Gabrielle P. Konin

Epicondylitis: Pathogenesis, Imaging, and Treatment

Epicondylitis commonly affects the elbow medially or laterally, typically in the 4th or 5th decade of life and without predilection with regard to sex. Epicondylitis is an inflammatory process that may be more accurately described as tendinosis. In the lateral epicondylar region, this process affects the common extensor tendon; in the medial epicondylar region, the common flexor tendon is affected. The condition is widely believed to originate from repetitive overuse with resultant microtearing and progressive degeneration due to an immature reparative response. Advances in understanding of the anatomy and pathophysiology of epicondylitis have shaped current treatment practices. Conservative measures are undertaken initially, because symptoms in most patients improve with time and rest. Those who fail to respond to conservative therapy are considered for surgical treatment. When surgery is contemplated, magnetic resonance imaging or ultrasonography is useful for evaluating the extent of disease, detecting associated pathologic processes, excluding other primary sources of elbow pain, and planning the surgical approach. Familiarity with the normal anatomy, the pathophysiology of epicondylitis and its mimics, and diagnostic imaging techniques and findings allows more accurate diagnosis and helps establish an appropriate treatment plan.

Rate of Union After Segmental Midshaft Shortening Osteotomy of the Lesser Metatarsals.

Background: Current literature reports excellent rates of union following various lesser metatarsal osteotomy techniques. However, it is our experience that segmental midshaft shortening osteotomies heal very slowly and have a greater potential for nonunion than has previously been reported. The purpose of this study was to assess union rates and report the time required for segmental midshaft shortening osteotomies to achieve radiographic union. Methods: We reviewed the charts and postoperative radiographs of 58 patients (representing 91 osteotomies) who underwent segmental midshaft shortening osteotomies with internal fixation between January 2009 and December 2013. Radiographs were reviewed to determine when union was achieved. Union was defined as the bridging of 2 or more cortices in the anteroposterior, lateral, and oblique radiographic views. Osteotomies were classified as delayed union if they were not healed at 3 months postoperatively and nonunions if they were not healed at 6 months postoperatively. Results: Overall, 27 of 91 osteotomies met our radiographic classification of union and were healed by 3 months (29.7%). Sixty-nine of the 91 osteotomies healed by 6 months (75.8%) and were considered delayed unions. Twenty-two osteotomies were not healed yet and therefore were considered nonunions (24.2%). Of the 22 nonunions, 7 healed in an additional 2 months (8 months) for an overall healing percentage of 83.5%, (76 of 91). By 10 months, 6 more nonunions were healed (overall healing percentage of 90.1%, 82 of 91). Three additional nonunions went on to heal by 12.9 months, yielding a final union rate of 93.4% (85 of 91), while 6 were still considered nonunions (6.6%). Conclusion: We report that a significant percentage of segmental midshaft metatarsal shortening osteotomies experienced delayed unions and nonunions. These findings contrast those previously reported in the literature that metatarsal osteotomies have very low nonunion rates. These results support our hypothesis that these osteotomies require a prolonged amount of time to achieve bony healing and that they have a higher tendency to develop delayed and nonunions than previously reported. Level of Evidence: Level IV, retrospective case series.

Posterior Humeral Avulsion of the Glenohumeral Ligament and Associated Injuries Assessment Using Magnetic Resonance Imaging

Background: Lesions associated with posterior humeral avulsion of the glenohumeral ligament (HAGL) can lead to persistent symptoms related to posterior shoulder instability and can be commonly missed or delayed in diagnosis. Purpose: To identify and characterize the MRI findings in patients with a posterior HAGL lesion. Study Design: Case series; Level of evidence, 4. Methods: This retrospective case series included 27 patients (28 shoulders) identified by search through the senior authors’ databases, with cross-reference to their institutional radiologic communication system for MRI review. Baseline patient demographic data were collected, including age and sex. All posterior HAGL lesions were identified on MRI and characterized as partial, complete, or floating lesions. All acute glenohumeral pathologic changes concurrent with the posterior HAGL were documented. Chondrolabral retroversion of the injured shoulder was measured on axial MRI. Results: The average age of the identified cohort was 33.6 years (range, 15-81 years), and 23 patients were male (86%). Posterior HAGL injuries were found to be complete tears (71%), partial tears (25%), and floating lesions (4%); concomitant bony HAGL avulsion was found in 7% of injuries. Additional traumatic glenohumeral disorders occurred in 93% of cases. The most common concurrent injuries were reverse Hill-Sachs lesions (36%), anterior Bankart lesions (29%), and posterosuperior rotator cuff tears (25%). Notably, concomitant anterior labral or capsular injury was found in 50% of patients, signifying bidirectional disruption of the capsule. In addition, increased chondrolabral version was found in this cohort (10.2° ± 3.7° retroversion). Conclusion: This study depicts the high association of combined injury with posterior HAGL lesions and increased chondrolabral retroversion. Findings on MRI related to a posterior HAGL injury could potentially be masked by additional injury and may occur with mechanisms that also lead to anterior glenohumeral disorders.

Optimal Starting Point for Fifth Metatarsal Zone II Fractures: A Cadaveric Study

Background: Identifying the optimal starting point for intramedullary fixation of tibia and femur fractures is well described in the literature using a retrograde or anterograde technique. This technique has not been applied to the fifth metatarsal, where screw trajectory can cause iatrogenic malreduction. The generally accepted starting point for the fifth metatarsal is “high and inside” to accommodate the fifth metatarsal’s dorsal apex and medial curvature. We used a retrograde technique to identify the optimal starting position for intramedullary fixation of fifth metatarsal fractures. Methods: Five matched cadaveric lower extremity pairs were dissected to the fifth metatarsal neck. An osteotomy was made to access the intramedullary canal. A retrograde reamer was passed to the base of the fifth metatarsal to ascertain the ideal entry point. Distances from each major structure on the lateral aspect of the foot were measured. Computed tomography scans helped assess base edge measurements. Results: In 6 of 10 specimens, the retrograde reamer hit the cuboid with a cuboid invasion averaging 0.7 mm. The peroneus brevis and longus were closest to the starting position with an average distance of 5.1 mm and 5.7 mm, respectively. Distances from the entry point to the dorsal, plantar, medial, and lateral edges of the metatarsal base were 8.3 mm, 6.9 mm, 9.7 mm, and 9.7 mm, respectively. Conclusion: Optimal starting position was found to be essentially at the center of the base of the fifth metatarsal at the lateral margin of the cartilage. Osteoplasty of the cuboid or forefoot adduction may be required to gain access to this site. Clinical Relevance: This study evaluated the ideal starting position for screw placement of zone II base of the fifth metatarsal fractures, which should be considered when performing internal fixation for these fractures.

One-Year All-Cause Mortality of Patients Diagnosed as Having In-Hospital Pulmonary Embolism After Modern Elective Joint Arthroplasty Is Low And Unaffected By Radiologic Severity

BACKGROUND We studied the 1-year complication rate of patients diagnosed as having a pulmonary embolism (PE) after elective total hip arthroplasty (THA) and total knee arthroplasty (TKA) surgery and the distribution of emboli in the pulmonary circulation, and determined if a relationship exists between the location of the PE and age, gender, body mass index, preoperative predisposing factors, American Society of Anesthesiology classification, type of surgery, prophylaxis, hospital stay, transfer to a higher level of care, and mortality. METHODS Two hundred sixty-nine patients who developed an in-hospital PE proved by computed tomography pulmonary angiography after elective THA or TKA between 2005 and 2012 were studied. RESULTS The most proximal location of the emboli was central in 62, segmental in 139, and subsegmental in 68. Nineteen patients (7%) developed a bleeding complication during PE treatment. Twenty-nine patients (11%) were readmitted during the first year. Two patients (0.74%) died: one had a segmental PE after TKA. He died 11 months after surgery due to an autopsy-proven sepsis. The second patient developed a segmental PE after THA. She was anticoagulated, developed an intracranial bleed, and died 8 months after surgery. Multivariate analysis showed that demographic variables, American Society of Anesthesiology class, preoperative comorbidities (with the exception of arrhythmia), and the presence of preoperative predisposing factors had no effect in the location of the PE. CONCLUSION The 1-year mortality rate of these patients is low. Death can be caused by bleeding complications secondary to anticoagulation or by unrelated conditions. This information may aid clinicians while counseling patients who developed a PE after surgery, particularly those with small subsegmental emboli.

Multiplanar CT Analysis of Fifth Metatarsal Morphology Implications for Operative Management of Zone II Fractures

Background: Percutaneous internal fixation is currently the method of choice treating proximal zone II fifth metatarsal fractures. Complications have been reported due to poor screw placement and inadequate screw sizing. The purpose of this study was to define the morphology of the fifth metatarsal to help guide surgeons in selecting the appropriate screw size preoperatively. Methods: Multiplanar analysis of fifth metatarsal morphology was completed using computed tomographic (CT) scans from 241 patients. Specific parameters were analyzed and defined in anteroposterior (AP), lateral, and oblique views including metatarsal length, distance from the base to apex of curvature, apex medullary canal width, apex height, and fifth metatarsal angle. Results: The average metatarsal length in the AP view was 71.4 ± 6.1 mm and in the lateral view 70.4 ± 6.0 mm, with 95% of patients having lengths between 59.3 and 83.5 mm and 58.4 and 82.4 mm, respectively. The average canal width at the apex of curvature was 4.1 ± 0.9 mm in the AP view and 5.3 ± 1.1 mm in the lateral view, with 95% of patients having widths between 2.2 and 5.9 mm and 3.2 and 7.5 mm, respectively. Average distance from apex to base was 42.6 ± 5.8 mm in the AP and 40.4 ± 6.4 mm in the lateral views. Every measurement taken in all 3 views had a significant correlation with height. Conclusions: When determining screw length, we believe lateral radiographs should be used since the distance from the base of the metatarsal to the apex was smaller in the lateral view. On average, the screw should be 40 mm or less to reduce risk of distraction. For screw diameter, the AP view should be used because canal shape is elliptical, and width was found to be significantly smaller in the AP view. Most canals can accommodate a 4.0- or 4.5-mm-diameter screw, and one should use the largest diameter screw possible. Larger individuals were likely to have more bowing in their metatarsal shaft, which may lead to a higher tendency to distract. Level of Evidence: Level III, comparative series.

Symptomatic Bipartite Medial Cuneiform Treated with Fluoroscopic and Ultrasound-Guided Injections

The bipartite medial cuneiform (BMC) is a rare congenital variant that was first described by Morel in the 18th century [2, 6]. Amongst the many causes of midfoot pain, BMC is primarily an imaging diagnosis that often depends on plain radiographs as the initial diagnostic test. Recognizing a BMC on radiographs can be difficult as the osseous segments are typically well corticated and blend with the remainder of the tarsal bones. Additionally, although there are many fracture patterns at the tarsometatarsal (TMT) joint level including Lisfranc injuries, the cleft between the osseous segments lies in the horizontal plane in contrast to the typical vertical orientation of isolated fractures through the medial cuneiform [9]. The cleft is formed by a pseudoarticulation between the osseous segments. Symptomatic patients typically present with chronic midfoot pain that is exacerbated with ambulation or acute injury typically due to the inherent instability of the pseudoarticulation resulting in stress response and/or degeneration. When a BMC is symptomatic, treatment has ranged from nonoperative to surgical interventions including fusion and excision, as well as a previously described computed tomography (CT)-guided corticosteroid injection [3]. We believe our case is unique in that the patient underwent imaging using plain radiographs, CT, and magnetic resonance imaging (MRI) as well as successful image-guided injections using fluoroscopy and ultrasound on a bipartite medial cuneiform with a fibrous pseudoarticulation. The procedures and outcomes of minimally invasive fluoroscopic and ultrasound-guided steroid and anesthetic injections have not been previously described.

Imaging of shoulder arthroplasty.

Imaging is central to the pre- and postoperative evaluation of shoulder arthroplasty, which is increasingly performed due to its clinical efficacy. Implant design, indications, and common complications affecting the different types of shoulder prostheses are reviewed.

Imaging Evaluation of the Painful or Failed Shoulder Arthroplasty

Managing a patient with a painful or failed shoulder arthroplasty can be a difficult diagnostic dilemma for surgeons. While multiple imaging modalities can be useful in making a diagnosis, the use of MRI is becoming more accepted with the advent of artifact-reduction protocols. These MRI protocols can minimize artifact around metal implants to allow visualization of the surrounding soft tissues. In this chapter, we will discuss the most common reasons for a painful or failed shoulder arthroplasty and outline the ways in which imaging can help. Namely, we will discuss implant loosening, periprosthetic fracture, infection, rotator cuff dysfunction, and instability.

Imaging of the Rotator Cuff

Imaging plays a critical role in defining the extent of rotator cuff tears, which has important implications in clinical decision making, surgical planning, and prognosis. Multiple imaging modalities are available including magnetic resonance (MR) imaging, ultrasound, computed tomography (CT), and conventional radiographs, and each provides particular advantages. MR imaging and ultrasound are the most commonly used imaging modalities in the evaluation of rotator cuff pathology, as both offer detailed evaluation of rotator cuff tears with MR imaging providing a more comprehensive evaluation. CT provides information about the degree of atrophy and fatty infiltration of the cuff musculature and is useful for preoperative evaluation of the osseous integrity of the glenoid in rotator cuff tear arthropathy. Radiographs are a good initial evaluation indicating whether a massive cuff tear is likely and readily demonstrates the presence of cuff tear arthropathy.