The gracilis and semitendinosus muscles: a morphometric study on 18 specimens with clinical implications

INTRODUCTION

The pes anserinus consists of the sartorius, semitendinosus, and gracilis muscles. They coalesce together with the leg fascia to form the anserine plate. The semitendinosus and gracilis both form the deep layer of this plate and are clinically relevant for ligament reconstruction. The aim of the study is to report a detailed morphometric evaluation of the semitendinosus and gracilis muscles and assess their clinical implications.

METHODS

Using a rigorous dissection process on 18 cadaveric hips, measurements of both the semitendinosus and gracilis muscles with bone parameters were conducted. We measured the following: (a) total femur, femoral shaft, and neck lengths, (b) total muscle lengths, and (c) intra-muscular and extra-muscular (free) tendon lengths. Correlation values between bone variables, muscle variables, and in-between muscle variables were computed.

RESULTS

The total muscle and the distal intra-muscular tendon length of the St and Gr are correlated with the total femur length. When compared to gracilis, the total muscle and distal intra-muscular tendon lengths of the ST are much better correlated with the total femur length. The free distal tendon length for both muscles did not show a significant correlation with any of the femoral bone lengths.

CONCLUSION

The variability of tendon length of the ST/Gr poses a significant challenge to surgeons. This study reports a detailed morphometric evaluation of the ST/Gr hamstring muscle and tendons. It revealed a positive correlation between the femoral length and the ST/Gr graft lengths. This could help orthopedic surgeons in predicting the graft lengths pre-operatively and develop better planning for reconstructive surgeries.

Biometry of the calcaneocuboid joint: biomechanical implications

Precise biometric data of calcaneus, cuboid bones and calcaneocuboid joint are not alluded to in textbooks of anatomy. This study focussed on the biometry of 50 calcanei, 30 cuboid dry bones, and anatomical specimens of 21 transverse tarsal joints. Measurement of the length, width, angular orientation, contact surface and radius of curvature, rolling band of the joints surfaces according to the main axes were performed. The results focussed on biometric variations with several morphological types never identified previously. Measurements obtained on dry bones and anatomical specimens with the functions of ligaments were distinguished. The morphology of the calcaneus could explain the results of osteotomy procedures for the treatment of adult flatfoot. A better knowledge of the joint surfaces and biometric data would generate a modeling of the calcaneocuboid joint and function in locking the transverse tarsal joint.

Endopelvic migration of a sternoclavicular K-wire. Case report and review of literature

We report a unique case, never before published, of sternoclavicular joint fixation K-wire migration to the pelvic region, in a 56 year-old man. Two years previously, sternoclavicular dislocation had been fixed by three wires. A transitory episode of precordial thoracic pain followed by iterative abdominal pain accompanied the migration. Extraction was performed five years later. Scapular K-wire migration is frequent. The proximity of cardiovascular structures may have fatal consequences. This type of internal fixation raises questions, and migration prevention needs to be taken into account. Medical complications and the legal context are major factors leading us to abandon this type of osteosynthesis. Once migration has been diagnosed, the wire should be removed without delay.

Biometry of bone components in the talonavicular joint: a cadaver study

INTRODUCTION

Exhaustive biometric data of the talus and the navicular bones have not been reported in the classical anatomy treatises.

HYPOTHESIS

The radiographic measurements, being variable according to the X-ray beam inclination, have no real value. This biometric analysis aimed to specify the characteristics of the constitutive bone components of the talonavicular joint.

MATERIAL AND METHODS

This anatomic study investigated the biometry of the talus and the navicular bones separated from anatomic specimens with no previous disease history from adult subjects whose sex was unknown. It was completed by in situ dissection and evaluation of talonavicular and talocalcaneal joints conducted to gain an understanding of the bone specimens in three dimensions. The measurements were taken using a highly precise measuring tape and a comparator providing the length and the width of the articular surfaces. The comparator determined the surface pattern and the radii of curvature in the two main axes.

RESULTS

The results emphasize the variations in the bone specimens. Three morphotypes emerged, which had never been identified before.

DISCUSSION AND CONCLUSION

These biometric data make up a database designed to improve clinical exploration. They can be used as landmarks for fundamental comparative research between all the bone structures of the hindfoot and thus provide a logical classification of the different pathological conditions and a reasoned adaptation of therapeutic protocols.

LEVEL OF EVIDENCE

Experimental study, level IV.

Chronic lateral ankle instability surgical repairs: the long term prospective

The present study sought to assess the clinical and radiological results and long-term joint impact of different techniques of lateral ankle ligament reconstruction.

MATERIAL AND METHODS

A multicenter retrospective review was performed on 310 lateral ankle ligament reconstructions, with a mean 13-year-follow-up (minimum FU: 5 years). Male subjects (53%) and sports trauma (78%) predominated. Mean duration of instability was 92 months; mean age at surgery was 28 years. Twenty-eight percent of cases showed subtalar joint involvement. Four classes of surgical technique were distinguished: C1, direct capsular ligamentous complex reattachment; C2, augmented repair; C3, ligamentoplasty using part of the peroneus brevis tendon and C4, ligamentoplasty using the whole peroneus brevis tendon. Clinical and functional assessment used Karlsson and Good-Jones-Livingstone scores; radiologic assessment combined centered AP and lateral views, hindfoot weight-bearing Méary views and dynamic views (manual technique, Telos or self-imposed varus).

RESULTS

The majority of results (92%) were satisfactory. The mean Karlsson score of 90 [19-100] (i.e., 87% good and very good results) correlated with the subjective assessment, and did not evolve over time. Postoperative complications (20%), particularly when neurologic, were associated with poorer results. Control X-ray confirmed the very minor progression in degenerative changes, with improved stability; there was, however, no correlation between functional result and residual laxity on X-ray. Unstable and painful ankles showed poorer clinical results and more secondary osteoarthritis. Analysis by class of technique found poorer results in C4-type plasties and poorer control of laxity on X-ray in C1-type tension restoration.

DISCUSSION

The present results confirm the interest of lateral ankle ligamentoplasty in the management of instability and protection against secondary osteoarthritis, and of precise lesion assessment (CT-scan/MRI) to adapt surgery to the ligamentary and associated lesions.

LEVEL OF EVIDENCE

Level IV. Retrospective therapeutic study.

Chronic ankle instability: biomechanics and pathomechanics of ligaments injury and associated lesions

The objective of this study was to evaluate the conditions of ankle stability and the morphological and/or lesional factors in sprains that determine when instability becomes chronic. It is based on a review of the literature and the data from the 2008 Sofcot symposium. The biomechanics of the ankle cannot be reduced to a simple flexion-extension movement with one degree of freedom as characterized by the talocrural joint: its function cannot be dissociated from the subtalar joint, allowing the foot to adapt to the ground surface. Functional stability is related to the combination of the particular biometry of the joint surfaces and a multiaxial ligament system. The bone morphology of the talus, shaped like a truncated cone, explains the potential instability in plantar flexion; the radii of curvature of the talar dome have a variable mediolateral distribution: most often the medial radius of curvature is inferior to the lateral radius of curvature (66%), sometimes equal (19%), or inverted (15%). Joint kinematics, combining rotation and slide, can therefore be modulated by the talar morphology, explaining the occurrence of at-risk ankles. Ligament stability relies on the organization in three parts of the lateral collateral ligament and the specific subtalar ligaments: the cervical and the talocalcaneal interosseous ligament. The different injury mechanisms are largely responsible for the sequence of ligament lesions: the most frequent is inversion. The first ligament stabilizers correspond to the cervical and anterior talofibular ligaments; the talocalcaneal ligament, by its oblique orientation, is solicited when there is a dorsal varus-flexion component. In chronic instability, these mechanisms explain the onset of associated lesions (impingement, osteochondral lesions, fibular tendon pathology), which can play a role in instability syndrome. Ligament lesions determine laxity, characteristic of mechanical instability. Functional instability goes along with proprioceptive deficiency. There are postural factors such as varus of the hindfoot that favor instability. Knowledge of all these factors, often associated, will provide a precise lesional assessment and treatment adapted to the instability.

Cortical and trabecular bone distribution in the femoral neck in osteoporosis and osteoarthritis

The increased hip fragility in osteoporosis has been attributed mainly to a thinning of the cortex. In contrast, hip arthritis (OA) is not associated with increased risk of hip fracture. The purpose of this study was to assess cortical and trabecular bone structures and their possible regional variability in the femoral neck taken from patients who sustained an osteoporotic hip fracture (OP) compared with patients with OA. We compared the distribution of bone in the ultradistal femoral neck in 21 postmenopausal women with OA (mean age: 66+/-7.8 years) and 20 postmenopausal women with an osteoporotic hip fracture (OP) (mean age: 79.5+/-1.9 years). Controlateral hip osteoporosis or osteopenia was confirmed in OP by DEXA (T-score: -2.5+/-0.8 in OP; -0.9+/-1.3 in OA). Histomorphometric parameters of bone structure, architecture and connectivity were measured on sections from the ultradistal part of the femoral neck, divided in 4 quadrants. When compared to OA, cortical thickness was significantly decreased in OP (p<0.0005) but was the highest in the inferior part in both groups. Cortical porosity was higher in OA (13.48+/-1.02 and 8.4+/-1.07% in OA and OP respectively). Compared to OA, the trabecular bone volume was decreased by 50% in OP (p<0.0001) with a diminution of the trabecular number (p<0.01) and thickness (p<0.0001). In parallel, OP group was characterized by a poor connectivity evaluated by the decreased number of nodes (p<0.0001), higher trabecular bone pattern factor (p<0.0001) and greater marrow star volume (p<0.0001). The connectivity was the lowest in the inferior quadrant in OP but not in OA. Our data suggest that in addition to the cortical thinning, the loss of the trabecular bone mass and connectivity plays a role in the skeletal fragility associated with hip fracture. Furthermore, the spatial distribution of the trabeculae differs between OP and OA whereas cortical thinning is homogenous.

[Degenerative changes of the metatarso-sesamoido-phalangeal complex]

OBJECTS

The aim of this work was to determine the frequency and the location of the degenerative lesions of the hallucal metatarsophalangeal joint in an elderly population. Our results help us to precise the anatomic characteristics of that articular complex.

METHODS

Our material comprised 21 feet from embalmed cadaver specimens. We studied the morphometrical parameters for the anatomic description of the first metatarsophalangeal joint of the forefoot. After complete dissection, a specific articular zone-mapping was made with a quantitative evaluation of the chondral lesions.

MAIN RESULTS

The measurements of the morphometrical parameters were in accordance with the literature data. The sesamoidal chondral lesions were more frequent for the medial sesamoid and at the proximal zone of the articular surface. The plantar metatarsal lesions were very frequent with diffuse or distal groove damage, and crista damage linked to the sesamoidal strap dislocation. The lesions involving the metatarsophalangeal compartment were less frequent and rather at the dorsal zone.

CONCLUSIONS

The degenerative lesions of the metatarso-sesamoido-phalangeal complex are nearly systematic in n elderly population. The morphological aspect of these lesions is very characteristic of the articular function and allows us to precise the biomechanic constraints.

[Selective dorsal T1-T6 fusion of the thoracic spine and effects on thorax growth: experimental study in prepuberal New Zealand White rabbits]

PURPOSE OF THE STUDY

The purpose of this study is to assess the consequences brought by selective dorsal arthrodesis of thoracic spine (T1-T6) to the growth of spine and thoracic volume in operated and sham-operated New Zealand White rabbits, between prepubertal age and the end of somatic growth, through the study of computerised tomography (CT) scans periodically carried out on them after arthrodesis surgery.

MATERIAL AND METHODS

Nine female rabbits were subjected to surgery for selective dorsal arthrodesis of the upper thoracic spine and three were sham-operated. Surgery was performed at age nine weeks, before the onset of puberty. Two "C"-shaped titanium bars were placed beside the spinous processes of the thoracic vertebrae to obtain a selective posterior arthrodesis of the first six thoracic vertebrae. Under general anesthesia, three CT scans were performed, 10 (t1), 55 (t2) and 139 (t3) days after surgery. Measures were obtained by Myrian Pro software for three different groups: group 1 with complete fusion, group 2 with incomplete fusion, group 3 sham-operated.

RESULTS

The total dorsal and ventral lengths of thoracic vertebral bodies in the spinal segment T1-T6 was smaller in group 1 and group 2 than in group 3, whereas no differences were observed between the three groups in the T7-T12 segment. The average of the dorsoventral/laterolateral thoracic diameter ratio at fused levels was less than 1 in group 1 as well as in group 2; on the contrary, in group 3 it was greater than 1. The sternum and lung volume grow less.

CONCLUSIONS

Vertebral arthrodesis in the treatment of progressive idiopathic scoliosis in prepubertal patients is not ideal, but is still a choice in treating major deformities of the spine. Postoperative assessment of spinal deformity is essential, feasible and recordable through CT scans. Dorsal arthrodesis in prepubertal rabbits changes thoracic growth patterns. In operated rabbits, the dorsoventral thoracic diameter grows more slowly than the laterolateral thoracic diameter. The sternum, the total lengths of thoracic vertebral bodies in the spinal segment T1-T6 and lungs grow less. The Crankshaft phenomenon is evident at the fused vertebral levels where there is a reduction of thoracic kyphosis.

Modélisation du carpe osseux et biomécanique

Carpal morphology and orientation of carpal bones are usually studied on two-plane radiography. Those measurements depend on the incidence of X-ray and on the expertise of physician. A method that eliminates both should improve the accuracy of those measurements. The digital data from computed tomography scans can be use to describe carpal geometry. We defined biometric and angular parameters allowing the study of carpal morphology and bones orientation. From digital data from computed tomography scans software can obtain bone volume, inertia principal axis and volume of ellipsoid of inertia. Bone centroid location and principal axis orientation can be used to study bones orientation. 3D distances ratio between geometry centroid of carpal bones. The measurements allowed by this methodology are numerous. A study of a more consistent series of normal wrists will allow in the future for each quantitative parameter to define the normal range. A comparative study of normal wrists and pathology wrists should allow defining, for each pathology, the most judicious quantitative parameters.

GSB III total elbow replacement in rheumatoid arthritis

Between 1993 and 2002, 58 GSB III total elbow replacements were implanted in 45 patients with rheumatoid arthritis by the same surgeon. At the most recent follow-up, five patients had died (five elbows) and six (nine elbows) had been lost to follow-up, leaving 44 total elbow replacements in 34 patients available for clinical and radiological review at a mean follow-up of 74 months (25 to 143). There were 26 women and eight men with a mean age at operation of 55.7 years (24 to 77).

At the latest follow-up, 31 excellent (70%), six good (14%), three fair (7%) and four poor (9%) results were noted according to the Mayo elbow performance score. Five humeral (11%) and one ulnar (2%) component were loose according to radiological criteria (type III or type IV). Of the 44 prostheses, two (5%) had been revised, one for type-IV humeral loosening after follow-up for ten years and one for fracture of the ulnar component. Seven elbows had post-operative dysfunction of the ulnar nerve, which was transient in five and permanent in two.

Despite an increased incidence of loosening with time, the GSB III prosthesis has given favourable mid-term results in patients with rheumatoid arthritis.

[The human body and the computer as pedagogic tools for anatomy: review of the literature]

Since the first dissections, the human body has been the main tool for the teaching of anatomy in medical courses. For the last 30 years, university anatomy laboratory dissection has been brought into question and the total hours of anatomy teaching have decreased. In parallel, new technologies have progressed and become more competitive and more attractive than dissection. The aim of this review of the literature was to evaluate the use of the human body as a pedagogic tool compared to today's computer tools. Twenty comparative studies were reviewed. Their analysis showed that the human body remains the main tool in anatomy teaching even if anatomic demonstration (prosection) can replace dissection, and that the computer tools were complementary but not a substitute to dissection.

Study of carpal bone morphology and position in three dimensions by image analysis from computed tomography scans of the wrist

The morphology and positioning of the carpal bones were studied in three dimensions in 18 normal adults on computed tomography (CT) scans of the wrist. The digital data from each CT scan were processed to extract the carpal bones and to automatically characterize their geometry (geometric centroid, principal axes of inertia) using specific software tools. Biometric and angular parameters were defined for this purpose, and most of these parameters showed a normal distribution. The mean distance between the geometric centroid of the capitate and that of the triquetrum, expressed as a relationship to the length of the first principal axis of inertia of the capitate, was found to be the greatest (157.6%+/-8.4%), whereas the smallest mean distance was between the hamate and triquetrum (91.4%+/-7.3%). In the sagittal plane, the first principal axis of inertia of the bones of the first carpal row projected in front of the vertical axis of the orthogonal reference system, whereas the first principal axis of the capitate projected behind it. Measurements using this methodology are far more numerous than those from standard plain radiographs and have the additional advantage of being independent of the examiner. Future investigations on normal wrists should provide a normal range for each quantitative parameter, and comparative study of normal and pathologic wrist measurements should help to define the most relevant parameters for specific traumatic pathologies of the wrist.

Plagiocephaly: morphometry of skull base asymmetry

The aim of this study was to perform a morphometric analysis of the skull base to understand the mechanism of asymmetry between malformational and deformational plagiocephaly. Since 1988, we have carried out 102 CT scans with three-dimensional reconstruction of the endocranial side of the skull base. There were 20 cases of malformational plagiocephaly, consisting of 18 unicoronal synostoses (UCS) and two unilambdoid synostoses (ULS), and 82 cases of plagiocephaly without synostosis, made up of 60 cases of frontal plagiocephaly (FP) and 22 of occipital plagiocephaly (OP). The skull base asymmetry was analyzed in three ways: (1) the hemibases and the cranial fossa angles were compared with each other; (2) the structural asymmetry of the chondrocranium was calculated; and (3) the architectural asymmetry was measured in relation to the medio-labyrinthine plane. The skull base asymmetry of malformational plagiocephaly was located in the anterior and middle cranial fossae for UCS and in the posterior and middle cranial fossae for ULS. The asymmetry was the result of a localized structural anomaly of the chondrocranium. The asymmetry of deformational plagiocephaly corresponded to a distortion in relation to the medio-labyrinthine plane while the chondrocranium remained symmetric. The skull base asymmetry of malformational plagiocephaly is secondary to a localized malformation of the chondrocranium, and that of the deformational plagiocephaly is secondary to an architectural deformation.

Biometry of the radial head: biomechanical implications in pronation and supination

The aim of this study was to perform biometry of the proximal extremity of the radius and to characterize the shape of the radial head. Knowledge of the size and shape of the radial head is necessary for the creation of a radial head prosthesis that is anatomically and biomechanically correct. Twenty-seven measurements, focused on the proximal extremity, were done on 96 radii. The shape of the radial head was determined by the difference between the maximum diameter and the minimum diameter. We considered the shape to be circular when the difference was less than 1 mm, and elliptical when the difference was greater than 1 mm. The shape of the radial head was compared with the neck/diaphysis angle. Fifty-seven percent of radial heads were elliptical and 43% were circular. When the head was elliptical the maximum diameter was 22 mm +/-2.9 and the minimum diameter was 20 mm +/-2.8 ( P<0.001). When the head was circular the maximum diameter was 21.2 mm +/-2.4 and the minimum diameter was 20.4 mm +/-2.4 ( P<0.14). The angle between the neck and the diaphysis varied with regard to the shape of the radial head. It was 166.75 degrees +/-3 for the circular heads and 168.62 degrees +/-3.2 for the elliptical heads ( P<0.01). The biomechanics of the circular shape and the elliptical shape are different, involving an adaptation of the angle between the neck and the radial diaphysis. This difference must be taken in consideration in the design of a radial head prosthesis.

[Interpretation of thoracic radiographs re-examined and corrected with tomodensitometry]

To our knowledge, conventional chest radiography is not likely to become obsolete or disappear from the daily practice of medical imaging. As such, it is important to insure that chest radiographs are acquired using optimal technique. Evaluation of chest radiograph findings must be comprehensive and the art of reading chest radiographs must be well thought to physicians in training. Chest radiography is characterized by the projection of tridimensional anatomical structures and disease processes onto a two-plane radiographic film. Correlation with cross-sectional data obtained from CT may greatly enhance the understanding and interpretation of conventional chest radiographs. Indeed, review of CT images facilitates anatomical understanding of the segmental and subsegmental anatomy, of the superior segments of the lower lobes and of the three dimensional orientation of the fissures. CT also has improved the understanding of some chest radiography findings. Careful review of findings at chest radiography is helpful to optimize CT acquisition protocols in order to reduce some of the pitfalls of CT and improve detection of specific processes that could otherwise be poorly demonstrated or overlooked. Chest radiographs can sometimes detect diseases or abnormalities that are difficult to demonstrate at CT.

[Optimal screening tool for thoracic diseases: chest X ray or CT?]

There are good reasons to believe that screening of lung parenchymal diseases by CT is superior to chest radiographs. Nevertheless, conventional chest radiography often remains the first examination performed for evaluation of thoracic diseases and, irrespective of clinical indication, it plays an important role in screening procedures. The interpretation methodology of a chest radiograph in a screening condition is reviewed. Specific attention to poor detectability zones is emphasized and a check-list is proposed, mainly to reduce the risk of overlooking lesions. Techniques, indications and respective diagnostic values for both chest radiography and CT scan are analyzed and applied to the screening of lung cancer, asbestos exposure and tuberculosis.

Free osteocutaneous scapular apophysis flap for reconstruction of the lateral malleolus

Lateral malleolus avulsion is uncommon, and fusion of the syndesmosis of the ankle joint is usually performed in such cases. Others have reported successful reconstruction of the lateral malleolus with a vascularized fibular head. A case of reconstruction in a 17-year-old girl, with a free scapular apophysis flap, is presented and compared with alternative flaps available. The anatomy and development of the scapular crest with its cartilaginous apophysis are discussed.

Carpal bone maturation assessment by image analysis from computed tomography scans

Bone maturation is the only reliable indicator of growth and its radiologic assessment with or without automated systems is a qualitative method. Image processing allows the study of bone maturation with quantitative data. Carpal bone maturation was studied in 20 children (13 boys and 7 girls, ages ranging from 4 to 15 years) without any clinical evidence of endocrine disease by image analysis from computed tomography (CT) scans. Each wrist CT scan was processed in order to extract the carpal bones and to measure quantitative data regarding volume, axes of inertia and density for each bone. The volumes and the length of the inertia axes were significantly correlated with age. Whatever the age, there were strong correlations between the volume or the length of the main inertia axis of one carpal bone and that of all others. The decrease in the carpal bone volume measured from the processing procedure compared with the theoretical volume of bone defined from the length of the three inertia axes indicated a change in bone shape during growth. Although the mean density was constant, there was an increase in the standard deviation of density with age. Skeletal maturity assessment with image analysis from CT scans seems to be a good complementary investigation to determine bone age in children.

Exposure to anaesthetic agents, cognitive functioning and depressive symptomatology in the elderly

BACKGROUND

Anaesthesia could provoke persistent alterations in specific cognitive domains in the elderly where ageing-related neuronal changes may exacerbate pharmacotoxic effects.

AIMS

To evaluate anaesthesia effects on the incidence of cognitive dysfunction after orthopaedic surgery in elderly patients.

METHOD

A total of 140 patients over the age of 64 years completed a full range of computerised cognitive tests. The study takes into account effects of pre-operative cognitive dysfunction, depressive symptomatology and ability to perform activities of daily living.

RESULTS

Postoperative cognitive decline persisted for up to 3 months in 56% of subjects. Dysfunction was limited to verbal, visuo-spatial and semantic abilities and secondary and implicit memory. Age, low educational level, pre-operative cognitive impairment or depression are risk factors.

CONCLUSIONS

Cognitive functions are not equally affected, type of impairment being determined by the risk factors described above and anaesthesia type.

Thoracic helical CT: influence of subsecond scan time and thin collimation on evaluation of peripheral pulmonary arteries

The objective of this study was to analyze the influence of collimation on the identification of peripheral pulmonary arteries on helical CT scans. Three hundred sixty of 370 consecutive helical CT angiograms of the pulmonary circulation obtained during an 18-month investigation period were considered as technically acceptable for the detection of acute pulmonary embolism and were retrospectively analyzed. Patients in group A (n = 274) underwent CT with 2-mm collimation and pitch of 2; those in group B (n = 86) underwent CT with 3-mm collimation and pitch 1.7; a 0.75-s rotation time was systematically used. A total of 2160 segmental (six arterial zones per patient) and 2160 subsegmental (six arterial zones per patient) arterial zones were assessed. Whereas the percentage of segmental arteries was not significantly different between group A (86%) and group B (89%), the percentage of analyzable subsegmental arteries was greater in group A (65%) than in group B (43 %) (P<0.001). The causes of inadequately depicted subsegmental arterial zones were partial-volume effects (group A, n = 302; 52%; group B, n = 197; 67%; P<0.001), suboptimal enhancement (group A, n = 145; 25%; group B, n = 43; 15%; P<0.05), motion artifacts (group A, n = 113; 20%; group B, n = 30; 10%), and unincluded arteries (group A, n = 20; 3%; group B, n = 25; 8%). Helical CT with 2-mm collimation at 0.75 s per revolution enables marked improvement in the analysis of subsegmental arteries in routine clinical practice.

[Assessment of carpal bone maturation by imaging: an alternative to bone age determination or a complementary study?]

Radiographic evaluation of skeletal maturation with or without automated systems relies on the comparison between the radiographic appearance of portions of a child's skeleton and the standardized appearance in a comparable population of children. Assessment of skeletal maturation using image analysis of wrist computerized-assisted tomography is a quantitative method allowing for measurements of the volume of each carpal bone, the axis of inertia, and the mean bone density. Morphological modifications of carpal bones are characterized by quantitative data relating to the length of the axis of inertia and the volume. Imaging is a potentially useful method for carpal bone assessment during growth.

Biometry of the capsular ligaments of the wrist

The aim of our study was to measure the length, width and inclination in the coronal plane of the capsular ligaments, and to express these measurements as a ratio in order to determine the correlation between these parameters and the bone index. The capsular ligaments were studied from 15 cadaveric upper limbs. We identified 11 volar and 2 dorsal intracapsular ligaments. For each ligament, we measured the length to its middle and to its proximal and distal edge, the width at its average portion, and the inclination in the frontal plane. There was a difference between the proximal or distal length and the middle length for four ligaments. In these cases, however, there was a significant correlation between the proximal or distal length and the middle length. The length of capitate, the length of the third metacarpal bone, and the carpal height were significantly correlated with four ligaments. There were correlations between the length of one ligament and that of all others. There was no correlation between the inclination of the radius and the inclination of ligaments in the coronal plane. Nevertheless, there were six significant correlations between the inclination of one ligament and that of all others.

[Apropos of a case of epidermoid carcinoma of the nail bed with intraneural metastasis to the median nerve]

The authors report a case of squamous cell carcinoma of the nail bed with multiple metastases including a metastasis of the median nerve. This particular site raises the problem of the mechanism of dissemination and the aggressiveness of this squamous cell carcinoma of the nail bed contrasts with the data reported in the literature. The initial treatment of this tumour must consist of amputation of the distal phalanx.

Helical CT angiography of thoracic outlet syndrome: functional anatomy

OBJECTIVE

The objective of this study is to determine the anatomic characteristics of the thoracic outlet in symptomatic patients before and after postural maneuver.

SUBJECTS AND METHODS

Seventy-nine symptomatic patients (61 female patients [group 1]; 18 male patients [group 2]; mean age, 38 years) underwent helical CT angiography of the thoracic apices in the neutral position and after a postural maneuver, enabling the evaluation of the functional anatomy of the musculoskeletal and arterial structures of the ipsilateral thoracic outlet.

RESULTS

A statistically significant difference was found between the distribution of the distances (maximum and costosubclavian) measured in the neutral position and after postural maneuver in groups 1 and 2. The median value of these distances was smaller after postural maneuver in groups 1 and 2. A statistically significant difference was found between the distribution of the distances (maximum and costosubclavian) measured in patients of group 1 with arterial stenosis and in patients of group 1 without arterial stenosis. A slight indentation of the anterior wall of the subclavian artery when it arches around the anterior scalene muscle was observed in 39 patients (64%) in group 1 and in 11 patients (61%) in group 2 in the neutral position, in 19 patients (31%) in group 1 and in six patients (33%) in group 2 after the postural maneuver. The predominant positional changes of the vascular structures were the posteroanterior displacement of the subclavian vessels observed in groups 1 and 2, the arch made by the subclavian artery above the first rib in 40 patients (66%) in group 1 and nine patients (50%) in group 2, and the posterior displacement of the axillary artery observed in 36 patients (59%) in group 1 and in 12 patients (67%) in group 2.

CONCLUSION

Helical CT shows significant narrowing of the costoclavicular space after postural maneuver in symptomatic patients.

CT angiography of thoracic outlet syndrome: evaluation of imaging protocols for the detection of arterial stenosis

PURPOSE

The purpose of this work was to evaluate the results of cross-sectional imaging and multiplanar and 3D reconstructions for the detection of thoracic outlet arterial stenosis on CT angiograms.

METHOD

Eighty-two patients were prospectively evaluated with CT angiography: in the neutral position and after postural maneuver (164 acquisitions); with contralateral injection of a 24% (Group 1; n = 68) or 30% (Group 2; n = 96) contrast agent; and reconstruction of four sets of images from each acquisition, that is, transverse CT scans, sagittal reformations, and 3D [shaded surface displays (SSD) and volume-rendered (VR)] images. A total of 656 sets of images were blindly and independently interpreted by three readers of variable experience. A consensus interpretation of the four sets of images of each acquisition was used as a standard of reference.

RESULTS

The number of examinations coded with an excellent degree of arterial enhancement was significantly higher in Group 2 than in Group 1 [68 (71%) vs. 35 (51%); p < 0.001]. The sensitivity and specificity for detection of arterial stenosis were 67 and 96% for transverse CT scans, 69 and 94% for sagittal reformations, 71 and 99% for 3D-SSDs, and 95 and 100% for VR images. Compared with the standard of reference, a concordant scoring of arterial stenosis severity was found in 54% of transverse CT scans, 84% of sagittal reformations, 78% of 3D-SSDs, and 91% of VR images. Underestimation of stenosis was found in 43% of transverse CT scans and 10% of sagittal reformations; overestimation of stenosis was more frequent on 3D-SSDs (16%) than on VR images (7%). The reader's experience was marked for the interpretation of cross-sectional images but did not influence the interpretation of 3D images.

CONCLUSION

Thoracic outlet arterial compression is best depicted with the injection of a 30% contrast agent and reconstruction of VR images.

[Spiral (helical) CT of tracheobronchial diseases]

The acquisition techniques, including some important dosimetric considerations, and the reconstruction methods reviewing the tomographic, bronchographic and endoscopic rendering techniques are first taken into consideration. They are applied to the most usual problems and diseases encountered in the daily activityThe main purpose of this review, which merges the modern technology of spiral (helical) CT with the multislice acquisition in the very near future, consists in delivering, whenever possible, an integrated diagnostic and therapeutic approach of imaging, endoscopy and surgery.

Total elbow arthroplasty in rheumatoid arthritis: 20 GSBIII prostheses followed 2-5 years

From 1993 to 1996, we implanted 20 primary GSB IlI prostheses in 17 patients with rheumatoid arthritis. The Mayo Clinic performance index for the elbow was used for the evaluation. The average follow-up was 3 (2-5) years. At the follow-up examination, 12 elbows had an excellent result and 8 a good result. The median performance index increased from 30 (15-53) points to 95 (80-100) points. The subjective assessment was excellent for 11 elbows, good for 8 and poor for 1.2 elbows had radiographic loosening with a progressive radiolucent line and a change in the orientation of the prosthesis.

Treatment of a simple bone cyst of the calcaneus by endoscopic curettage with cancellous bone injection

The authors report a case of simple bone cyst involving the calcaneus, treated by curettage under endoscopy with cancellous bone injection, and its course and follow-up at two years. This new technique has not yet been published for simple bone cysts of the calcaneus. Endoscopic curettage of the cavity of a simple bone cyst can be advocated for the calcaneus to minimize incisions and to avoid cutaneous complications.

[Anatomy, physiology and clinical examination of the shoulder]

Shoulder pain is usually caused by periarthritis. Impingement syndrome and frozen shoulder (adhesive capsulitis) are the more frequently clinical aspect observed. A shoulder standardised clinical examination often give a precise lesional diagnostic. Complementary examinations are useful to distinguish other cause of shoulder pain.

[Reconstruction techniques in spiral CT angiography]

Clinical applications of spiral CT angiography are mainly based on transverse CT scans which can be completed by several categories of additional reformations in order to provide the most accurate evaluation of the vessel(s)-of-interest. Two-dimensional reformations are the second most frequent category of reconstructions generated from a spiral data set, enabling the creation of planar (frontal, sagittal or oblique) or curved views of given vessel. Three-dimensional displays can also be generated from most post-processing consoles, namely surface shaded displays (SSD), maximum intensity projections (MIP) and images using the volume rendered technique (VRT). Shaded surface displays are based on a binary selection of voxels using a single or double thresholding whereas MIP images result from the selection of the voxels of highest attenuation value. Volume rendered images are generated by means of a probabilistic classification of voxels consisting of a systematic estimation of the amount of the tissue-of-interest in each voxel. In addition, a variable degree of opacity (or transparency) can be chosen for the vascular structures and/or the surrounding anatomical structures, thus avoiding interpretive difficulties due to superimposition. A fourth category of reconstruction, STS-MIP (i.e., sliding-thin-slab MIP) can be applied to the evaluation of peripheral intraparenchymal vasculatures.

[Evaluation of the Scarf osteotomy in hallux valgus related to distal metatarsal articular angle: a prospective study of 79 operated cases]

PURPOSE OF THE STUDY

The hallux valgus surgery concerns many operative techniques. The purpose of this report was to evaluate the radiographic results of the Scarf osteotomy related to Distal Metatarsal Articular Angle (DMAA).

MATERIAL AND METHODS

The Scarf osteotomy was performed on 79 feet with an hallux valgus deformity (75 females and 4 males from 16 to 82 years). Pre and postoperative weight-bearing X-rays were performed; We measured the Distal Metatarsal Articular Angle (DMAA), the intermetatarsal angle (M1-M2, M1-M5), the metatarsophalangeal angle, the obliquity of the metatarsocuneiform joint and the length of the first and second metatarsal.

RESULTS

All parameters were statistically significantly improved by the surgery. However correction on the DMAA was not sufficient (from 14.6 degrees to 12.6 degrees although normal value is 6 degrees). We found a correlation between the metatarsophalangeal angle and the DMAA.

DISCUSSION

The preoperative measures showed that the DMAA value increases with the value of the metatarsophalangeal angle; it is insufficiently decreased in comparison to the normal value. It has to be strongly taken in consideration in the preoperative evaluation.

CONCLUSION

The preoperative DMAA value is the most important factor in the hallux valgus evaluation. It determines if Scarf or other operative technique are indicated. Its normalisation may provide less recurrences.

[Radiographic analysis of the orientation of the distal articular surface of the first metatarsal in the horizontal plane]

PURPOSE OF THE STUDY

The lateral obliquity of the distal metatarsal articular surface is a predominant anatomical factor in hallux valgus pathology. It is important to know its normal angular value.

MATERIAL-METHODS

The study included 105 feet without any pathology (48 females and 57 males; 53 left and 52 right between 15 and 72 year old). Weight-bearing, anteroposterior X-rays of the foot was made. We measured the distal metatarsal articular angulation (DMAA), the intermetatarsal angle, the metatarsophalangeal angle, the obliquity of the metatarsocuneiform joint and the length of the first and second metatarsal, and the length of the hallux.

RESULTS

The main value of the DMAA was 5.78 degrees in our study, 6.79 degrees for women and 4.92 degrees for men. There was no difference between left and right side, no correlation between intermetatarsal angle and DMAA, neither between biometrics parameters and DMAA.

DISCUSSION

Our results confirm the Richardson study on cadaver with a main value of 6 degrees for the DMAA. The DMAA value increases in women and it does not increase proportionaly to the intermetatarsal angle; it increases with the value of the metatarsophalangeal angle. All these points have to be taken in consideration in hallux valgus evaluation.

CONCLUSION

The distal metatarsal articular surface has a lateral obliquity of 5.78 degrees. It must be evaluated before surgical correction of hallux valgus, in order to decrease recurrence rate of this pathology and iatrogenic deformity.

Biometry of the muscular branches of the median nerve to the forearm

The aim of this study was to determine the biometry of the muscular branches of the median nerve to the forearm in ten embalmed upper limbs. We measured the length of the forearm and the level of origin of each muscular branch of the median nerve to the forearm from the middle of a line between the medial and lateral epicondyles. The level of origin of each branch was then calculated as a percentage of the length of the forearm. Mean length of the forearm was 25 +/- 2.36 cm (range: 22-29 cm). Although the levels of origin of the proximal and distal nerves to pronator teres, and of the nerves to palmaris longus, flexor carpi radialis and flexor digitorum superficialis, were quite variable (coefficient of variation: CV > 48.61%), the level of origin of the anterior interosseous nerve (CV = 31.24%) and its branches (nerves to flexor pollicis longus and flexor digitorum profundus, CV = 20.06%) was less variable. These results suggest that the anterior interosseous nerve of the forearm is probably the nerve to connect in muscular free transfers in order to restore flexion of the fingers after damage to the flexor tendons to the forearm. We observed Martin-Gruber communications in six out of ten dissections.

Anatomic basis for the treatment of aneurysms of the upper cervical segment of the internal carotid artery by extra-intracranial cervico-petrous bypass with inverted "in situ" saphenous vein graft

In the surgical treatment of aneurysms of the upper cervical portion of the internal carotid a., exclusion of the affected vascular segment combined with an extra-anatomic cervico-petrous bypass using a vein graft (great saphenous v.) may be considered. One of the problems specific to these extra-anatomic bypasses is associated with the sub-cutaneous positioning of the vein graft, exposing it to risks of angulation, torsion or extrinsic compression that may lead to early venous thrombosis. We suggest an alternative technique using the principle of telescoping and consisting of positioning the vein graft within the cervical portion of the artery ("in situ" bypass). The cervical portion of the ICA may be used as a tunnel for the vein graft since there are no collateral arterial branches at this level. The technical features of such a bypass are defined by means of an anatomo-surgical study in the cadaver: exposure of the petrous portion of the internal carotid a. in its horizontal segment by subtemporal access, exposure of the ICA in the neck, transverse arteriotomies of the ICA, angioplasty with a Fogarty balloon, intracarotid telescoping of a saphenous vein graft from the cervical to the petrous region, distal end-to-end anastomosis between the vein graft and the petrous portion of the ICA, and proximal end-to-end anastomosis between the vein graft and the cervical portion of the ICA.

Carpal bone maturation during childhood and adolescence: assessment by quantitative computed tomography. Preliminary results

The aim of our study was to measure the volume of each carpal bone during childhood and adolescence by image processing from computed tomography (CT) scans, and to analyze the relationship between the eight carpal bones. Thirteen CT scans were performed in nine normal prepubertal, peripubertal and post-pubertal children, six boys and three girls, aged 5-14 years. Each scan was processed in order to extract the carpal bones. The volume was computed for each bone. There was a significant correlation between carpal bone volume and age (0.55 < r < 0.79), and a very strong correlation between the volume of a given carpal bone and the volume of all the others, whatever the age (0.87 < r < 0.99, p < 0.01). Image processing is a potentially useful method for assessing bone maturation. The constant ratio between carpal bone volumes indicates that these bones interact with each other in wrist bone maturation.

[Traumatic etiology of Kienboeck's disease. (Perilunate subluxations and semilunate necrosis)]

The authors have studied the incidence of lunate necrosis in 110 perilunate dislocations. Twenty-one cases (19%) developed a necrosis. The classification into three types, according to the amount of damage to the perilunar ligaments, is of prognostic value. There is no risk of necrosis in type 1, 17% in type II, and 50% in type III. An associated fracture of the scaphoid does not modify the risk. In neglected lesions, reduction of the lunate dislocation should be attempted, even at a late date, the risk of necrosis then being 50%. Surgical reduction increases the risk of secondary necrosis to a greater extent than does orthopedic treatment, but it is generally use in the most complex cases too. The authors advocate a closed reduction with percutaneous pin fixation.

[Anatomy of the interosseous and lumbrical muscles of the hand]

After anatomic dissections and cross section studies the authors gives detailed descriptions of the insertions of the dorsal and palmar interossei muscles and of the lumbrical muscles. For each anatomic structure the different terms used in the literature are recalled. The exact typographic relations of the interossei muscles at the level of the metacarpophalangeal and the proximal interphalangeal joints are described.

Avulsion of the flexor digitorum profundus tendon associated with a chondroma of the distal phalanx

An avulsion of the profundus tendon associated with a chondroma of the distal phalanx is presented. The injury occurred during housework and the tendon avulsion can be explained by a weakness of the profundus tendon insertion.

Tophaceous gout of the navicular bone as a cause of medial inflammatory tumor of the foot

A case of tophaceous gout of the navicular bone in a 24-year-old woman is reported. Emphasis is placed on the conditions that might have been precipitating, i.e., anorexia nervosa and alcoholism, and the mechanisms by which increased uric acid level may be explained. The main radiographic patterns of tophaceous gout of the foot are recalled to avoid unnecessary surgery in future cases.

[Surgical treatment of rheumatoid polyarthritis]

Surgical treatment of rheumatoid arthritis aims to suppress pain, correct deformities, and restore function. This treatment should be adapted to each patient on the basis of clinical and radiographic criteria, with priority given to surgical treatment of the lower limbs. In the early stages, conservative surgery is called for (tenosynovectomy, joint synovectomy) and in later stages, palliative surgery (arthrodesis, prosthesis).

The relationships of the bile duct and the retroduodenal arteries and their importance in the surgical treatment of hemorrhagic duodenal ulcer

The anatomic relationships of the gastroduodenal artery (GDA) and the posterior superior pancreaticoduodenal artery (PSPD) with the bile duct in their retroduodenal courses were studied in 35 bloc specimens from normal cadavers, injected after removal. The distances between the GDA, the pylorus, and the bile duct were measured in the sagittal plane. The origin and course of the PSPD in relation to the bile duct were studied. The relation of the GDA and the bile duct were divisable into four types: in Type 1 (n = 22) the two structures separated progressively, the artery being on the left of the bile ducts; in Type 2: (n = 7) the structures approached each other without crossing, Type 3: (n = 5) the GDA crossed in front of the bile duct at the level of the first part of the duodenum (D1), Type 4: (n = 1) the GDA crossed the bile duct below D1 and ran along its right border. The PSPD originated at the posterior face of D1 in 20% of cases (n = 7) and crossed the anterior surface of the bile duct at the posterior surface of D1. In four cases there was no pancreatic tissue between the PSPD and the bile ducs. It follows that the risk of injury to the bile duct when securing hemostasis by transfixing a bleeding duodenal ulcer in the D1 segment is great when the arterial structures (GDA and PSPD) cross the bile duct. This risk is increased when there is no pancreatic tissue between them.

Circular arterial supply of the pisiform bone

The arterial vascularization of the pisiform bone was studied from 15 cadavers to assess the possibility of pedicled pisiform transfer in Kienböck's disease. The arterial vascularization of the pisiform bone comes from three pedicles: an upper pedicle arising from the dorsal carpal artery, a lateral pedicle arising from the ulnar artery, and a lower pedicle arising from the deep palmar branch of the ulnar artery. The pisiform bone is well vascularized and, whatever the distribution of the pedicles within the bone itself, we always found an arterial circle around it. The lengths of the upper and lower pedicles expressed as ratios of the length or width of the pisiform bone were variable, as indicated by the coefficient of variation that was greater than 36%. There was no significant correlation between the length of the upper or lower pedicle and the length or width of the pisiform bone. The length of the upper pedicle, which was greater than the distance between the origin of the dorsal carpal artery and the center of the lunate, allows a pedicled pisiform transfer in Kienböck's disease. Nevertheless, it is difficult to assert definitively that the upper pedicle is sufficient to avoid a partial necrosis of the pedicled pisiform bone.

Postoperative shoulder rotators strength in stages II and III impingement syndrome

In healthy subjects, the shoulder internal rotator muscle strength overrides the external rotators. This has been confirmed in different isokinetic studies showing the ratio of the relative strengths of the internal to external rotators to range from 1.3 to 1.5 points, depending on the study. The authors previously reported a decrease in the relative strength ratio of the internal to external rotators to close to 1 in patients suffering from Neer's impingement syndrome. The aim of the present study was to assess, long after surgery (mean, 44.5 months), the isokinetic strength performance of shoulder rotator muscles in 72 patients who had had operative treatment for chronic subacromial impingement using anterior acromioplasty, sometimes combined with cuff repair surgery. Tests were conducted with a Biodex Multi-Joint System in the plane of the scapula and in 45 degrees abduction at 60 degrees and 180 degrees per second. Peak torque and average power were calculated. The mean ratios of relative strengths of the internal to external rotators ranged from 1.3 to 1.6 points depending on the parameter studied and the test speed. These results indicate that surgery restores normal muscular balance between shoulder rotator muscles affected by the impingement syndrome.

Diagnostic value of clinical tests for shoulder impingement syndrome

Results of three clinical tests for detecting shoulder impingement syndrome (Neer's, Hawkins', and Yocum's tests) and four tests for determining the location of the rotator cuff lesion (Jobe's test [supraspinatus], Patte's test [infraspinatus], lift-off test [subscapularis], and palm-up test [long head of the biceps brachii]) were compared to intraoperatively observed anatomic lesions in 55 consecutive patients who had surgery for Neer's syndrome. For Jobe's and Patte's tests, both pain (denoting tendinitis) and functional impairment (denoting tendon rupture) were evaluated. All clinical tests were done by the same examiner and all surgical procedures (acromioplasty with or without rotator cuff repair) by the same surgeon. The location and extent of the lesions (size of the tear in the 34 patients with rotator cuff defects) were determined intraoperatively. The sensitivity, specificity, and positive and negative predictive values of each test were calculated. Sensitivity was satisfactory but specificity was poor, in particular for determining the location and type of rotator cuff lesions. The severity of functional impairment during Jobe's and Patte's maneuvers was not correlated with the size of the tear.

Tophaceous gout of the patella with primary hyperparathyroidism

The case of an 81-year-old woman with persistent post-traumatic pain of the knee linked to tophaceous gout of the patella is presented. This gout was associated with adenomatous primary hyperparathyroidism. The relationship between hyperuricemia, hyperparathyroidism and chronic renal failure is discussed.