James Teh

Acquired adult flat foot due to isolated plantar calcaneonavicular (spring) ligament insufficiency with a normal tibialis posterior tendon

BACKGROUND We present nine cases of acquired flat foot deformity (AFFD) in adults caused by isolated spring ligament insufficiency. METHODS We present the clinical sign that allows differentiation of this diagnosis from posterior tibialis tendon (PTT) dysfunction namely the ability to single leg tiptoe, but with persistent forefoot abduction and heel valgus. In addition we illustrate the unique radiological features which allow confirmation of the diagnosis. Only a solitary previous case report has documented this alternative aetiology of AFFD; in that case, diagnosis was made intra-operatively. RESULTS Six patients have been managed with orthoses. Three patients underwent surgery; one patient who presented early had isolated repair of the spring ligament complex. The remaining two required a calcaneal osteotomy and flexor digitorum longus transfer as for a PTT reconstruction. CONCLUSION We propose that early diagnosis (with ultrasound confirmation) and management of this condition would offer a better prognosis and allow less interventional surgery.

Ischiofemoral impingement: a retrospective analysis of cases in a specialist orthopaedic centre over a four-year period.

Background Ischiofemoral impingement is a recently identified cause of chronic hip pain, the pathophysiology and clinical features of which are poorly understood. Aim To determine the clinical significance of MRI findings of ischiofemoral impingement. Materials and Methods Retrospective search for cases of ischiofemoral impingement in the Nuffield Orthopaedic Centre, Oxford, over a 4 year period, and review of medical notes to identify correlation between clinical and MRI features. Results Sixteen hips in 13 patients with MRI signs of ischiofemoral impingement were identified. All patients were females with a median age of 36 years (range 17-80 years). In six patients the symptoms corresponded to the side of the quadratus femoris abnormality and narrowed ischiofemoral distance. In two patients the symptoms were on the same side as the abnormality but were more consistent with back pain and sciatica. In five patients the symptoms were not anatomically related to the abnormality. Abnormalities identified; seven patients had muscle oedema (six unilateral, one bilateral) and six had muscle wasting (four unilateral, two bilateral). Of the patients with quadratus femoris oedema, two had gluteus medius enthesopathy and one had hamstring enthesopathy. Two patients presented with a chronic loud clunking of the hip on walking. Conclusions Ischiofemoral impingement on MRI is seen in patients with pain localised to the ipsilateral buttock and in patients with symptoms unrelated to the abnormality. The condition may be associated with wasting or oedema of the quadratus femoris muscle on MRI and may occur secondary to injury in other muscles controlling movement of the hip such as the hamstrings and gluteus medius. Ischiofemoral impingement is a cause of a clunking hip.

Recommendations of the ESSR Arthritis Subcommittee for the Use of Magnetic Resonance Imaging in Musculoskeletal Rheumatic Diseases.

This article presents the recommendations of the European Society of Musculoskeletal Radiology Arthritis Subcommittee regarding the standards of the use of MRI in the diagnosis of musculoskeletal rheumatic diseases. The recommendations discuss (1) the role of MRI in current classification criteria of musculoskeletal rheumatic diseases (including early diagnosis of inflammation, disease follow-up, and identification of disease complications); (2) the impact of MRI on the diagnosis of axial and peripheral spondyloarthritis, rheumatoid arthritis, and juvenile spondyloarthritis; (3) MRI protocols for the axial and peripheral joints; (4) MRI interpretation and reporting for axial and peripheral joints; and finally, (5) methods for assessing MR images including quantitative, semiquantitative, and dynamic contrast-enhanced MRI studies.

Stress Fractures in the Young Athlete: A Pictorial Review

Stress fractures are an uncommon but important source of pain and disability in young athletes. The presentation and differential diagnosis of stress fractures in young athletes differs from that of older athletes. This pictorial review outlines the pathogenesis and imaging features of stress fractures. Other pathologies that can mimic stress fractures and the advantages of the use of magnetic resonance imaging will be discussed. An imaging algorithm for a suspected stress fracture is suggested.

Ultrasound-guided interventional procedures of the wrist and hand

This pictorial review will outline the rationale, indications, techniques, controversies and possible complications of ultrasound-guided interventional procedures of the hand and wrist.

Ultrasound of Muscle

This pictorial review illustrates the ultrasound appearances of pathological conditions affecting muscle with particular emphasis on extended field-of-view imaging.

Investigating suspected bone infection in the diabetic foot

Accurate and early diagnosis of this condition is key to successful management. This article guides you through the diagnostic options

Oncogenic hypophosphataemic osteomalacia : biomarker roles of fibroblast growth factor 23, 1,25 -dihydroxyvitamin D3 and lymphatic vessel endothelial hyaluronan receptor 1

Oncogenic osteomalacia (OOM) is characterised by tumour production of fibroblast growth factor 23 (FGF23) that results in hypophosphataemia and renal phosphate wasting, reduced 1,25-dihydroxyvitamin D3 (1,25(OH)2D3) synthesis and osteomalacia. Here, we demonstrate the roles of serum FGF23 and 1,25(OH)2D3, together with the lymphatic vessel endothelial hyaluronan receptor 1 (LYVE-1), as biomarkers for OOM. A previously well 52-year-old man presented with a 2-year history of generalised musculoskeletal pain and proximal myopathy. He had hypophosphataemia, elevated serum alkaline phosphatase activity, low serum 1,25(OH)2D3 and a reduced tubular maximum of phosphate/glomerular filtration rate. These findings indicated a diagnosis of OOM, but magnetic resonance imaging (MRI) and octreotide scintigraphy did not identify any tumours. Treatment with oral phosphate and calcitriol resolved the symptoms and biochemical abnormalities within 6 months. Four years later, he relapsed whilst on treatment with oral phosphate and calcitriol. Serum FGF23 concentration was elevated and MRI identified a 2 cm tumour within Hoffas fat pad of the left knee. Removal of the tumour resulted in a complete resolution of symptoms and normalisation of the serum biochemical abnormalities including serum FGF23. Histology demonstrated a phosphaturic mesenchymal tumour, mixed connective tissue variant (PMTMCT), which revealed immunostaining with anti-LYVE-1 antibody and hence the presence of lymphatic vessels. Serum FGF23 and 1,25(OH)2D3 were found to be reliable biomarkers for OOM. In addition, the demonstration of lymphatics in the PMTMCT helps to distinguish this tumour from most typical benign haemangiomas.

Imaging in the Assessment and Management of Overuse Injuries in the Foot and Ankle

Overuse injuries of the ankle and foot are common in the general and athletic populations. The wide spectrum of overuse injuries includes ligamentous injuries, soft tissue and osseous impingement, osteochondral lesions, tendon injuries, and stress fractures. Some conditions such as impingement syndromes and stress fractures may be missed on initial physical examination, and patients with such injuries often present to a sports or orthopedic clinic with persistent symptoms. With the increasing participation in sports, health-care professionals involved in the care of athletes at all levels must have a thorough understanding of overuse conditions of the foot and ankle, and the use of imaging in the management of these conditions. This article covers the clinical presentation, pertinent anatomy, imaging features, and management of overuse injuries of the foot and ankle.

Ultrasound of soft tissue masses of the hand

Most soft tissue mass lesions of the hand are benign. Ganglia are the commonest lesions encountered, followed by giant cell tumors of the tendon sheath. Malignant tumors are rare. Often a specific diagnosis can be achieved on imaging by considering the location and anatomical relations of the lesion within the hand or wrist, and assessing its morphology. Magnetic resonance imaging is an excellent modality for evaluating soft tissue tumors with its multiplanar capability and ability to characterize tissue. Ultrasound plays a complementary role to MRI. It is often the initial modality used for assessing masses as it is cheap and available, and allows reliable differentiation of cystic from solid lesions, along with a real time assessment of vascularity. This review describes the US appearances of the most frequently encountered soft tissue masses of the wrist and hand, correlating the findings with MRI where appropriate.