Frequency of sternal variations and anomalies in living individuals evaluated by MDCT.

PURPOSE: The aim of this retrospective study was to present the frequency and MDCT appearances of sternal variations and anomalies, as well as to highlight their clinical significance. METHODS: This retrospective study was carried out on 1150 patients, who underwent chest MDCT. Axial planes, multiplanar and curved-planar reconstructed images were studied. Age and sex distribution of the variations was evaluated. RESULTS: Anatomical variations of the sternum were found in 74.1%. The most frequent variation was the double-ended xiphoid process (36.9%), followed by the single xiphoidal foramen (25.8%) and the sternal sclerotic band (12.8%). Other variations observed were: sternal notch (10.1%), xiphoidal ligament calcification (8.3%), sternal foramen (4.9%), complete manubriosternal fusion (4.1%) and sternoxiphoidal fusion (4.1%), triple-ended xiphoid process (3.7%), sternal cleft (1.5%), whereas the rest of the variations including sternoxiphoidal junction pseudoforamen, suprasternal bone, pseudocleft, suprasternal tubercle and absence of xiphoid process were in less than 1%. In our subjects, sternal and xiphoidal foramina were adjacent to: the pericardium (37.14%), the diaphragm (22.9%), the mediastinal fat (17.1%), the liver (11.4%), the lung (8.5%) and to the stomach (2.9%). CONCLUSIONS: Sternal variations are frequent, asymptomatic, detected incidentally at cross-sectional imaging and may be confused with pathologic conditions. Radiologists should be familiar with these variations in order to discriminate them from pathologies and avoid complications during interventional procedures. ADVANCES IN KNOWLEDGE: This study presents thoroughly the sternal variations' MDCT appearance, detected in a Greek population, correlates them with age and gender and discuss their clinical significance in detail.

Facial nerve: A review of the anatomical, surgical landmarks and its iatrogenic injuries.

Facial nerve iatrogenic injuries are serious and can negatively affect the quality of life of the patients. Due to the properties of the nerve, the complications are devastating involving the aesthetic appearance and the function of the face. Moreover, the multiple branches of the nerve increase the risk of an iatrogenic injury making the detailed knowledge of the anatomical correlations around them critical. In this review, a meticulous analysis was performed including the surgical procedures posing the greater risk of an iatrogenic injury as well as the full description of all the reported anatomical landmarks involving the extracranial course of the facial nerve.

Amyand's hernia: presumptive diagnosis by CT and literature review.

Amyand's hernia is a rare inguinal hernia containing the appendix presenting mainly in male adults. The clinical presentation is usually without symptoms, however an inflammation can occur leading to strangulation, necrosis or rupture of the appendix. Differential diagnosis may be difficult including orchitis, testicular torsion, inflammation of the ovaries and bowel inflammation. We present a case of a 61 years old, male patient who was presented with persistent right abdominal pain. There was no medical history of previous hospitalization or surgery of the abdomen. Laboratory tests and radiological investigation with plain radiographs and ultrasound were not clear. A CT scan with contrast imaging was performed to reveal the diagnosis. Amyand's hernia is difficult to be revealed and a high index of suspicion is needed in order to promptly diagnose the hernia and proceed to the appropriate treatment. CT scan is critical contributing to the accurate depiction and to the classification of the hernia.

Searching for the 'winner' hip fracture patient: the effect of modifiable and non-modifiable factors on clinical outcomes following hip fracture surgery.

BACKGROUND: Various factors, other than the quality of surgery, may influence clinical outcomes of hip fracture patients. We aimed to evaluate the relative impact of several factors on functional outcome, quality of life, re-fracture and mortality rates following surgery for hip fractures. METHODS: We studied 498 (62.2%) women and 302 (37.8%) men with a mean age of 81.3 years (range, 60-95) with hip fractures (femoral neck and pertrochanteric). The mean follow-up was 74 months (range 58-96). Various patient-related and surgery-related parameters were recorded and correlated to both objective and subjective mobility, functional recovery and quality of life scales. Mortality and re-fracture rates were also evaluated. RESULTS: Using multiple regression analysis, age >80 years (p = 0.000; 95% CI, 1.077-1.143) and ASA score III and IV (p = 0.000; 95% CI, 2.088-3.396) (both non-modifiable factors) both proved to be independent (s.s.) factors affecting mortality rates. Age <80 years (p = 0.000; 95% CI, 0.932-0.974), surgery delay less (modifiable factor) than 48 hours (p = 0.046; 95% CI, 0.869-0.999), low dementia CDR index (p = 0.005; 95% CI, 0.471-0.891) (non-modifiable factor), and osteoporosis medical treatment (modifiable factor) (p = 0.006; 95% CI, 0.494-0.891) were shown to be independent (s.s.) factors affecting HOOS-symptoms. Osteoporosis medical treatment used proved to be an independent (s.s.) factor affecting HOOS-daily activities (p = 0.049; 95% CI, 0.563-1.000) and quality of life (E-Qol-5D) (p = 0.036; 95% CI, 0.737-1.325). CONCLUSIONS: A hip fracture patient aged <80 years old, with an ASA I-II, with low dementia CDR index and on osteoporosis medication has a better chance of an improved outcome (winner patient).

Complications After Anterior Cruciate Ligament Reconstruction and Their Relation to the Type of Graft: A Prospective Study of 958 Cases.

BACKGROUND: Complications and adverse events after anterior cruciate ligament (ACL) reconstruction are well known, but they have been underestimated in previous studies. PURPOSE: To describe the complications and adverse events after ACL reconstruction within a 2-year follow-up and analyze them in relation to the type of graft. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: From 2000 to 2012, 958 patients with an isolated ACL injury underwent surgery by a single knee surgeon. ACL reconstruction was performed with the medial portal technique for the femoral tunnel and the use of bone-patellar tendon-bone (BPTB) or hamstring tendon graft. Patients were reviewed at 6 weeks and 3, 6, 12, and 24 months after surgery with the International Knee Documentation Committee score, plain radiographs, and the KT-1000 arthrometer. RESULTS: Of 958 patients enrolled, 147 (15%) were lost at last follow-up. The 2 groups (bone-patellar tendon-bone [n = 257] and hamstring [n = 554]) were similar regarding the mean age at the time of surgery and preoperative anterior laxity. The main complications were as follows: anterior knee pain (n = 130 of 811, 16%), stiffness (n = 72, 8.8%), secondary meniscal lesions (n = 59, 7.2%), pain attributed to fixation (n = 79, 9.7%), ACL rerupture (n = 47, 5.7%), contralateral ACL ruptures (n = 24, 3%), patellar fractures (n = 3, 0.3%), infections (n = 9, 1%), and thromboembolic complications (n = 5, 0.6%). There was no significant difference between the grafts with respect to the frequency of joint stiffness, secondary meniscal lesions, or anterior knee pain. During the first 2 postoperative years, the percentage of patients with anterior knee pain was higher in the patellar tendon group (23.3% vs 12.6%, P < .001); however, this difference was not significant after the 2-year interval (3.1% vs 2.5%, P = .63). The percentage of patients with a rerupture of the graft was significantly lower in the patellar tendon group than in the hamstring group (25 of 811 [3.1%] vs 57 of 811 [7%], P = .023). Similar results were recorded regarding the pain related to the hardware material (7 of 811 [0.8%] in the BPTB group vs 113 of 811 [13.9%] in the hamstring group, P = .001). The percentage of ACL ruptures contralateral to the repair was higher in the patellar tendon group (41 of 811 [5%] vs 17 of 811 [2%], P = .016). CONCLUSION: The total rate of complications after an ACL reconstruction was 39%, and the surgical revision rate for any reason was 28%. Problems with the hardware material were more frequent in the hamstring group, leading to an increased rate of surgical revision. Anterior knee pain was initially higher in the patellar tendon group, but there was no significant difference in a 2-year interval. The rerupture rate was statistically higher in the hamstring group.

Genesis 1 posterior cruciate-retaining total knee arthroplasty with asymmetric tibial tray: An 18-to-26-year long-term clinical outcome study.

BACKGROUND: To present the long-term clinical and radiological outcomes of the Genesis I posterior cruciate-retaining total knee arthroplasty (TKA) (Smith & Nephew Orthopaedics, Memphis, TN, USA) (one of the first designed with an asymmetric tibial tray). METHODS: Prospectively collected data from 117 cemented TKAs performed on 95 patients were evaluated using this design, with a mean follow-up of 21.5 years (range, 18-26). Failures, complication rates, and clinical (both subjective and objective) and radiological outcomes were assessed for all patients. RESULTS: Seven failures occurred (wear and structural failure of the polyethylene insert) and six revision surgeries were performed at a mean of 10 years (range, three to 14) from the index operation. No revision of either the femoral or tibial components for aseptic loosening was performed. Survivorship analysis showed a cumulative success rate of 93.53% (95% CI, 92.75-94.32%) at 20 and 25 years, with revision for any reason as an end point. All patients showed a statistically significant improvement (P = 0.001) in the Knee Society and Oxford knee rating scores. CONCLUSIONS: This study demonstrated satisfactory long-term clinical outcomes for this TKA design, with revisions being related to polyethylene wear structural failure.

Withdrawn: A Randomized Controlled Trial Comparing Modular and Nonmodular Neck Versions of a Titanium Stem.

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Recurrent posterior knee laxity: diagnosis, technical aspects and treatment algorithm.

PURPOSE: Aim of this study was to determine the characteristics, clinical and radiological diagnostic methods of PCL isolated and combined knee injuries. METHODS: One hundred and twelve patients with a recurrent posterior knee laxity were surgically treated. Clinical examination, MRI, Telos™ stress dynamic X-rays, KT-1000 measurements and the IKDC questionnaire were used to diagnose and evaluate these injuries. RESULTS: Median follow-up was 4.5 years (2-11 years). Thirty-two patients (28.6 %) had an isolated posterior laxity, 53 (47.3 %) a posterior posterolateral laxity, 21 (18.7 %) a posterior posteromedial laxity and six (5.4 %) patients had a complex posterior and mediolateral laxity. Road traffic accidents and sports injuries were the main causes of trauma. The mean preoperative value of posterior tibial translation was 13.5 mm (SD 1.4) and the mean postoperative value was 4.4 mm (SD 1.7) as measured with the Telos device. In the cases with a concomitant ACL rupture, the mean preoperative value of anterior tibial translation was 6.5 mm (SD 1.3) and the mean postoperative value was 1.7 mm (SD 0.8). The mean pre- and postoperative IKDC scores were 74.5 (SD 4.2) and 87.9 (SD 3.1), respectively. Meniscal and/or cartilage injuries were found in 80 patients (71.4 %). CONCLUSIONS: Recurrent posterior knee laxity can be restored with the one-stage PCL reconstruction using a quadriceps graft and reconstruction of the posteromedial-posterolateral lesions using the LaPrade techniques. The benefits of this study include enabling surgeons to accurately manage these injuries from a clinical perspective, and treating them with a specific surgical algorithm. LEVEL OF EVIDENCE: III.

No difference in osteoarthritis after surgical and non-surgical treatment of ACL-injured knees after 10 years.

PURPOSE: Aim of this study was to record and compare the functional and activity level as well as the manifestations of osteoarthritis after isolated ACL ruptures between patients with conservative treatment and ACL reconstruction with hamstrings tendon graft. METHODS: Thirty-two patients diagnosed with ACL rupture were recorded. Clinical examination included the Tegner and Lysholm activity scale, the International Knee Documentation Committee Subjective Form and KT-1000 arthrometer. Narrowing of the medial and lateral joint spaces was assessed using the IKDC knee examination score. RESULTS: Median follow-up was 10.3 years (range 10-11). Fifteen patients were conservatively treated (median age 33 years, range 25-39). Seventeen patients were operated (median age 31 years, range 20-36). There was significant difference between the mean values of IKDC scores in favour of the ACL-reconstruction group of patients, 86.8 (SD 6.5) versus 77.5 (SD 13.8), respectively (p = 0.04). The mean value of anteroposterior tibial translation was 1.5 mm (SD 0.2) for ACL-reconstruction group of patients, while the corresponding mean value for ACL-conservative group was 4.5 mm (SD 0.5), p = 0.03. Four patients in ACL-reconstruction group had radiological findings of grade C or D according to IKDC form. In ACL-conservative group, five patients presented similar signs (n.s.). CONCLUSIONS: ACL reconstruction using hamstrings autograft resulted in better functional outcome and laxity measurements than ACL-conservative management. However, the incidence of radiological osteoarthritis was similar between the two groups and independent on the pre-operative grade of laxity and functional status of the patients. Equally, bone bruises were not found as a risk factor for the development of osteoarthritis after ACL rupture. LEVEL OF EVIDENCE: Prospective randomized study, Level II.

The effect of osteoporotic treatment on the functional outcome, re-fracture rate, quality of life and mortality in patients with hip fractures: a prospective functional and clinical outcome study on 520 patients.

Numerous high quality studies have shown the positive effects of various osteoporotic medical treatment regimens on bone mass and on the reduction of risk for new spinal, hip and non-spinal fractures in osteoporotic patients. However, the effect of osteoporotic treatment on the functional and clinical outcome of patients who have sustained hip fractures and been treated surgically has not yet been addressed. Five hundred and twenty patients out of 611 who were admitted (2009-2011), operated on due to a hip fracture and completed their follow-up evaluations were included in this study. Data related to functional outcome scores, re-fracture rate, quality of life and mortality rate were prospectively recorded, analysed and correlated to osteoporotic medical treatment. There were 151 (25%) men and 369 (71%) women with a mean age of 80.7 years (range, 60 to 90 years). At a mean follow-up of 27.5 months (range, 24 to 36 months) a mortality rate of 23.6% at 2 years was recorded. Mean values of functional and quality of life scores were found to have progressively improved within two years after surgery. Seventy-eight (15%) patients were taking osteoporotic treatment before their hip fracture and 89 (17.1%) started afterwards. Osteoporotic treatment proved to be an important predictor of functional recovery (all p values<0.05), re-fracture rate (p=0.028) and quality of life (EQ-5D, all dimensions, p values<0.05). Osteoporotic treatment did not affect post-fracture mortality rates. Osteoporotic treatment taken before or initiated after fracture is a strong predictor of functional and clinical outcome in patients with hip fractures treated surgically.