Eugene Kots

A Dynamic Ultrasound Examination for the Diagnosis of Ankle Syndesmotic Injury in Professional Athletes A Preliminary Study

Background Syndesmotic ankle injuries are not easy to recognize when an associated fracture or frank diastasis is not present. There is a need for a simple, fast, inexpensive, and easily reproducible diagnostic tool to assess the integrity of the distal tibiofibular synedesmosis. Hypothesis Dynamic ultrasound (US) examination can accurately diagnose anteroinferior tibiofibular ligament (AITFL) rupture. Study Design Cohort study (diagnosis); Level of evidence, 2. Methods We evaluated 3 groups: 9 consecutive professional athletes with recent AITFL rupture, a control group of 18 subjects without a history of ankle injury, and 20 patients with lateral ankle sprain. The dynamic US examination was performed in neutral (N), forced internal rotation (IR), and external rotation (ER) of the foot for measuring the tibiofibular clear space on the anterior aspect of the ankle, at the level of the AITFL, 1 cm proximal to the joint line. Results The mean age of the study group was 27 years (range, 16-32). Magnetic resonance imaging (MRI) confirmed the diagnosis of AITFL rupture in all cases. Differences between the injured and control group were statistically significant for the N, IR, and ER positions (P < .001) and for the measured Δ between the AITFL in the ER and N positions (P < .01). The difference in the tibiofibular clear space between the 2 ankles of the injured athletes was significantly different compared with the control athletes for all 3 positions (P < .001). The measured difference between the ER and N positions for both sides of the study group showed a specificity and sensitivity of 100% (P < .001; cutoff point of 0.9 mm and 0.7 mm, respectively). The Δ (Δ = ER — N) of the injured side showed a specificity and sensitivity of only 89% (P < .001; cutoff point of 0.4 mm). Additionally, the third group with the history of lateral ankle sprain showed, as expected, that this type of injury does not correlate with AITFL injury on dynamic US examination. Conclusion We conclude that dynamic US examination can be used to accurately diagnose an AITFL rupture. This preliminary study has found the described method to be a simple, inexpensive, and easily reproducible examination.

Transcatheter arterial embolisation in anticoagulant‐related haematoma – a current therapeutic option: a report of four patients and review of the literature

The aim of this study is to present the computed tomography (CT) and angiographic findings of life‐threatening extraperitoneal haemorrhage complicating anticoagulant therapy, treated with transcatheter arterial embolisation (TAE). CT and angiographic studies of four consecutive patients with large, extraperitoneal anticoagulant‐related haematomas (ACH) treated by TAE were retrospectively reviewed. Attention was directed to the location of the haematoma and to the possible presence of active arterial extravasation on CT. Four women (mean age 70 years) with large extraperitoneal ACHs demonstrated on CT as extended rectus sheath haematoma in three and expanding iliopsoas haematoma in one, were successfully treated by TAE of the inferior epigastric (n = 3) and lumbar artery (n = 1). Two patients were diagnosed by contrast‐enhanced CT as having active arterial bleeding within the haematoma requiring TAE. The other two were referred to angiography because of haemodynamic instability. We also reviewed the imaging findings of 26 patients with extraperitoneal ACHs requiring TAE described in the literature. In the reviewed cases, a female predominance was found, the retroperitoneum was the most frequent site and most patients recovered. To conclude, unenhanced CT has proved an excellent modality for the diagnosis of ACHs. TAE has been shown to be an effective and safe method for managing such haematomas when conservative treatment is insufficient. We suggest that whenever a large extraperitoneal ACH is seen on unenhanced CT, a subsequent contrast‐enhanced dynamic scan should be performed, unless contraindicated. Enhanced CT has a supplementary role in detecting active bleeding that provides an indication for angiographic therapy. Awareness of this optional treatment improve patients outcome.

Standardization of the functional syndesmosis widening by dynamic U.S examination

BackgroundDynamic US examination is a convenient, accurate, inexpensive and reproducible diagnostic tool for assessing the integrity of the distal tibiofibular syndesmosis in ankle injuries. However normal values for physiological functional widening of the anterior tibiofibular clear space in healthy subjects has yet to be determined. The purpose of this study was to determine normal values for the syndesmosis clear space on ultrasound examination.MethodsWe evaluated 110 healthy subjects. A dynamic U.S examination was performed in neutral (N), forced internal rotation (IR) and external rotation (ER) of the ankle. In each position the anterior tibiofibular clear space was measured at the level of the anterior inferior tibio-fibular ligament (AITFL). Height and calf length were also recorded. Results were analyzed in relation to age, activity, dominant leg and gender.ResultsMean age was 32 years (range 16–60). There were 59 males and 51 females. 60% were professional athletes. Mean height was 173 cm (range 149–192). Functional Mean position measurements for clear space opening were: N=3.7mm, IR=3.6mm and ER=4.0mm. In younger men and women the clear space was significantly wider in neutral (Men: Y=3.8, O=3.4 \ Women: Y=3.8, O=3.4) and with rotational force application (Men ER: Y=4.1, O=3.6 \ Women ER: Y=4.1, O=3.8) compared to older subjects (p<0.05). There was no correlation with activity, height or the leg length.Females had a higher syndesmosis widening ratio (ER/N) under stress than males (p<0.01) this tended to occur more commonly in active subjects.ConclusionsNormal values for the syndesmosis clear space on ultrasound examination were determined as 3.78mm in neutral, 3.64mm in internal rotation and 4.08mm in external rotation. The clear space was shown to decrease with age both as an absolute measure and when rotational stresses are applied. Females tend to have a larger clear space and a greater functional widening.These findings provide a useful reference for radiologists and sports physicians when performing ultrasound assessment of ankle syndesmotic injuries and we encourage use of this modality.

Anatomy of the sural nerve and its relation to the achilles tendon by ultrasound examination.

Sural nerve injury is a relatively common complication after surgery on the Achilles tendon. Studies to determine the course of the sural nerve have been performed on cadaveric specimens. The purpose of this cross-sectional study was to use ultrasound to determine the relations of the sural nerve in a healthy population. The authors performed ultrasound examination of the posterior triangle of the ankle and Achilles tendon to determine the course of the sural nerve relative to the Achilles tendon in healthy participants. The mean distance between the nerve and the tendon was 21.48, 11.47, 5.8, and 0.81 mm lateral to the Achilles tendon as measured at the insertion and 4, 8, and 11 cm proximally, respectively. Male participants tended to have a nerve that was initially more lateral to the Achilles insertion compared with women. The distance between the sural nerve and the Achilles tendon was found to be lower in older participants, with the nerve passing significantly closer to the tendon at all levels (P<.01). Three anatomical variants were reported, with the nerve crossing the lateral border of the Achilles low or high or with multiple branches yet to converge. The course of the sural nerve can be visualized and plotted relative to the Achilles tendon using ultrasound examination in healthy participants. Older patients may be at an increased risk of iatrogenic nerve injury because the nerve courses closer to the Achilles tendon than that in young patients. Intraoperative ultrasound examination may be a useful modality to prevent sural nerve injury during Achilles tendon surgery.

A psoas abscess complicating an infected ureteral stump: CT diagnosis

Abstract A rare case of a secondary psoas abscess, caused by an infected, obstructed ureteral stump, 32 months following nephrectomy, is reported. The findings of both pathological processes were clearly demonstrated by contrast-enhanced computerized tomography, enabled the urologist to choose the therapeutic approach.