Direct reconstruction of chronic extensor digitorum longus tendon rupture using interposed scar tissue in the foot: A case report.

RATIONALE: Primary repair of acute ligament injury is possible due to the proximity of the ends. In the case of chronic injury, however, primary repair is difficult because the ends of ruptured ligament will have receded, and tendon graft, transfer, or reconstruction is needed. Satisfactory clinical results have been reported after reconstruction with newly formed interposed scar tissue between the ends of the ruptured tendon in chronic Achilles tendon injury and chronic extensor halluces longus (EHL) tendon injury. Here, we report a patient treated with reconstructive surgery using well-formed scar tissue between the ends in a case of chronic EDL tendon rupture. PATIENT CONCERNS: A 34-year-old woman visited the clinic with pain in the dorsum aspect of the right foot associated with weakness and loss of extension of the second toe. She had sustained an injury to the dorsal aspect of her foot by falling on broken glass 3 months before coming to our clinic. The patient reported pain and limitation of the extension of the second toe for 2 months. Her pain continued to worsen, and 1 month later she was transferred to our hospital because a different local clinician suspected she had ruptured her second EDL tendon. DIAGNOSIS: Magnetic resonance imaging (MRI) revealed complete rupture of the second EDL tendon at the metatarsal neck junction, with displacement of the distal end to the proximal phalanx shaft area and of the proximal end to the metatarsal shaft area. INTERVENTIONS: Chronic rupture of the EDL tendon was treated with direct reconstruction using interposed scar tissue. OUTCOMES: At the 3-month follow-up, the patient was almost asymptomatic and had nearly full range of motion in dorsiflexion of the second toe. She has no discomfort in her daily life and has returned to almost her preoperative level of functional activities. LESSONS: Here, we presented an extremely rare case of reconstruction using interposed scar tissue in a patient with neglected EDL tendon rupture. Direct reconstruction using interposed scar tissues located between the ends of the ruptured tendon is considered a reliable method with satisfactory clinical results in carefully selected patients.

Volumetric Changes in the Bony External Auditory Canal in Unilateral Chronic Otitis Media.

BACKGROUND AND OBJECTIVES: Pneumatization of air cells in the mastoid bone is decreased in chronic otitis media (COM). A decrease in the size of the external auditory canal (EAC) is also found frequently in patients with COM, but this has been little studied. We compared the size of affected bony EACs and the contralateral side in patients with single-side COM using high-resolution computed tomography. SUBJECTS AND METHODS: In total, 99 patients with single-side COM were included. Four indicators related to the size of the bony EAC and IAC were measured using high-resolution computed tomography: the axial and coronal lengths of the tympanic membrane, the length of the isthmus, and the area of the bony ear canal. We also compared both internal auditory canals as negative controls. These assessments were made by radiologists who were blinded to the objective of this study. RESULTS: In patients with single-side COM, the axial length of the tympanic membrane was significantly shorter than normal, and the volume of the EAC was also significantly smaller. The length of the isthmus of the EAC was shorter on the affected side, but the difference was not significant. The IAC volume showed no difference between the two sides. CONCLUSIONS: COM affects general temporal bony development, including the bony EAC and mastoid bone. Therefore, whether to correct this should be considered when preparing for COM surgery.

Papillary Carcinoma Within a Thyroglossal Duct Cyst in a 17-Year-Old Child.

Thyroglossal duct cyst is a frequent event; however, papillary carcinoma within a thyroglossal duct cyst is rare, particularly in children. A 17-year-old girl presented with an asymptomatic mid-submental mass for the last 2 months. The diagnosis of thyroglossal duct cyst was made based on physical examination and computed tomography finding. After performance of Sistrunk procedure, an incidental papillary carcinoma within the thyroglossal duct cyst was observed on pathology. We reviewed the pediatric cases of thyroglossal duct carcinoma, and then decided not to perform a concurrent thyroidectomy. We will continue close follow-up for future thyroid involvement.

Imaging of Herniated Discs of the Cervical Spine: Inter-Modality Differences between 64-Slice Multidetector CT and 1.5-T MRI.

OBJECTIVE: To assess inter-modality variability when evaluating cervical intervertebral disc herniation using 64-slice multidetector-row computed tomography (MDCT) and magnetic resonance imaging (MRI). MATERIALS AND METHODS: Three musculoskeletal radiologists independently reviewed cervical spine 1.5-T MRI and 64-slice MDCT data on C2-3 though C6-7 of 51 patients in the context of intervertebral disc herniation. Interobserver and inter-modality agreements were expressed as unweighted kappa values. Weighted kappa statistics were used to assess the extents of agreement in terms of the number of involved segments (NIS) in disc herniation and epicenter measurements collected using MDCT and MRI. RESULTS: The interobserver agreement rates upon evaluation of disc morphology by the three radiologists were in fair to moderate agreement (k = 0.39-0.53 for MDCT images; k = 0.45-0.56 for MRIs). When the disc morphology was categorized into two and four grades, the inter-modality agreement rates were moderate (k-value, 0.59) and substantial (k-value, 0.66), respectively. The inter-modality agreements for evaluations of the NIS (k-value, 0.78) and the epicenter (k-value, 0.79) were substantial. Also, the interobserver agreements for the NIS (CT; k-value, 0.85 and MRI; k-value, 0.88) and epicenter (CT; k-value, 0.74 and MRI; k-value, 0.70) evaluations by two readers were substantial. MDCT tended to underestimate the extent of herniated disc lesions compared with MRI. CONCLUSION: Multidetector-row computed tomography and MRI showed a moderate-to-substantial degree of inter-modality agreement for the assessment of herniated cervical discs. MDCT images have a tendency to underestimate the anterior/posterior extent of the herniated disc compared with MRI.

Comparison of Quantitative Cartilage T2 Measurements and Qualitative MR Imaging between Professional Ballet Dancers and Healthy Volunteers.

PURPOSE: To compare qualitative magnetic resonance (MR) images and quantitative T2 measurements of the tibiotalar cartilage between ballerinas and healthy volunteers. MATERIALS AND METHODS: Institutional review board approval for this study and informed consent (from all participants) were obtained. MR examinations were performed by using a 3-T MR imaging system with 21 professional female ballet dancers and 20 healthy female volunteers. Two musculoskeletal radiologists qualitatively measured tibiotalar cartilage T2 values in the anterior zones, middle zones, and posterior zones of cartilage. MR findings were also qualitatively analyzed in both groups. RESULTS: The tibial cartilage T2 values measured in the anterior and posterior zones and the talar cartilage T2 values measured in all three zones were significantly higher in the ballerina group than in the control group (P < .001). The posterior zones exhibited the highest T2 values among the three tibiotalar cartilage zones in both groups (P < .001). A significant between-group difference was evident in terms of the presence of posterior soft-tissue edema (P = .001) and flexor hallucis longus tenosynovitis (P < .001). CONCLUSION: The findings showed a trend toward increasing cartilage T2 values in ballerinas when compared with control subjects, indicating that quantitative T2 measurement may potentially be used as a noninvasive imaging tool for early detection of cartilage lesions in the tibiotalar joint.

Median nerve T2 assessment in the wrist joints: preliminary study in patients with carpal tunnel syndrome and healthy volunteers.

PURPOSE: To perform a prospective quantitative analysis of median nerve T2 values and cross-sectional area (CSA) in patients with carpal tunnel syndrome (CTS) as compared to asymptomatic volunteers. MATERIALS AND METHODS: Twelve CTS patients with positive nerve conduction results and 12 healthy volunteers (controls) were enrolled and underwent axial T2 mapping of the wrist joints. Median nerve T2 values and CSAs at the distal radioulnar joint, pisiform, and hook of hamate levels were compared between the groups. RESULTS: The T2 values at the proximal and distal carpal tunnel were higher in the CTS patients than in the controls (P < 0.05). The T2 values at the distal radioulnar joint did not differ between the groups (P = 0.99). The CSAs of the median nerve at all levels of the carpal tunnel were significantly larger in the CTS patients than in the controls (P < 0.05). CONCLUSION: In conclusion, our study demonstrated that median nerve T2 assessment is feasible and that T2 assessment may offer functional information about the median nerve in the carpal tunnel and has the potential to be a promising complementary method for evaluation of CTS patients. A future study with larger sample sizes is necessary to investigate the potential effect of median nerve T2 assessment to a reliable tool in the diagnosis of CTS.

Clinical analysis of an ultrasound system in the evaluation of skin cancers: correlation with histology.

BACKGROUND: The assessment of skin cancers in the clinical setting is often difficult, with important features such as depth and width remaining unknown until the biopsy with pathology reports are received. When we remove skin cancers, with those especially involving the face, aesthetics and invasion to surrounding structures such as bone and cartilage are important features for deciding the optimal surgical procedure and future reconstructive options. The aim of the study was to compare the accuracy of the ultrasound system in vivo and to correlate the results with the histopathological tumor thickness measured in skin cancer patients. PATIENTS AND METHODS: From March 2010 to February 2012, we reviewed 40 patients who comprised a total of 49 skin lesions involving the face, neck, and scalp. Each skin lesions were classified by 9 facial aesthetic units. The patient's various skin lesions were scanned using an ultrasound system device (Philips iU22 xMatrix US), with a 5-17-MHz compact linear transducer. Using the ultrasound system, we analyzed the shape, depth, echogenicity, size, invasion skin level, and vascularity of the skin cancer lesions. The results were correlated with the histology, with special note to the depth of involvement. RESULTS: Of the 40 patients recruited, 15 were male and 25 were female, ranging in age from 53 to 92 years (mean ± SD 78.7 ± 13.7 years). Clinically, 49 lesions suspicious of skin cancer were identified and ultrasounds were performed preoperatively. Depth was measured by ultrasound and histology. Mean ultrasound depth of skin lesion was 3.97 ± 3.15 mm (range 0.80-14.00), and it was found to be 4.04 ± 2.92 mm (range 1.00-14.00) based off of histology. There was excellent correlation (interclass correlation coefficient, 0.953) between the depth of the skin lesions measured histologically and by using the ultrasound. CONCLUSION: The ultrasound is not meant to replace histologic evaluations, but it can be used as another diagnostic tool to provide improved preoperative planning. It can be used as a noninvasive, easy, and low-cost screening method for various skin cancers, and provides valuable information such as lesion margins, shape, layers of involvement, and vascularity patterns.

MR imaging of articular cartilage at 1.5T and 3.0T: comparison of IDEAL 2D FSE and 3D SPGR with fat-saturated 2D FSE and 3D SPGR in a porcine model.

BACKGROUND: IDEAL technique is a robust fat-water separation method which is potentially useful in cartilage imaging with significant improvement in the cartilage signal-to-noise ratio (SNR). PURPOSE: To identify whether iterative decomposition of water and fat with echo asymmetry and least-squares estimation (IDEAL) improved diagnostic performance for IDEAL 2D fast spin echo (FSE) and 3D spoiled gradient-recalled echo (SPGR) versus fat-saturated (FS) protocols at 1.5 and 3.0 T in the evaluation of patella-femoral cartilage lesions. MATERIAL AND METHODS: Forty-six artificial cartilage lesions were created in femoro-patellar articular cartilages of 11 porcine knees. All knees underwent MR examination at 1.5 and 3.0 T with MR protocol consisting of sagittal FS 2D FSE and 3D SPGR and IDEAL 2D FSE and IDEAL 3D SPGR, respectively. Qualitative assessment was performed to compare the diagnostic performance between 1.5- and 3.0-T protocols and between IDEAL and FS protocols. RESULTS: IDEAL 3D SPGR had a significantly higher accuracy for detecting partial thickness cartilage lesions (P < 0.01) than FS SPGR protocols, whereas there was no significant difference in diagnostic performance between IDEAL and FS 2D FSE except for one cartilage lesion. For all imaging sequences, no significant difference was observed in the diagnostic performance between 1.5- and 3.0-T imaging protocols (P = 0.42-0.91). CONCLUSION: Compared with conventional FS SPGR imaging, IDEAL 3D SPGR provided a better diagnostic performance for evaluation of porcine knee articular cartilage lesions in the knee joints at 1.5 and 3.0 T. IDEAL 3D SPGR may therefore be useful for detecting partial-thickness cartilage lesions in patients with degenerative osteoarthritis.

Comparison of MRI T2 relaxation changes of knee articular cartilage before and after running between young and old amateur athletes.

OBJECTIVE: To compare changes in T2 relaxation on magnetic resonance (MR) images of knee articular cartilage in younger and older amateur athletes before and after running. MATERIALS AND METHODS: By using a 3.0-T MR imager, quantitative T2 maps of weight-bearing femoral and tibial articular cartilages in 10 younger and 10 older amateur athletes were acquired before, immediately after, and 2 hours after 30 minutes of running. Changes in global cartilage T2 signals of the medial and lateral condyles of the femur and tibia and regional cartilage T2 signals in the medial condyles of femoral and tibia in response to exercise were compared between the two age groups. RESULTS: Changes in global cartilage T2 values after running did not differ significantly between the age groups. In terms of the depth variation, relatively higher T2 values in the older group than in the younger group were observed mainly in the superficial layers of the femoral and tibial cartilage (p < 0.05). CONCLUSION: Age-related cartilage changes may occur mainly in the superficial layer of cartilage where collagen matrix degeneration is primarily initiated. However, no trend is observed regarding a global T2 changes between the younger and older age groups in response to exercise.