Defining Reference Values for the Normal Adult Lisfranc Joint Using Weightbearing Computed Tomography

The uninjured contralateral feet of consecutive patients undergoing cone-beam weightbearing computed tomography for acute Lisfranc injury between July 2017 and October 2019 were retrospectively analyzed. Of these, any cases with history or radiological evidence of trauma to the Lisfranc interval were excluded. The area of the non-weightbearing (NWBA) and weightbearing (WBA) Lisfranc joint was calculated (in mm²) using a novel technique. Area difference (AD) was calculated as WBA-NWBA. Area ratio (AR) was calculated as WBA/NWBA. A subset of cases was double-measured by 2 technologists to evaluate inter- and intraobserver variability. A total of 91 patients aged 15 to 74 years were included in the study. The measurement technique was reproducible with excellent intraobserver correlation (intraclass correlation coefficient [ICC]: 0.998, 95% confidence interval [CI]: 0.996-0.999) and high interobserver correlation (ICC: 0.964, CI: 0.939-0.979). The median NWBA was 83 (range 52-171) and median WBA was 86 (range 52-171). Median AD was 1 mm² (range -3 to 10) and median AR was 1.01 (range 0.96-1.11). No significant difference was identified in AD or AR when adjusted for age, gender, patient-weight or weight put through the foot. Both AD and AR distributions were highly skewed toward 0 and 1, respectively. Based on 95% CI, normal reference range for AD is -1 to 7 mm² and for AR is 0.98 to 1.09. Absolute area of the Lisfranc joint is highly variable between individuals. The Lisfranc joint is rigid with little to no physiologic widening in most subjects. The normal upper limit of widening of the Lisfranc area on weightbearing was 9%. Differences in age, sex, patient-weight or weight put through the foot were not significantly associated with the extent of joint widening.

Weightbearing Cone-Beam Computed Tomography of Acute Ankle Syndesmosis Injuries

Syndesmotic injuries are common, but only a subset of these injuries are unstable. A noninvasive tool for identifying instability would aid in the selection of patients for surgery. Weightbearing computed tomography (CT) data have been reported for healthy patients, but there are limited data on unstable syndesmoses. We evaluated the syndesmotic area of arthroscopically proven unstable ankles after acute injury. This is a prospective comparative study of consecutive patients recruited to a weightbearing CT database. Thirty-nine patients were included for analysis with arthroscopically proven unstable syndesmoses and an uninjured contralateral ankle. The syndesmosis area was measured for both ankles, in non-weightbearing and weightbearing positions, and compared. Syndesmosis area of the unstable ankle was significantly greater than the uninjured ankle of the same patient, by a mean of 22.9 ± 10.5 mm². This was a significantly greater difference than that observed with non-weightbearing CT (9.8 ± 10.2 mm², p < .001). Dynamic change in area, from non-weightbearing to weightbearing, of the unstable ankle (13.7% [16.6 ± 9.9 mm²]) was significantly greater than that of the uninjured ankle (3.1% [3.4 ± 6.7 mm²], p < .001). The intraobserver and interobserver correlations were good with intraclass correlation coefficients of 0.983 and 0.970, respectively. Weightbearing CT demonstrated significantly greater diastasis in unstable ankles than did conventional non-weightbearing CT. Syndesmosis area measurement was reliable and reproducible. Dynamic change in area and weightbearing comparison with the contralateral uninjured ankle are 2 parameters that may prove useful in the future for predicting syndesmotic instability.

Preliminary Results and Learning Curve of the Minimally Invasive Chevron Akin Operation for Hallux Valgus

Minimally invasive surgery is increasing in popularity. It is relevant in hallux valgus surgery owing to the potential for reduced disruption of the soft tissues and improved wound healing. We present our results and assess the learning curve of the minimally invasive Chevron Akin operation for hallux valgus. A total of 120 consecutive feet underwent minimally invasive Chevron Akin for symptomatic hallux valgus, of which 14 were excluded. They were followed up for a mean of 25 (range 18 to 38) months. The patients were clinically assessed using the American Orthopaedic Foot and Ankle Society score. Complications and patient satisfaction were recorded. The radiographs were analyzed and measurements recorded for hallux valgus and intermetatarsal angle correction. The mean age of the patients undergoing surgery was 55 (range 25 to 81) years. Of the 78 patients, 76 (97.4%) were female and 2 (2.6%) were male; 28 (35.9%) cases were bilateral. The mean American Orthopaedic Foot and Ankle Society score improved from 56 (range 23 to 76) preoperatively to 87 (range 50 to 100) postoperatively (p < .001). The mean hallux valgus and intermetatarsal angles preoperatively were 29.7° (range 12° to 46°) and 14.0° (range 8° to 20°). The corresponding postoperative angles were 10.3° (range 0° to 25°) and 7.6° (range 3° to 15°; p < .001). The patients were satisfied with the results of surgery in 87% of cases (92 of 106). The incidence of reoperation was 14% (15 of 106). These are the only reported results for this technique. They display a steep associated learning curve. However, the results are promising, and the learning curve is comparable to that for open hallux valgus surgery.

Plantaris Excision and Ventral Paratendinous Scraping for Achilles Tendinopathy in an Athletic Population

BACKGROUND

Achilles tendinopathy is a frequent problem in high-level athletes. Recent research has proposed a combined etiologic role for the plantaris tendon and neovascularization. Both pathologies can be observed on ultrasound imaging.(1,13) However, little is known about the change in structure of the Achilles tendon following the surgical treatment of these issues. The purpose of the study was to assess if excising the plantaris and performing ventral paratendinous "scraping" of the neovascularization improved symptoms of Achilles tendinopathy and whether there was a change in the fibrillar structure of the tendon with ultrasound tissue characterization (UTC) following this operation.

METHODS

This prospective consecutive case series included 15 professional/semiprofessional athletes (17 Achilles tendons) who underwent plantaris excision and paratendinous scraping to treat noninsertional Achilles tendinopathy. The plantaris tendon was excised if adherent to the Achilles tendon, and the area of neovascularization for scraping was demarcated on preoperative imaging. Preoperative and postoperative Victorian Institute of Sports Assessment-Achilles (VISA-A) scores were taken. UTC was performed on 11 of 17 tendons preoperatively and postoperatively. The mean follow-up was for 25 months.

RESULTS

Fourteen of 15 patients had a successful outcome after the surgery. The mean VISA-A improved from 51 to 95 (p=.0001). There was a statistically significant (p=.04) improvement in the aligned fibrillar structure of the tendon confirmed with UTC scanning following surgery from 90% (±8) to 96% (±5).

CONCLUSION

This group of high-level athletes derived an excellent clinical result from this operation. Furthermore, UTC scanning offered an objective method to evaluate the healing of Achilles tendons.

LEVEL OF EVIDENCE

Level IV, case series.

Evaluation of Musculoskeletal Disorders in Dentists and Application of DMAIC Technique to Improve the Ergonomics at Dental Clinics and Meta-Analysis of Literature

INTRODUCTION

Musculoskeletal disorders (MSD) result in discomfort, pain and illness that can result in disruption or impairment of dental practice.

MATERIALS AND METHODS

A cross-sectional study consisting of 60 dentists was carried out to determine musculoskeletal work related pain in major cities of Northern India. The study was planned in two phases. In the first phase, the subjects were given questionnaire related to the musculoskeletal pain happened over the last twelve months. In the second phase of study, improvement was carried out by recommending the subjects to implement ergonomics at their workplace. After three months subjects were again approached and given questionnaire about the musculoskeletal disorders. DMAIC (define, measure, analyse, improve and control) methodology of six sigma strategy was used to access the MSDs. Chi-square test was used for the analysis and a p-value of less than or equal to 0.05 was considered statistically significant.

RESULTS

The overall prevalence of musculoskeletal problems in the present study was found to be 68.3%. After three months only 23 respondents applied ergonomics at their work place, prevalence of pain was reduced in neck from 47.8% to 21.7% out of total 23 respondents, shoulder pain 39.1% to 17.3%, pain in elbows from 26% to 21.7%, as well as in other locomotor organs. The p-value was significant with p <0.05.

CONCLUSION

MSD represents a major occupational health issue for dentists in India as well as worldwide and result revealed necessitates the need of workshops to create awareness of ergonomics as effective measures for reducing MSD among dentists.

Eureka! A reliable, home-made water volumetry device

Background

Water displacement is considered to be the gold standard for measuring foot volume; however, it is time-consuming and infrequently used in clinical practice. The objectives of this study were to determine whether a home-made water displacement device is a reliable and time-efficient method for determining foot volume.

Methods

Thirty participants with no foot pathologies were enrolled and had their foot volume measured in two home-made water volumetry devices (Preski and PreskiLite). The participants' foot volumes were measured on two occasions on each of two different days.

Results

All measurements were achieved in less than 90 seconds. Within-day reliability was high (intraclass correlation [ICC]=0.997–0.999) with the minimal detectable change (MDC) at the 90% confidence level (MDC90) of less than 25 ml for both devices. Mean differences in volume displaced between days were small (range 0.6– -5.4 mls). For between-day measures on the same leg, the mean coefficient of variation ranged from 0.65–1 with associated ICCs of 0.989–0.997. The MDC90 for between-day measures was 46 ml for the PreskiLite and 23 ml for the Preski. The difference in volume displaced between right and left legs was less than the MDC90 for both devices.

Conclusions

A novel, home-made water volumetry device provides reliable measures of foot volume both within and between days. Measurements taken on the contralateral leg provide an adequate control. These portable devices provide rapid measurements and only one measurement is needed per day.

Arthroscopic treatment of osteochondral lesions of the ankle with matrix-associated chondrocyte implantation: early clinical and magnetic resonance imaging results

BACKGROUND

Conventional autologous chondrocyte transplantation in the ankle often requires tibial or fibular osteotomies with potential morbidity for the patient. Advances in biotechnology and surgical techniques have resulted in the development of matrix-associated chondrocyte implantation (MACI). As the chondrocyte-loaded scaffold can be applied arthroscopically, this procedure is especially useful for the treatment of osteochondral defects in the ankle.

HYPOTHESIS

Arthroscopic MACI is a safe procedure in the ankle with good clinical and magnetic resonance imaging results.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

The authors reviewed all patients (n = 18) who had arthroscopic MACI for osteochondral lesions of the ankle (n = 19) between February 2006 and May 2008 clinically and with magnetic resonance imaging. The pain and disability module of the Foot Function Index (FFI), the American Orthopaedic Foot & Ankle Society (AOFAS) clinical rating system, the Core Scale of the Foot and Ankle Module of the American Academy of Orthopaedic Surgeons (AAOS) Lower Limb Outcomes Assessment Instruments, and the Magnetic Resonance Observation of Cartilage Repair Tissue (MOCART) score were used. The clinical results up to 3 years after MACI (mean follow-up, 24.5 months) were compared with preoperative data for 14 cases and the magnetic resonance imaging data for all 19.

RESULTS

A significant improvement (50.3% ± 13.2%) in all clinical scores was noted (FFI pain before MACI: 5.5 ± 2.0, after MACI: 2.8 ± 2.2; FFI disability before MACI: 5.0 ± 2.3, after MACI: 2.6 ± 2.2; AOFAS before MACI: 58.6 ± 16.1, after MACI: 80.4 ± 14.1; AAOS standardized mean before MACI: 59.9 ± 16.0, after MACI: 83.5 ± 13.2; AAOS normative score before MACI: 23.0 ± 13.0, after MACI: 42.2 ± 10.7). According to the AOFAS Hindfoot score, 64% were rated as excellent and good, whereas 36% were rated fair and poor. The results correlated with the age of the patient and the duration of symptoms, but not with the size of the lesion. Sixteen patients (89%) reported regular sports activities before the onset of symptoms; 13 of them (81%) returned to sports after the MACI, 56% (n = 9) to the same level. The mean MOCART score was 62.4 ± 15.8 points. In general, there was no relation between MOCART score and clinical outcome, although the filling of the defect showed some correlation with the AAOS score.

CONCLUSION

Arthroscopic MACI is a safe procedure for the treatment of osteochondral lesions in the ankle with overall good clinical and magnetic resonance imaging results.

Arthroscopic treatment of osteochondral lesions of the ankle with matrix-associated chondrocyte implantation: early clinical and magnetic resonance imaging results

BACKGROUND

Conventional autologous chondrocyte transplantation in the ankle often requires tibial or fibular osteotomies with potential morbidity for the patient. Advances in biotechnology and surgical techniques have resulted in the development of matrix-associated chondrocyte implantation (MACI). As the chondrocyte-loaded scaffold can be applied arthroscopically, this procedure is especially useful for the treatment of osteochondral defects in the ankle.

HYPOTHESIS

Arthroscopic MACI is a safe procedure in the ankle with good clinical and magnetic resonance imaging results.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

The authors reviewed all patients (n = 18) who had arthroscopic MACI for osteochondral lesions of the ankle (n = 19) between February 2006 and May 2008 clinically and with magnetic resonance imaging. The pain and disability module of the Foot Function Index (FFI), the American Orthopaedic Foot & Ankle Society (AOFAS) clinical rating system, the Core Scale of the Foot and Ankle Module of the American Academy of Orthopaedic Surgeons (AAOS) Lower Limb Outcomes Assessment Instruments, and the Magnetic Resonance Observation of Cartilage Repair Tissue (MOCART) score were used. The clinical results up to 3 years after MACI (mean follow-up, 24.5 months) were compared with preoperative data for 14 cases and the magnetic resonance imaging data for all 19.

RESULTS

A significant improvement (50.3% ± 13.2%) in all clinical scores was noted (FFI pain before MACI: 5.5 ± 2.0, after MACI: 2.8 ± 2.2; FFI disability before MACI: 5.0 ± 2.3, after MACI: 2.6 ± 2.2; AOFAS before MACI: 58.6 ± 16.1, after MACI: 80.4 ± 14.1; AAOS standardized mean before MACI: 59.9 ± 16.0, after MACI: 83.5 ± 13.2; AAOS normative score before MACI: 23.0 ± 13.0, after MACI: 42.2 ± 10.7). According to the AOFAS Hindfoot score, 64% were rated as excellent and good, whereas 36% were rated fair and poor. The results correlated with the age of the patient and the duration of symptoms, but not with the size of the lesion. Sixteen patients (89%) reported regular sports activities before the onset of symptoms; 13 of them (81%) returned to sports after the MACI, 56% (n = 9) to the same level. The mean MOCART score was 62.4 ± 15.8 points. In general, there was no relation between MOCART score and clinical outcome, although the filling of the defect showed some correlation with the AAOS score.

CONCLUSION

Arthroscopic MACI is a safe procedure for the treatment of osteochondral lesions in the ankle with overall good clinical and magnetic resonance imaging results.

Proton spectroscopy and diffusion imaging on the first day of life after perinatal asphyxia: preliminary report

BACKGROUND AND PURPOSE

MR techniques have proved useful in assessing brain injury from perinatal asphyxia when the injury is subacute or chronic. Recent advances in understanding the molecular mechanisms of brain injury have made medical intervention plausible, creating a need for assessment of the brain within the first few hours of life. We report the results of early (first 24 hours after birth) MR imaging in seven patients, including proton MR spectroscopy in six.

METHODS

MR studies were performed within the first 24 hours of life in seven consecutive patients who were encephalopathic after complicated deliveries. Standard T1-, T2-, and diffusion-weighted sequences were performed in all patients; single-voxel MR spectroscopy was performed in two locations in six of the seven patients. Follow-up MR studies were performed in four patients at ages 7, 8, 9, and 15 days, respectively.

RESULTS

T1-weighted images were normal in all seven patients. T2-weighted images were normal in three patients and showed T2 prolongation in the basal ganglia or white matter in the other four. Diffusion images showed small abnormalities in the lateral thalami or internal capsules in all seven patients. Comparison with clinical course in all seven patients and with follow-up MR studies in four showed that the diffusion images underestimated the extent of brain injury. Proton MR spectroscopy showed substantial lactate elevation in all six of the patients studied. Two patients died in the neonatal period and the other five were left with clinically significant neurologic impairment.

CONCLUSION

MR spectroscopy performed in the first 24 hours after birth is sensitive to the presence of hypoxic-ischemic brain injury, whereas diffusion imaging may help identify but underestimate the extent of the injury. Further studies are ongoing in an attempt to expand upon this observation.

Global myocardial revascularization without cardiopulmonary bypass using innovative techniques for myocardial stabilization and perfusion

BACKGROUND

In off-pump coronary bypass grafting (CABG), invasiveness is reduced but technically perfect anastomosis is jeopardized by cardiac motion and the need to hurry to reduce the time of ischemia. Also, a major cause of postoperative morbidity and mortality is ungrafted circumflex coronary artery disease. We have devised a means of overcoming these shortcomings and performing multivessel CABG. The objective of this study was to assess the safety and efficacy of our technique.

METHODS

One hundred patients with severe triple-vessel disease underwent multivessel off-pump CABG. For cardiac stabilization, a combination of local pericardial stabilization sutures and lifting and rotating the heart by means of posterior pericardial sutures were used. For myocardial perfusion, a technique of retrograde coronary sinus perfusion by arterial blood from the ascending aorta was used.

RESULTS

Each patient received an average of 3.8 grafts (range 3 to 5). Complications included conversion to cardiopulmonary bypass (CPB) in 1 patient and a perioperative myocardial infarction in the same patient. In all other patients we were able to perform a satisfactory grafting in all territories with no operative mortality. Rapid recovery allowed 95% of our patients to resume normal activity within 1 month. A predischarge graft angiogram in 35 patients showed 97.8% patency.

CONCLUSIONS

These results suggest that off-pump CABG with our techniques is effective and safe. Early clinical outcome and excellent patency rates suggest its more widespread use in selected cases.

Osteosarcoma of the scapula arising in osteogenesis imperfecta

A case of osteosarcoma arising in the scapula of a 37 year old woman with severe congenital sporadic white sclera type osteogenesis imperfecta (OI) is presented. Osteosarcoma occurs as a sporadic rather than a related occurrence in patients with OI. A delay in the diagnosis of osteosarcoma may occur due to the similarity in symptomatology between the two conditions and because of the difficulty in differentiating between hyperplastic callus and tumor using conventional radiographic imaging techniques.

Differences in impulse distribution in patients with plantar fasciitis

The impulse distribution based upon vertical foot-floor reaction forces and time under the fore-, mid-, and hindfoot was determined using Tekscan's F-Scan system. This was compared in 40 barefoot patients with long-standing plantar fasciitis with an equal number of normal subjects. The patient group tended to load the hind- and midfoot to a lesser extent than the control group. Consequently, a greater proportionate load was borne by the forefoot. This result was highly significant for both the midfoot (P < 0.001) and forefoot (P = 0.002) comparisons. An objective biomechanical method such as this may be useful as a diagnostic aid, to identify individuals predisposed to this condition, and for evaluating the efficacy of various treatment modalities.

An audit of early hospital readmission after primary knee joint replacement

BACKGROUND

Hospital readmissions following arthroplasty represent a considerable burden to the community. The present study investigates the magnitude of this problem and the reasons for early readmission.

METHODS

The medical records of patients who underwent primary knee joint replacements between July 1989 and December 1994 were reviewed retrospectively. Readmission within 12 months of surgery was noted and the prognosis of these patients assessed.

RESULTS

A total of 160 patients (180 arthroplasties) were appropriate for review. The readmission rate for knee-related morbidity was 18%. The main reasons for this included pain, stiffness, and the investigation/management of an inflamed joint. Notably, patellofemoral disease was common, particularly in the group without resurfaced patellae, manipulation of a stiff joint was rarely effective unless instituted early and aetiologies aside from sepsis often resulted in the patient returning with an inflamed joint.

CONCLUSIONS

Readmission is a significant problem which heralds a poor 12-month prognosis.

Foreign body in the heart

Images

Morphometric analysis of the right gastroepiploic artery and the internal mammary artery

BACKGROUND

The internal mammary artery (IMA) and the right gastroepiploic artery (RGEA) are frequently used as conduits for coronary artery bypass grafting.

METHODS

Morphometric measurements and histologic characteristics of the RGEA and the IMA were studied in 25 patients undergoing coronary artery bypass grafting.

RESULTS

External radius was found to be more in the IMA (range, 18 to 56 microns; mean, 39.56 microns) in comparison with the RGEA (range, 24 to 51 microns; mean, 32.52 microns; p < 0.01). There was no significant difference between the vessels in intimal thickness (IMA: 0.0 to 0.25 micron; mean, 0.05 micron; RGEA: 0.0 to 0.28 micron; mean, 0.09 micron), internal radius (IMA: 5 to 47 microns; mean, 28.40 microns; RGEA: 16 to 42 microns; mean, 23.56 microns), area of media (IMA: 1,690 to 3,476 microns2; mean, 2,777.52 microns2; RGEA: 1,659 to 3,600; mean, 3,012.44 microns2), intimal thickening index (IMA: 0.0 to 0.02; mean, 0.01; RGEA: 0.0 to 0.13; mean, 0.01), and medial index (IMA: 0.14 to 0.60; mean, 0.36; RGEA: 0.18 to 0.63; mean, 0.39). Histologic examination of the RGEA showed more defects in continuity of internal elastic lamina and rich smooth muscle cells in the media.

CONCLUSIONS

There was no difference in the morphometric measurements of the IMA and the RGEA except external radius, which was greater for the IMA. The histologic differences found in the RGEA may indicate an increased propensity for atherosclerosis of the RGEA as compared with the IMA. Some concern regarding the long-term patency of the RGEA in myocardial revascularization is warranted.

Geographical variations in the presentation of ruptured aneurysms of sinuses of valsalva: evaluation of surgical repair

From 1981 to 1992, 13 male and 7 female patients underwent surgical correction for ruptured aneurysms of sinus of valsalva. A total surgical experience of 22 procedures including 2 reoperations is presented, accounting for 1.37% of open heart surgery for congenital heart disease at PGIMER Chandigarh. Ninety percent were in the 20- to 40-year age group. Forty-five percent of patients had symptoms of > 1-year duration (range 2 months to 20 years) and catastrophic onset of symptoms was noted in four (18%). All patients had localized aneurysms originating either in right coronary sinus (14 pts) or noncoronary sinus (8 pts). Sites of origin and rupture are detailed. Associated congenital abnormalities such as ventricular septal defect (VSD) (13 pts), aortic regurgitation (3 pts), and left superior vena cava and atrial septal defect (ASD) (1 pt each) were noted. The data pertaining to Oriental and Western groups of patients were analyzed, and the differences in age, mode of presentation, site of origin, rupture, and the spectrum of associated abnormalities were elucidated. The majority of the patients (86.4%) were operated by the Bicameral approach. Repair was tailored according to the extent and severity of the defect in the sinus of Valsalva and aortic valve annulus and also the presence and site of VSD.

Coronary-to-coronary bypass using a free internal mammary artery: an alternative

Paucity of conduit of adequate length or quality poses a dilemma in the occasional patient. We report such a patient, in whom we used a modified anastomotic technique using the normal right coronary artery for the proximal anastomotic site of a free right internal mammary artery graft.

Papillary fibroelastoma of the mitral valve associated with rheumatic mitral stenosis

Papillary fibroelastoma of the mitral valve diagnosed and treated in life is extremely rare. There have been eight cases documented so far. We report the first case of a mitral valve papillary fibroelastoma associated with severe rheumatic mitral stenosis and tricuspid regurgitation with stenosis. The tumor arose from the posteromedial papillary muscle of the mitral valve. The mitral valve was replaced after excising the valve with the tumor and the tricuspid valve was repaired. The patient did well and remains asymptomatic.

Coronary-to-coronary artery bypass using a free right internal mammary artery: an alternative

Lack of a conduit of adequate length or quality poses a dilemma in the occasional patient. We report such a case in whom we applied a modified anastomotic technique using the normal right coronary artery for the proximal anastomotic site of a free right internal mammary artery graft.

Homograft aortic root replacement for destructive prosthetic endocarditis

Prosthetic aortic valve endocarditis with extensive destruction of the aortic root, annular abscess formation, and left ventriculoaortic discontinuity was seen in 3 patients, with aorta to left atrial fistula formation in 2. Homograft aortic root replacement with use of the anterior mitral leaflet of the aortic root to repair the fistula was used successfully in all 3 patients. Their case reports are discussed to highlight the use of the homograft aortic root in these complicated cases, and to report the occurrence of aorto-left atrial fistula in prosthetic valve endocarditis.