Range of motion in the talo-navicular and the calcaneo-cuboid joints evaluated by ultrasound during clubfoot treatment with normal references up to the age of four years.

PURPOSE: Previous ultrasound studies of clubfeet have mainly focused on the first year of life. The purpose of this study was to improve the evaluation of the talo-navicular and calcaneo-cuboid joints by adding new variables, evaluating the repeatability of ultrasound measurements for normal feet and clubfeet and establishing values for normal feet up to four years of age. METHODS: A control group of 105 children divided into ten age groups, and 71 clubfeet in 46 children were examined. Four new variables were introduced: medial malleolus-Talar head-Navicular distance, medial tangent of the talus to the medial border of the navicular distance, the angle between the longitudinal axis of the talus and a line from the centre of the talar head to the medial corner of the navicular, the angle between the lateral borders of the calcaneus and the cuboid. The mobility in the talo-navicular and the calcaneo-cuboid joints was assessed by comparing measurements with the foot in adduction and abduction. RESULTS: The variables could be assessed with fair to very good intra- and inter-observer repeatability (intraclass correlation coefficient > 0.8 and ≥ 0.6, respectively), with a few exceptions. There was less movement in talo-navicular and calcaneo-cuboid joints in clubfeet than in controls. CONCLUSION: Morphology of normal feet and clubfeet, as well as mobility in the talo-navicular and calcaneo-cuboid joints, can be assessed by ultrasound with a fair to very good reliability from birth to the age of four years. LEVEL OF EVIDENCE: III.

Assessment of the ankle joint in clubfeet and normal feet to the age of four years by ultrasonography.

PURPOSE: To establish reproducible posterior ultrasonographic projections for evaluation of the movement in the talocrural joint in clubfeet and normal feet from the perinatal period up to the age of four years. METHODS: The feet in 105 healthy children and 46 patients (71 clubfeet and 21 normal feet) were examined. In all, 14 feet in seven patients were examined twice by two examiners independently to evaluate the repeatability of the ultrasonography scans. A posterior sagittal projection was used. The distance from the posterior aspect of the tibial physis to the posterior border of the talocalcaneal joint (Tib. phys - TCJ) was measured with the foot in neutral position and dorsiflexion. In plantar flexion the shortest distance between the tibial physis and the calcaneus was measured. The distance from the skin to the tibial epiphyses and the talus was measured in neutral position. The intraclass correlation coefficient (ICC) was calculated to evaluate the repeatability of the measurements. RESULTS: The interexaminer reliability was 0.71 to 0.89 ICC. The intra- and interobserver reliability measured as ICC was 0.68 to 0.99 for all measurements. The correlation between Tib. phys. - TCJ and clinical dorsiflexion varied much between the age groups. CONCLUSION: Ultrasonography of the posterior aspect of the ankle joint can be done with high interexaminer reliability. The repeatability of image evaluation was high. Correlation to clinical measurements varied, therefore dynamic ultrasound in real time is clinically more useful than single measurements on frozen ultrasound images.

Morphological patterns of the pretendinous cord in Dupuytren's disease: a predictor of clinical outcome?

The morphology of the pretendinous cord in Dupuytren's disease is poorly described in vivo and especially with respect to recurrence after treatment. This prospective study was designed to describe the morphology of Dupuytren's cords by ultrasound and to identify possible correlation between the ultrasonographic characteristics of these cords and the clinical outcomes two years after treatment. Thirty-nine patients with a contracture of at least 20° in the metacarpophalangeal (MCP) joint, who were scheduled for local treatment by either injectable collagenase clostridium histolyticum (CCH) or percutaneous needle fasciotomy (PNF), were examined by ultrasound. The echogenicity and position of the pretendinous cords in relation to flexor tendons and neurovascular bundles were categorized. The structure of the cords was described and characterized as predominantly nodular or fibrillar. All 39 patients were assessed clinically after two years. A majority of the patients (84%) had cords with nodular components, and six patients (16%) had fibrillar cords. After two years, the clinical results were compared to the ultrasonographic findings before treatment. Three patients had recurrent contracture, and a retrospective analysis showed that all of these patients had cords with mixed echogenicity and nodules before treatment. Fifteen patients had a palpable pretendinous cord, and all but one of these had cords with mixed echogenicity and nodular structure before treatment. This pilot study indicates that some ultrasonographic features of the Dupuytren's cord, such as mixed echogenicity and nodular structure, may predict recurrence after minimally invasive treatment for Dupuytren's contracture. However, a larger study in correlation with histological examination of the excised cords would be necessary to confirm the pathoanatomical significance of these ultrasonographic features.

Cone-beam computed tomography, a new low-dose three-dimensional imaging technique for assessment of bone erosions in rheumatoid arthritis: reliability assessment and comparison with conventional radiography - a BARFOT study.

OBJECTIVES: To determine the intra- and inter-observer agreement of erosions detected and scored with cone-beam computed tomography (CBCT) of bones in the hands and feet, and to compare CBCT with conventional radiography (CR) for assessment of bone erosions in patients with long-standing rheumatoid arthritis (RA). METHOD: Thirty patients with long-standing RA from the Better Anti-Rheumatic PharmacOTherapy (BARFOT) cohort were examined with CBCT and CR of hands and feet at their 15 year follow-up. Intra- and inter-class correlation coefficients (ICCs) were calculated. Erosions were analysed with the total rheumatoid arthritis magnetic resonance imaging erosion score (RAMRIS erosion score) for ICCs with CBCT, and with the modified RAMRIS erosion score (RAMRIS-mod.) for the same locations as used in the Sharp van der Heijde score and Sharp van der Heijde erosion score for CR. RESULTS: All 30 patients showed erosions on CBCT and 26 on CR. The ICCs for both intra- and inter-observer reliability were 0.92-0.99. CBCT showed numerically more erosions than CR for all regions compared, although a statistically significant difference was found only for the metacarpophalangeal joints [median number of eroded joints 1.0 (range 0-14) with CBCT and 0.5 (0-13) with CR, p = 0.044]. CONCLUSION: CBCT has high reproducibility and is more sensitive than CR in detecting erosions in this cohort of patients with long-standing RA. CBCT has the potential to become an important tool in the detection and follow-up of erosions in patients with RA.

Ultrasonographic examination of the ruptured cord after collagenase treatment or needle fasciotomy for Dupuytren's contracture.

Local treatment of Dupuytren's contracture, either by collagenase or needle fasciotomy, allows disruption of the pathological cord during forced extension. The purpose of this study was to investigate the cord before and after both treatments by ultrasound. A total of 39 patients with a minimum of 20° contracture in the metacarpophalangeal joint were included and randomized to treatment with either collagenase (20 patients) or needle fasciotomy (19 patients). The distance between the distal and the proximal parts of the ruptured cord was measured by ultrasound and the difference in passive joint movement before and after treatment was measured with a goniomenter. There were no significant differences between the collagenase and needle fasciotomy groups in the size of the rupture or gain of mobility. Most cords treated with collagenase and subsequent forced extension had the same ultrasonographic appearance as cords disrupted mechanically by needle fasciotomy. LEVEL OF EVIDENCE: III.

Repeatability of sonographic measurements in clubfeet.

PURPOSE: To assess the intra- and interobserver agreement of ultrasound assessment of clubfoot patho-anatomy in early childhood. MATERIAL AND METHODS: Seventeen clubfeet in 12 children were sequentially scanned by 2 examiners and repeat assessments were carried out independently. Three well-defined imaging planes were chosen to evaluate navicular displacement: the medial malleolus-navicular (MM-N) distance, soft tissue thickness, talar deformity and the calcaneo-cuboid (C-C) distance. Intra- and interobserver agreement was analysed using Cohen's kappa for the discrete variables and by Bland-Altman's graphic technique for measurements. RESULTS: Kappa values for intra-observer agreement were 0.82 for navicular displacement, 0.93 for "talar head pointing laterally", and 0.70 for medial deviation of the talar neck. The corresponding interobserver kappa values were 0.70, 0.68, and 0.36. The mean difference between the two observers for the MM-N distance was 0.42 +/- 3.0 mm and for the soft tissue thickness 0.35 +/- 2.0 mm; the C-C distance showed a mean interobserver distance of 0.0 +/- 2.8 mm. CONCLUSION: The imaging planes used to study the talo-navicular and calcaneo-cuboid relationships are reproducible and relatively easy to learn. Intra- and interobserver assessments were acceptable for MM-N distance, soft tissue thickness, navicular displacement and "talar head pointing laterally", but questionable for the C-C distance and medial deviation of the talar neck.

Ultrasound anatomy in the neonatal clubfoot.

Our objective was to assess clubfoot anatomy by US in newborn babies before and in the early phase of treatment. Reproducible US projections and measurements were carried out on 30 untreated clubfeet in 22 children, consecutively included in the study. The position of the navicular in relation to the head of the talus was visualised in all feet. The mean distance between the medial malleolus and the navicular was significantly shorter in the clubfeet than in normal feet. There was a tendency to medial displacement of the cuboid. Soft tissue thickness at the medial side of the foot was increased in all deformed feet. The measurements showed an acceptable intra- and inter-observer reliability for the different variables assessed ( r=0.71-0.96, Pearson's correlation coefficient). With US it is possible to obtain well-defined planes of investigation that give important information about the clubfoot deformity concerning the talo-crural, the talo-navicular and the calcaneo-cuboid joints. The method is simple enough to be used in everyday clinical practice and we recommend it as a guide during the non-operative treatment and for preoperative planning.

Ultrasound anatomy in the normal neonatal and infant foot: an anatomic introduction to ultrasound assessment of foot deformities.

The aim of this study was to establish guidelines for US assessment of the talo-crural, the talo-navicular and the calcaneo-cuboid joints during the first year of life, which could serve as a reference while studying foot deformities. The feet of 54 healthy children were examined at birth and at the age of 4, 7 and 12 months by using three easily defined and reproducible US projections. With a medial projection the relation of the navicular in relation to the medial malleolus and the head of the talus was studied. A lateral projection revealed the calcaneo-cuboid relationship and a dorsal projection the talo-navicular alignment in the sagittal plane. Normal values for measurements of these cartilaginous relationships were established for the different age groups. Intra- and inter-observer reliability was assessed and found to be acceptable ( r=0.53-0.90, Pearson correlation coefficient). With US it is possible to obtain reproducible planes of investigation that give reliable information about the talo-crural, the talo-navicular and the calcaneo-cuboid relationships during the first year of life.

Radiographic stage of osteoarthritis or sex of the patient does not predict one year outcome after total hip arthroplasty.

OBJECTIVE: To investigate whether patients with severe radiographic osteoarthritis (OA) have a different outcome at one year after total hip replacement than patients with moderate radiographic OA. To investigate sex related differences in preoperative radiographic and self reported status and in postoperative outcome. METHODS: 184 patients (96 women) with a mean age at surgery of 71.4 years (50-92), with primary OA of the hip were investigated preoperatively and six and 12 months postoperatively with two self administered questionnaires, SF-36 and WOMAC. The radiographs were evaluated by two independent radiologists using an atlas. Minimal joint space narrowing, osteophytes, cysts, sclerosis, and deformity were assessed. A summary grade 0-3 was made, based on joint space, where 3 is severe OA. The reference population for SF-36 consisted of 2901 subjects matched for age and sex from the general Swedish population. RESULTS: 162 patients fulfilled the study criteria. 113 had grade 3, 47 grade 2, and two grade 1 radiographic OA. There was no difference in preoperative or postoperative pain and physical impairment between patients with moderate and severe radiographic OA. There were no sex related differences in preoperative radiographic status, or in postoperative outcome. Neither were any differences in preoperative radiographic status of OA found in patients with previous total hip replacement of the contralateral hip, compared with those who had not been operated on before. All patients, regardless of preoperative radiographic OA stage, showed significant postoperative improvement and at one year achieved a health related quality of life similar to that of the reference group. CONCLUSION: The severity of radiographic changes indicating OA often weighs heavily in the surgeon's decision to perform a total hip replacement. Yet, the findings of this study emphasise that the preoperative radiographic stage of OA has no correlation with the postoperative outcome after one year. Furthermore, this study failed to detect any sex related differences in preoperative radiographic and self reported status or in postoperative outcome of hip replacement.

Percutaneous puncture and drainage of pancreatic pseudocysts. A retrospective study.

Experience with 19 consecutive patients who had 20 pancreatic pseudocysts treated by percutaneous puncture and/or drainage was reviewed. Ten pseudocysts (5 infected, 5 non-infected), underwent complete resolution after percutaneous treatment only and there was a considerable regression in 6 (5 infected, 1 non-infected), which means an overall cure rate of 80 per cent. Only one small pseudocyst remained unchanged. Complementary surgery was necessary in 3 cases. Fine needle evacuation was the method in 13 cases (11 cured) and catheter drainage in 7 (5 cured). We conclude that percutaneous drainage is a safe method for the treatment of pancreatic pseudocysts, that will cure the patient in most cases.