on false profile views? (3) Is there an objective way to assess appropriate pelvic rotation for the false profile view? METHODS Eight cadaver hips (four female, four male; one hip randomly selected per pelvis) were included in the study. Hips with degenerative changes, evidence of previous fracture or trauma, or previous surgical intervention were excluded. Specimens were between 68 to 92 years of age (median, 76 years). The specimens were fixed to a custom jig, and radiographs were taken at 5° intervals of rotation (45-85°) and 5° intervals of pelvic tilt (+10° to -10°). The primary outcome variable, anterior center edge angle, was measured for each rotation and tilt. RESULTS Every degree increase in pelvic rotation toward a true lateral resulted in 0.18° increase in the anterior center edge angle (95% confidence interval [CI], 0.07-0.29; p = 0.002). For every degree increase in pelvic tilt, the anterior center edge angle increased 0.65° (95% CI, 0.5-0.8; p < 0.001). We verified that standard pelvic rotation of 65° for a false profile radiograph was present when the space between the femoral heads is 66% to 100% of the diameter of the femoral head being imaged. CONCLUSIONS This study shows that the anterior center edge angle increases as pelvic tilt increases, with a 6° increase in anterior center edge angle for each 10° increase in pelvic tilt. Since the false profile radiograph is obtained standing, the patient should be counseled to avoid adopting a forced posture, ensuring the radiograph remains an accurate functional representation of the patient's anatomy. In contrast, pelvic rotation did not influence the anterior center edge angle by an important margin, and while we recommend that radiographs continue to be obtained with standardized pelvic rotation, aberrant pelvic rotation will likely not result in a clinically meaningful difference in anterior center edge angle measurements. In the future, studies to identify the specific regions of acetabular anatomy that constitute the radiographic measurement of the anterior center edge angle would enhance current understanding of the associated radiographic anatomy, and consequently improve the ability of the surgeon to treat the specific area of pathology. CLINICAL RELEVANCE In practice, the clinician should pay close attention to pelvic tilt, as a 10° change in tilt may cause 6° of change in the anterior center edge angle. However, false profile radiographs obtained within ± 20° of the targeted 65° of rotation will result in less than 4° change in the anterior center edge angle.
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Fu X, Ma L, Zeng Y, He Q, Yu F, Ren L, Luo B, Fu S, Zhang L. Implications of Classification of Os Trigonum: A Study Based on Computed Tomography Three-Dimensional Imaging. Med Sci Monit 2019; 25:1423-1428. [PMID: 30794531 PMCID: PMC6396439 DOI: 10.12659/msm.914485] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND The os trigonum is an accessory bone that is not fully fused with the talus during secondary ossification, and is one of the risk factors of posterior malleolus impact syndrome. The purpose of this study was to classify the os trigonum and to guide the diagnosis and treatment of related clinical diseases. MATERIAL AND METHODS Ankle computed tomography (CT) scans of 586 Chinese patients between October 2014 and October 2018 were reviewed. CT images of 1011 ankle joints were reconstructed to evaluate the classification of the os trigonum and the measurement of anatomical parameters. RESULTS The incidences of os trigonum in 3 groups were determined as type I (1.9%), type II (10.5%), and type III (14.7%). The macro-axis of type II (0.89±0.31) cm was significantly larger than with type I (0.65±0.24 cm) and type III (0.74±0.23 cm) (p<0.05).The minor axis of similar of type I (0.41±0.23 cm) was significantly shorter than that of type II (0.58±0.32 cm) and type III (0.55±0.16 cm) (p<0.05).The distance from os trigonum to calcaneal tubercle was significantly different than that of type I (1.33±0.52 cm), type II (1.67±0.55 cm), and type III (1.84±0.45 cm) (p<0.05). CONCLUSIONS This study showed that os trigonum has a high incidence. Type I was the least common, the volume of type II was larger, and type III was more common. The anatomical parameters of each type may improve treatment of related diseases and the further development of ankle arthroscopic surgery.
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Affiliation(s)
- Xiaoyong Fu
- Department of Foot and Ankle Surgery, Guangzhou Orthopedic Hospital, Guangzhou, Guangdong, China (mainland)
| | - Li Ma
- School of Integrated Chinese and Western Medicine, Southwest Medical University, Luzhou, Sichuan, China (mainland)
| | - Yan Zeng
- Department of Nephrology, Affiliated Traditional Chinese Medicine Hospital of Southwest Medical University, Luzhou, Sichuan, China (mainland)
| | - Qizhou He
- Department of Radiological, Affiliated Traditional Chinese Medicine Hospital of Southwest Medical University, Luzhou, Sichuan, China (mainland)
| | - Fei Yu
- Department of Radiological, Affiliated Traditional Chinese Medicine Hospital of Southwest Medical University, Luzhou, Sichuan, China (mainland)
| | - Lin Ren
- Department of Radiological, Affiliated Traditional Chinese Medicine Hospital of Southwest Medical University, Luzhou, Sichuan, China (mainland)
| | - Bei Luo
- School of Basic Medical, Southwest Medical University, Luzhou, Sichuan, China (mainland)
| | - Shijie Fu
- Department of Orthopedic, Affiliated Traditional Chinese Medicine Hospital of Southwest Medical University, Luzhou, Sichuan, China (mainland).,Academician Workstation in Luzhou, Luzhou, Sichuan, China (mainland)
| | - Lei Zhang
- Department of Orthopedic, Affiliated Traditional Chinese Medicine Hospital of Southwest Medical University, Luzhou, Sichuan, China (mainland).,Academician Workstation in Luzhou, Luzhou, Sichuan, China (mainland).,National Key Discipline of Human Anatomy, School of Basic Medical Sciences, Southern Medical University, Guangzhou, Guangdong, China (mainland)
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Lee DW, Park IK, Kim MJ, Kim WJ, Kwon MS, Kang SJ, Kim JG, Yi Y. Three-Dimensional computed tomography tunnel assessment of allograft anatomic reconstruction in chronic ankle instability: 33 cases. Orthop Traumatol Surg Res 2019; 105:145-152. [PMID: 30502025 DOI: 10.1016/j.otsr.2018.10.008] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2017] [Revised: 10/16/2018] [Accepted: 10/23/2018] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Although clinical results of anatomic reconstruction using allograft are reportedly good, studies on how accurately the tunnel has been made after surgery are very rare. The purpose of this study was to analyze the postoperative locations of the tunnels through 3-dimensional computed tomography (3D-CT) after anatomic ligament reconstruction and to evaluate its clinical results. HYPOTHESIS We hypothesized that anatomic lateral ligament reconstruction could lead to excellent results in clinical outcomes by repositioning anterior talofibular ligament (ATFL) and calcaneofibular ligament (CFL) accurately. MATERIALS AND METHODS Thirty-three special forces of soldiers who were diagnosed as chronic ankle instability (CAI) were included. Visual analogue scale (VAS), American orthopaedic foot and ankle society (AOFAS) ankle-hind foot functional scores, and Tegner activity scale were comparatively analyzed before the surgery and at final follow-up. The locations of the talar, fibular and calcaneal tunnels were evaluated with 3D-CT taken after the surgery. Talar tilt and anterior drawer displacement were measured on stress radiographs. RESULTS The mean follow-up period was 26.8±3.6 months. The VAS decreased from 6.9±1.6 to 1.7±1.3, AOFAS ankle-hindfoot functional score increased from 61.3±14.8 to 88.7±9.2, and Tegner activity scale improved from 5.3±1.2 to 6.4±1.3 (p<0.001). Talar tunnel for ATFL was located about68% of the way from the lateral talar process, and fibular tunnels for ATFL and CFL were approximately 52% and 20% of the way from the fibular tip. The calcaneus tunnel was approximately 17mm posterosuperior from the peroneal tubercle on 3D-CT. Talar tilt decreased from 15.8±4.8 to 3.9±2.1 degrees (p<0.001). There were excellent inter-observer agreements for CT evaluation (Kappa values were from 0.83 to 0.92). There was no relapse of lateral instability. DISCUSSION Anatomic reconstruction of the lateral ligaments using allograft and the interference screw for CAI showed good results in postoperative stability and subjective clinical evaluation by repositioning the location of ATFL and CFL accurately on radiological determination. LEVEL OF EVIDENCE IV, Case-series.
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Affiliation(s)
- Dhong Won Lee
- Department of Orthopedic Surgery, KonKuk University Medical Center, Seoul, Korea
| | - In Keun Park
- Department of Orthopedic Surgery, Inje University Seoul Paik Hospital, Seoul, Korea
| | - Min Jeong Kim
- Department of Radiology, Ewha Womans University Mokdong Hospital, Seoul, Korea
| | - Woo Jong Kim
- Department of Orthopedic Surgery, Soonchunhyang University Cheonan Hospital, Cheonan, Korea
| | - Min Soo Kwon
- Department of Orthopedic Surgery, Inje University Seoul Paik Hospital, Seoul, Korea
| | - Sung Jin Kang
- Department of Orthopedic Surgery, KonKuk University Medical Center, Seoul, Korea
| | - Jin Goo Kim
- Department of Orthopedic Surgery, KonKuk University Medical Center, Seoul, Korea
| | - Young Yi
- Department of Orthopedic Surgery, Inje University Seoul Paik Hospital, Seoul, Korea.
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Schindler BR, Venderley MB, Mikula JD, Chahla J, Dornan GJ, Turnbull TL, LaPrade RF, Philippon MJ. Comparison of Radiographs and Computed Tomography for the Screening of Anterior Inferior Iliac Spine Impingement. Arthroscopy 2017; 33:766-772. [PMID: 28063761 DOI: 10.1016/j.arthro.2016.10.018] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2016] [Revised: 09/28/2016] [Accepted: 10/20/2016] [Indexed: 02/02/2023]
Abstract
PURPOSE To compare radiographic and 3-dimensional (3D) computed tomography (CT) imaging modalities for the screening of anterior inferior iliac spine (AIIS) impingement by establishing imaging measurement related to the AIIS. METHODS Anteroposterior and false-profile radiographs and 3D CT scans were obtained on 10 human cadaveric pelvises. On the anteroposterior view for each methodology, 2 measurements were calculated: distance to the most lateral AIIS from the 12 o'clock position on the acetabular rim, and the angle between the lateral AIIS and the sagittal plane. On the false-profile view for each methodology, 2 measurements were calculated: distance to the anterior AIIS from the 12 o'clock position on the acetabular rim, and the angle between the anterior AIIS and the sagittal plane. Inter-rater and intrarater reliability analyses were performed for both methods in addition to an intermethod analysis. RESULTS The radiographic false-profile view was the most repeatable orientation, with intraclass correlation coefficients showing excellent reproducibility in both inter-rater (angle: 0.980, distance: 0.883) and intrarater (angle: 0.995, distance: 0.995) analyses. The mean distance from the 12 o'clock position of the acetabular rim to the most anterior/lateral aspect of the AIIS was 41.4 mm and 16.0 mm on the radiographic false-profile and anteroposterior views, respectively. Intermethod analysis showed a systematic, quantitative bias between modalities (anteroposterior view: -4.1 mm, 6.7°; false-profile view: -0.1 mm, 8.3°), which will remain relatively consistent as evidenced by the strong individual reproducibility of each measurement. CONCLUSIONS AIIS morphology in relation to the acetabular rim 12 o'clock position and its angle relative to the sagittal plane can be quantitatively determined using either radiographic or 3D CT imaging modalities. CLINICAL RELEVANCE Radiographic evaluation may be a valuable tool in the screening of AIIS impingement.
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Affiliation(s)
- Broc R Schindler
- Department of BioMedical Engineering, Steadman Philippon Research Institute, Vail, Colorado, U.S.A
| | - Melanie B Venderley
- Department of BioMedical Engineering, Steadman Philippon Research Institute, Vail, Colorado, U.S.A
| | - Jacob D Mikula
- Department of BioMedical Engineering, Steadman Philippon Research Institute, Vail, Colorado, U.S.A
| | - Jorge Chahla
- Department of BioMedical Engineering, Steadman Philippon Research Institute, Vail, Colorado, U.S.A
| | - Grant J Dornan
- Department of BioMedical Engineering, Steadman Philippon Research Institute, Vail, Colorado, U.S.A
| | - Travis Lee Turnbull
- Department of BioMedical Engineering, Steadman Philippon Research Institute, Vail, Colorado, U.S.A
| | - Robert F LaPrade
- Department of BioMedical Engineering, Steadman Philippon Research Institute, Vail, Colorado, U.S.A.; The Steadman Clinic, Vail, Colorado, U.S.A
| | - Marc J Philippon
- Department of BioMedical Engineering, Steadman Philippon Research Institute, Vail, Colorado, U.S.A.; The Steadman Clinic, Vail, Colorado, U.S.A..
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12
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Williams BT, James EW, Jisa KA, Haytmanek CT, LaPrade RF, Clanton TO. Radiographic identification of the primary structures of the ankle syndesmosis. Knee Surg Sports Traumatol Arthrosc 2016; 24:1187-99. [PMID: 26294053 DOI: 10.1007/s00167-015-3743-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2015] [Accepted: 07/28/2015] [Indexed: 12/14/2022]
Abstract
PURPOSE The purpose of this study was to quantitatively describe the locations of the syndesmotic ligaments and the tibiofibular articulating cartilage surfaces on standard radiographic views using reproducible radiographic landmarks and reference axes. METHODS Twelve non-paired ankles were dissected to identify the anterior-inferior tibiofibular ligament (AITFL), posterior-inferior tibiofibular ligament (PITFL), interosseous tibiofibular ligament (ITFL), and the cartilage surfaces of the syndesmosis. Structures were marked with 2-mm radiopaque spheres prior to obtaining lateral and mortise radiographs. Measurements were performed by two independent raters to assess intra- and interobserver reliability via intraclass correlation coefficients (ICCs). RESULTS Measurements demonstrated excellent agreement between observers and across trials (all ICCs ≥ 0.960). On the lateral view, the AITFL tibial origin was 9.6 ± 1.5 mm superior and posterior to the anterior tibial plafond. Its fibular insertion was 4.4 ± 1.7 mm superior and posterior to the anterior fibular tubercle. The centre of the tibial cartilage facet of the tibiofibular contact zone was 8.4 ± 2.1 mm posterior and superior to the anterior plafond. The proximal and distal aspects of the ITFL tibial attachment were 45.9 ± 7.9 and 12.4 ± 3.4 mm proximal to the central plafond, respectively. The superficial and deep PITFL coursed anterior and distally from the posterior tibia to fibula. On the mortise view, the AITFL tibial attachment centre was 5.6 ± 2.4 mm lateral and superior to the lateral extent of the plafond (4.3 mm lateral, 3.3 mm superior), and its fibular insertion was 21.2 ± 2.1 mm superior and medial to the inferior tip of the lateral malleolus. CONCLUSIONS Quantitative radiographic guidelines describing the locations of the primary syndesmotic structures demonstrated excellent reliability and reproducibility. Defined guidelines provide additional clinically relevant information regarding the radiographic anatomy of the syndesmosis and may assist with preoperative planning, augment intraoperative navigation, and provide additional means for objective postoperative assessment.
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Affiliation(s)
- Brady T Williams
- Department of BioMedical Engineering, Steadman Philippon Research Institute, Vail, CO, USA
| | - Evan W James
- Department of BioMedical Engineering, Steadman Philippon Research Institute, Vail, CO, USA
| | - Kyle A Jisa
- Department of BioMedical Engineering, Steadman Philippon Research Institute, Vail, CO, USA
| | - C Thomas Haytmanek
- Department of BioMedical Engineering, Steadman Philippon Research Institute, Vail, CO, USA.,The Steadman Clinic, Vail, CO, USA
| | - Robert F LaPrade
- Department of BioMedical Engineering, Steadman Philippon Research Institute, Vail, CO, USA.,The Steadman Clinic, Vail, CO, USA
| | - Thomas O Clanton
- Department of BioMedical Engineering, Steadman Philippon Research Institute, Vail, CO, USA. .,The Steadman Clinic, Vail, CO, USA.
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13
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Magnetic Resonance Imaging of Ankle Ligaments. Can Assoc Radiol J 2016; 67:60-8. [DOI: 10.1016/j.carj.2015.09.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2015] [Accepted: 09/10/2015] [Indexed: 11/23/2022] Open
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Lee WA, Saroki AJ, Løken S, Trindade CAC, Cram TR, Schindler BR, LaPrade RF, Philippon MJ. Radiographic Identification of Arthroscopically Relevant Acetabular Structures. Am J Sports Med 2016; 44:67-73. [PMID: 26589837 DOI: 10.1177/0363546515612083] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND The anatomy of the acetabulum has been described extensively in the literature, but radiographic acetabular guidelines have not been well established. This study provides a radiographic map of acetabular landmarks in the hip. PURPOSE/HYPOTHESIS The purpose of this study was to quantify the precise radiographic location of arthroscopic landmarks around the acetabulum. The hypothesis was that their locations were reproducible despite variability in the anatomy and positioning of pelvic specimens. STUDY DESIGN Descriptive laboratory study. METHODS Ten fresh-frozen cadaveric specimens were dissected, and radio-opaque hardware was placed for each landmark of interest. Anteroposterior (AP) and false-profile radiographs were obtained, and measurements were taken using a digital picture archiving and communication system. RESULTS On AP radiographs, the direct and indirect heads of the rectus femoris were a mean 48.2 ± 4.6 mm and 44.7 ± 4.3 mm proximal to the teardrop line, respectively. The mean radiographic distance between their insertions was 5.0 ± 3.4 mm. Moreover, the anterior inferior iliac spine was a mean 11.5 ± 3.8 mm from the acetabular rim. On false-profile radiographs, the mean distance between the direct and indirect heads of the rectus femoris was 31.4 ± 6.2 mm. The mean distance between the superior margin of the anterior labral sulcus (the psoas-u) and the midpoint of the transverse acetabular ligament was 41.0 ± 5.7 mm. Additionally, the direct and indirect heads of the rectus femoris corresponded to the 2:30 and 1:30 locations on the acetabular clockface, respectively. The midpoint of the transverse acetabular ligament was located at 7 o'clock on the clockface. CONCLUSION The most important finding of this study, determined by quantitative measurements, was that the described surgical landmarks had reliable locations on radiographs. Distances between landmarks as well as distances between landmarks and reference lines were reproducible in both AP and false-profile views. CLINICAL RELEVANCE An understanding of how acetabular structures present on radiographs could lead to more accurate portal and hardware placement intraoperatively during arthroscopic surgery as well as better preoperative and postoperative assessments.
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Affiliation(s)
- W Andrew Lee
- Steadman Philippon Research Institute, Vail, Colorado, USA
| | | | - Sverre Løken
- Steadman Philippon Research Institute, Vail, Colorado, USA Department of Orthopaedics, Oslo University Hospital, Oslo, Norway
| | | | - Tyler R Cram
- Steadman Philippon Research Institute, Vail, Colorado, USA
| | | | - Robert F LaPrade
- Steadman Philippon Research Institute, Vail, Colorado, USA The Steadman Clinic, Vail, Colorado, USA
| | - Marc J Philippon
- Steadman Philippon Research Institute, Vail, Colorado, USA The Steadman Clinic, Vail, Colorado, USA
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Lee WA, Saroki AJ, Løken S, Trindade CAC, Cram TR, Schindler BR, LaPrade RF, Philippon MJ. Radiographic Identification of Arthroscopically Relevant Proximal Femoral Structures. Am J Sports Med 2016; 44:60-6. [PMID: 26632607 DOI: 10.1177/0363546515612436] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Anatomic landmarks located on the proximal femur have only recently been defined, and there is a lack of radiographic guidelines for their locations presented in the literature. With the confident identification of these landmarks, radiographs could provide more assistance in preoperative evaluations, intraoperative guidance, and postoperative assessments. PURPOSE To quantify the radiographic locations of endoscopic landmarks of the proximal femur. STUDY DESIGN Descriptive laboratory study. METHODS Ten cadaveric specimens were dissected, and radio-opaque hardware was placed for each landmark of interest. Radiographs were obtained and measurements recorded in anteroposterior (AP) and Dunn 45° views. RESULTS In the AP view, the gluteus medius insertion was located a mean 12.9 ± 2.4 mm and 34.7 ± 5.1 mm from the piriformis fossa and vastus tubercle, respectively. The piriformis fossa was a mean 14.8 ± 5.9 mm and 4.9 ± 1.9 mm from the anterior and posterior tips of the greater trochanter, respectively. The anterior and posterior tips of the greater trochanter were a mean 14.8 ± 5.1 mm from each other. In the Dunn 45° view, the piriformis fossa was a mean 13.3 ± 2.0 mm, and the vastus tubercle was a mean 21.5 ± 6.0 mm, from the gluteus medius insertion. Moreover, the vastus tubercle was a mean 33.5 ± 6.4 mm from the anterior tip of the greater trochanter and 31.6 ± 8.5 mm from the posterior tip of the greater trochanter. CONCLUSION In spite of the variation in cadaveric sizes, quantitative descriptions of endoscopic landmarks were reproducible in clinical views. CLINICAL RELEVANCE A detailed understanding of how the described landmarks present radiographically is relevant to preoperative planning, intraoperative evaluations, and postoperative assessments.
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Affiliation(s)
- W Andrew Lee
- Steadman Philippon Research Institute, Vail, Colorado, USA
| | | | - Sverre Løken
- Steadman Philippon Research Institute, Vail, Colorado, USA Department of Orthopaedics, Oslo University Hospital, Oslo, Norway
| | | | - Tyler R Cram
- Steadman Philippon Research Institute, Vail, Colorado, USA
| | | | - Robert F LaPrade
- Steadman Philippon Research Institute, Vail, Colorado, USA The Steadman Clinic, Vail, Colorado, USA
| | - Marc J Philippon
- Steadman Philippon Research Institute, Vail, Colorado, USA The Steadman Clinic, Vail, Colorado, USA
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Clanton TO, Williams BT, James EW, Campbell KJ, Rasmussen MT, Haytmanek CT, Wijdicks CA, LaPrade RF. Radiographic Identification of the Deltoid Ligament Complex of the Medial Ankle. Am J Sports Med 2015; 43:2753-62. [PMID: 26443536 DOI: 10.1177/0363546515605514] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND An injury to the deltoid ligament complex of the ankle can require surgical intervention in cases of chronic instability. There is an absence of data describing medial ankle ligament anatomy on standard radiographic views. PURPOSE To quantitatively describe the anatomic origins and insertions of the individual ligamentous bands of the superficial and deep deltoid on standard lateral and mortise radiographic views with reference to osseous landmarks and anatomic axes. STUDY DESIGN Descriptive laboratory study. METHODS Twelve nonpaired, fresh-frozen cadaveric foot and ankle specimens were utilized. Specimens were dissected free of all overlying soft tissue to identify individual ligamentous bands of the superficial and deep deltoid ligaments and to isolate their distinct origins and insertions. Footprint centers were identified on standard lateral and mortise radiographs by 2-mm stainless steel spheres embedded at the level of the cortical bone. Distances to osseous landmarks were measured independently by 2 blinded reviewers to calculate mean distances and evaluate reliability and repeatability measures using intraclass correlation coefficients. RESULTS Varying subsets of the 4 superficial deltoid bands including the tibionavicular (12/12), tibiospring (12/12), tibiocalcaneal (9/12), and superficial posterior tibiotalar (9/12) ligaments were found across specimens. On the lateral view, the tibionavicular ligament was the most anterior and attached 7.6 ± 1.9 mm superior and anterior to the inferior tip of the medial malleolus. The tibiospring ligament attached 12.1 ± 2.2 mm superior and anterior to the inferior tip of the medial malleolus and attached to the spring ligament, which coursed from its origin 12.3 ± 1.6 mm anterior and slightly inferior to the posterior point of the sustentaculum tali to its insertion on the navicular tuberosity. The tibiocalcaneal ligament and superficial posterior tibiotalar ligament were found posteriorly in the majority of specimens. Two constituents of the deep deltoid, including the deep anterior tibiotalar (11/12) and deep posterior tibiotalar (12/12) ligaments, were found in the majority of specimens. The deep posterior was larger and coursed from the tibia, 8.1 ± 2.2 mm posterior and superior to the inferior tip of the medial malleolus, to its attachment on the talus, 15.5 ± 2.4 mm superior and anterior to the posterior inferior point of the talus on the lateral view. CONCLUSION Quantitative radiographic relationships describing the anatomic origins and insertions of the individual superficial and deep deltoid constituents were defined with excellent reliability and reproducibility. CLINICAL RELEVANCE Radiographic parameters will augment current anatomic data by assisting with preoperative planning, intraoperative guidance, and postoperative assessment. These radiographic guidelines will facilitate the development of novel anatomic reconstructions and allow surgeons to plan the locations of reconstruction tunnels.
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Affiliation(s)
- Thomas O Clanton
- Department of BioMedical Engineering, Steadman Philippon Research Institute, Vail, Colorado, USA The Steadman Clinic, Vail, Colorado, USA
| | - Brady T Williams
- Department of BioMedical Engineering, Steadman Philippon Research Institute, Vail, Colorado, USA
| | - Evan W James
- Department of BioMedical Engineering, Steadman Philippon Research Institute, Vail, Colorado, USA
| | - Kevin J Campbell
- Department of BioMedical Engineering, Steadman Philippon Research Institute, Vail, Colorado, USA
| | - Matthew T Rasmussen
- Department of BioMedical Engineering, Steadman Philippon Research Institute, Vail, Colorado, USA
| | - C Thomas Haytmanek
- Department of BioMedical Engineering, Steadman Philippon Research Institute, Vail, Colorado, USA The Steadman Clinic, Vail, Colorado, USA
| | - Coen A Wijdicks
- Department of BioMedical Engineering, Steadman Philippon Research Institute, Vail, Colorado, USA
| | - Robert F LaPrade
- Department of BioMedical Engineering, Steadman Philippon Research Institute, Vail, Colorado, USA The Steadman Clinic, Vail, Colorado, USA
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