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Functional outcome following anatomic restoration of tarsal-metatarsal fracture dislocation.

Anatomic restoration of displaced fracture-dislocation of the tarsometatarsal junction of the foot is essential, as even “minor” disruptions of this joint complex leads to poor clinical results. In order to determine a “key” element associated with good or poor functional outcomes, 11 patients with excellent radiographic results following surgical treatment of unilateral closed Lisfranc fracture-dislocation of the tarsometatarsal joint of the foot were evaluated at an average of 41.2 (range, 14 to 53) months following their injury and surgery. Their average age was 40.6 (range, 21 to 58) years. AOFAS midfoot scores averaged 71.0 (range, 30 to 95). Radiographic analysis at follow-up revealed anatomic reduction in 10 of 11. Eight of 11 had evidence of arthritis of the tarsometatarsal joints. Clinical alignment was normal in all subjects, with nine of 11 clinically exhibiting decreased relative range of motion. Gait analysis was performed with the F-Scan (Tekscan, Boston, MA) in-shoe pressure-monitoring system. Vertical ground reaction force was recorded under the hallux, first metatarsal head, lateral metatarsals, and heel. Stance phase duration, rate of loading, rate of unloading, peak loading, and total loading were recorded at each of the named regions. There was no statistical difference in the parameters measured between the injured and normal control feet. The results of this study reveal that when anatomic reduction is accomplished in tarsometatarsal fracture dislocation of the foot, objective measures of gait analysis are returned to normal. In spite of excellent radiographic results and return to normal dynamic walking patterns, subjective patient outcomes were less than satisfactory. It is presently well accepted that fracture-dislocations of the tarsometatarsal junction of the foot are best treated with anatomic restoration by closed, percutaneous or open methods. Many individuals achieve poor functional results. It is well accepted that patients are likely to develop late joint deformity at the tarsometatarsal junction, joint separation, and radiographic and clinical evidence of post-traumatic arthritis when anatomic reduction is not obtained. 1–7 The goal of this study was to determine if clinical results and subjective patient outcomes are assured with anatomic reduction. It appears that the major function of the tarsometatarsal joint complex is the regulation and redirecting of loading forces during weightbearing. There is very limited motion of the tarsometatarsal joint during walking. 8 This knowledge has prompted support for anatomic restoration following injury. Even with seemingly anatomic restoration of normal alignment, many patients fare poorly. The goal of this study was to objectively analyze the components of vertical ground reaction force during walking in patients who had evidence of excellent surgical reduction measured on follow-up weightbearing radiographs following isolated injury to the tarsometatarsal joint complex. We hoped to detect some key element of gait altered by the injury, and responsible for why patients fare poorly following this injury. By dissecting out the components of mechanical loading and unloading of the foot during walking, we wished to determine if there was a “key” factor associated with either favorable or unfavorable subjective clinical outcomes.

Enlarged peroneal process with peroneus longus tendon entrapment.

Abstract A 50-year-old man was treated conservatively for chronic bilateral ankle pain for several years. Plain radiographs obtained following exacerbation of symptoms showed bilateral enlarged peroneal processes. CT and MRI demonstrated bony detail of the unusual processes and also showed isolation of the peroneus longus tendons and associated tendinitis and partial tears.

Flexion and traction effect on C5-C6 foraminal space

OBJECTIVE To determine the effects of cervical flexion and traction on foraminal volume and isthmus area at the C5-C6 foraminal space in cadavers. DESIGN This study evaluated the foraminal space at C5-C6 in cadaver specimens during flexion and traction of the cervical spine. SETTING An orthopedic biomechanics laboratory and department of radiology of a university medical center. PATIENTS OR OTHER PARTICIPANTS Nine cadaver cervical spines, C1 through T3, were used in the study. Superficial tissues were dissected, preserving the ligaments. INTERVENTIONS Proximal and distal portions of the cadaver spines were potted using bone cement. Spines were mounted and imaged with computed tomography in neutral position, 15 degrees of flexion, and maximum flexion with and without 25lbs of axial traction. MAIN OUTCOME MEASURES The areas and volumes of the foramen were measured and calculated. RESULTS Flexion alone significantly increased the foraminal volume and isthmus area at C5-C6. Traction resulted in little additional change. CONCLUSIONS For cervical spines with mild to moderate degenerative changes at C5-C6, cervical flexion with or without traction produces significant increases in foraminal volume and area at the foraminal isthmus.

Multifocal vascular lesions of bone: imaging characteristics.

Abstract Objective. Multifocal vascular processes which arise in bone are a very inhomogeneous class of diseases. Four of these processes are derived from endothelial precursors, however, and share a similar radiographic spectrum. These four entities are reviewed in order to clarify their imaging patterns and the diagnostic utility of imaging modalities. Methods. Eight cases of cystic angiomatosis, multifocal hemangioma, hemangioendothelioma and angiosarcoma presenting to a tertiary referral center over a 7-year period were reviewed. The medical literature was also reviewed for information concerning the imaging of these processes. Results. All four diseases produced radiolucent defects on plain radiographs with variable margination reflecting the aggressiveness of the lesions. Computed tomography was used to examine five patients and provided supportive, though generally non-diagnostic, information in the five cases in which it was performed. Radionuclide bone scintigraphy, as reported in the literature, underestimated the extent of skeletal involvement in all eight cases, though some lesions were identified. Radionuclide imaging with labeled red blood cells, performed in three cases, did not add any information, which is contrary to some reports in the literature. Magnetic resonance imaging proved the most sensitive for identifying lesions, although the imaging characteristics were not diagnostic. Conclusions. Plain radiographs are the mainstay for imaging multifocal endothelial processes. Radiographs provide information on aggressiveness, multifocality and distribution of lesions. Computed tomography provides similar information. Magnetic resonance imaging often detects additional lesions. The insensitivity of radionuclide bone scintigraphy is surprising. Reports of unique deposition of radionuclide in tagged red blood cell scanning has been reported to support the diagnosis of vascular lesions, but it did not do so in these cases.

Health Related Quality of Life in Patients with Supination-External Rotation Stage IV Ankle Fractures

Background: While open reduction of displaced ankle fractures generally is accepted as the standard of care, relatively little is known about the health related quality of life after treatment. It is generally accepted that clinical results of treatment for supination-external rotation stage IV ankle fractures are favorable. The goal of this investigation was to determine the relationship between clinical results and health-related quality of life outcome measures in a consecutive series of patients treated for closed supination-external rotation stage IV ankle fractures. Methods: Twenty-six of 156 patients who had operative treatment for closed, displaced supination-external rotation stage IV ankle fractures during a 9-year period, completed the Short Musculoskeletal Function Assessment (SMFA) outcome questionnaire. Radiographs and clinical records were reviewed to determine quality of operative repair, postoperative morbidity, and the development of post-traumatic arthritis. Results: There were no postoperative complications. Of the 26 patients who returned the SMFA questionnaires, 19 had “good,” and seven had “fair” reduction of their fractures. Six showed radiographic evidence of arthritis at followup. Study participants reported scores that were similar to the general population in five of the six domains of the SMFA. Their scores in the mobility index were statistically less favorable (23.72 vs. 13.61, p = 0.016) when compared to the general population. Participants with “good” operative reductions and no evidence of arthritis at followup showed no significant difference to the general population. Participants with either a “fair” operative reduction or evidence of postoperative arthritis at followup had less favorable scores in the daily activities (mean 13.45 vs. 11.82, p = 0.004), mobility (43.43 vs. 13.61, p = 0.001), dysfunction (32.89 vs. 12.70, p = 0.014), and bother (35.80 vs. 13.77, p = 0.020) domains, when compared to the general population. Conclusions: The results of this investigation suggest that patients with excellent radiographic operative reductions and no arthritis as early as 6 months after surgery sustain no lasting unfavorable effect on health related quality of life. Patients with “fair” radiographic reduction, or presence of arthritis or both at followup, are likely to have a negative effect on their quality of life.

Effects of motion segment level, Pfirrmann intervertebral disc degeneration grade and gender on lumbar spine kinematics

MRI allows non‐invasive assessment of intervertebral disc degeneration with the added clinical benefit of using non‐ionizing radiation. What has remained unclear is the relationship between assessed disc degeneration and lumbar spine kinematics. Kinematic outcomes of 54 multi‐segment (L1‐Sacrum) lumbar spine specimens were calculated to discover if such an underlying relationship exists with degeneration assessed using the Pfirrmann grading system. Further analyses were also conducted to determine if kinematic outcomes were affected by motion segment level, gender or applied compressive preload. Range of motion, hysteresis, high flexibility zone size and rotational stiffness in flexion‐extension, lateral bending and axial rotation were the kinematic outcomes. Caudal intervertebral discs in our study sample were more degenerative than cranial discs. L5‐S1 discs had the largest flexion‐extension range of motion (p < 0.005) and L1‐L2 discs the lowest flexion high flexibility zone size (p < 0.013). No other strict cranial‐caudal differences in kinematic outcomes were found. Low flexibility zone rotational stiffness increased with disc degeneration grade in extension, lateral bending and axial rotation (p < 0.001). Trends towards higher hysteresis and lower range of motion with increased degeneration were observed in flexion‐extension and lateral bending. Applied compressive preload increased flexion‐extension hysteresis and augmented the effect of degeneration on hysteresis (p < 0.0005). Female specimens had about one degree larger range of motion in all rotational modes, and higher flexion extension hysteresis (p = 0.016). These results suggest that gender differences exist in lumbar spine kinematics. Additionally high disc loads, applied compressive preload or applied moment, are needed to kinematically distinguish discs with different levels of degeneration.

Application of the RADPEER™ Scoring Language to Interpretation Discrepancies Between Diagnostic Radiology Residents and Faculty Radiologists

PURPOSE The objectives of this study were to assess the rate of discrepancies between radiology residents and faculty radiologists at an academic hospital using the RADPEER(™) scoring language and to determine if a correlation existed between assigned RADPEER score (2, 3, or 4) and the clinical significance of the error. METHODS Over 19 months, preliminary resident interpretations were graded using the RADPEER scoring system. A retrospective review of discrepant cases was performed to assess the percentage of discrepancy, change in clinical management, and identification of error patterns. RESULTS Of 2,255 preliminary interpretations, 29 discrepancies (1.29%) were judged to be potentially clinically significant. Of these, 14 (0.62%) resulted in immediate changes in clinical management. Discrepancies assigned RADPEER scores of 3 or 4 were significantly more likely to be judged clinically significant than those assigned scores of 2 (54.5% of 33 studies graded 3 or 4 and 7.7% of 142 studies graded 2, P < .0001). CT imaging generated a higher percentage of discrepancies that were predicted to be clinically significant than plain-film radiography, as well as a higher percentage of discrepancies that resulted in immediate changes in management, but the incidence of each remained low overall (≤2.1%). CONCLUSIONS Discrepancy rates in this study are comparable with previously reported data for discrepancies between attending radiologists and those between attending radiologists and residents data. A significant correlation was observed between increasing RADPEER scores and the clinical significance of discrepancies. This study supports the use of the RADPEER scoring language as both a resident quality assurance measure and an educational tool for quality improvement.

Evaluation of Bone Incorporation of Patellar Tendon Autografts and Allografts for ACL Reconstruction Using CT

Anterior cruciate ligament (ACL) reconstruction is a relatively common orthopedic procedure, with patellar tendon frequently a graft source. However, controversy exists regarding the decision to use autograft or allograft patellar tendon tissue. This experimental study used computed tomography (CT) to compare the percentage of bone graft incorporation following ACL reconstruction using autografts and allografts. Fifty consecutive patients undergoing ACL reconstruction were included in the study. The tibial bone plug was imaged with CT 1 week, 2 months, and 5 months postoperatively. Four images from each completed scan were analyzed for percentage of incorporation of the bone graft. The results of autograft and allograft incorporation for each of the time intervals were compared. No statistically significant difference was found in the amount of bone incorporation at the tibial bone plug 1 week, 2 months, and 5 months. Clinical concerns regarding slower or less complete healing of allograft bone tissue compared to autograft are not supported with regard to the grafts studied.

Magnetic resonance imaging of abnormal shoulder pain following influenza vaccination

The influenza vaccine is increasingly available to the general public and mandated by many employers in the United States. The prevalence of post-vaccination complications is likely on the rise. Complications are well known to general clinicians, but are under-reported in the imaging literature. We present four cases of post-vaccination shoulder pain with magnetic resonance imaging (MRI) findings. An intrasubstance fluid-like signal in deep muscular and/or tendinous structures was the most common finding on MRI of these four cases. Focal bone marrow signal within the humeral head and inflammatory changes in the subacromial/subdeltoid bursa were also observed. The most likely reason for a humeral intraosseous edema-like signal was presumed injection of vaccine substance directly into osseous structures that might lead to focal osteitis. In the published literature, there is little emphasis on the imaging of local injection site complications accompanying influenza vaccination. We intended to increase familiarity of MRI findings in the setting of prolonged or severe clinical symptoms following influenza vaccination through the imaging findings of these four cases.

Fibrous dysplasia complicated by aneurysmal bone cyst formation affecting multiple cervical vertebrae

Fibrous dysplasia is a well-known benign dysplastic process of bone. However, fibrous dysplasia is very uncommon in the spine. Further, to our knowledge, coexistence of fibrous dysplasia and aneurysmal bone cyst in the spine has not been reported. This manuscript presents a patient who had both processes involving the cervical spine.