Anthropometric measurements: effect of CT depth of pretracheal soft tissue on tracheotomy tube selection.

BACKGROUND AND PURPOSE: Tracheotomy is a commonly performed procedure; however, in the obese, it can be associated with a high morbidity and mortality, partially due to accidental decannulation. We hypothesize that a simple and rapid measurement of the DPST on CT will accurately predict those patients in need of an extended-length tracheotomy tube. MATERIALS AND METHODS: A retrospective review of the electronic health record and available CT imaging of the neck was performed for all patients who underwent tracheotomy at a tertiary care center. Measurement of the DPST was performed and compared with the recorded tracheotomy tube used at surgery. RESULTS: Five hundred twenty-two adult patients underwent an initial tracheotomy procedure, of whom 293 met the inclusion criteria for the study. A statistically significant correlation between the DPST and the need for an extended-length tracheotomy tube was seen. A discriminatory soft-tissue depth indicating the need for an extended-length tracheotomy tube was calculated. CONCLUSIONS: CT measurement of the anterior soft-tissue depth is a simple tool that appears to provide a discriminatory threshold for the need for an extended-length tracheotomy tube. Further validation of this model through prospective application is needed. Although routine use of CT as a pretracheotomy evaluation is not advocated, the anatomic information is often available through prior imaging and has the potential to decrease the incidence of tracheotomy tube dislodgement in the obese and subsequent morbidity.

Stress fracture of the tibia after arthrodesis of the ankle or the hindfoot.

We studied twelve patients who had a stress fracture of the tibia and one patient who had a stress fracture of the fibula after arthrodesis of the ankle or the foot. A second stress fracture subsequently developed in two patients. All but two patients were managed non-operatively, and the fractures healed uneventfully. One patient who was managed operatively had a below-the-knee amputation to treat a painful non-union of a tibial fracture, and the other had interlocking intramedullary nailing for a displaced fracture. All but one of the arthrodesis sites had fused before the stress fracture occurred. All of the stress fractures that occurred after arthrodesis of the ankle were in the middle and distal aspects or the distal aspect of the tibia, while those that occurred after triple arthrodesis were in the distal aspect of the fibula or the medial malleolus. Although six of the thirteen patients still had uncorrected alignment and deformity after the arthrodesis, optimum alignment after the arthrodesis did not preclude the occurrence of a stress fracture. We conclude that stress fracture must be considered in the differential diagnosis of pain months or even years after solid fusion at the site of an ankle or triple arthrodesis.

Late reconstruction of the midfoot and tarsometatarsal region after trauma.

The management of painful arthritis and deformity after trauma to the midfoot starts with careful assessment by physical examination and appropriate investigation to identify the affected joints. Conservative treatment may be very effective and includes the use of NSAIDs, custom insoles with arch support, and a rocker-bottom sole with extended steel shank with or without a SACH heel. If this treatment fails, usually a year after the injury, then arthrodesis of all the symptomatic joints with restoration of the arch and alignment of the weight-bearing surface is the recommended treatment. The long-term results of these fusions may be compromised by the subsequent development of arthritis in adjacent joints.

Morton's neuroma: a review of recent concepts.

A number of new concepts in the pathology, diagnosis, and management of Morton's metatarsalgia have been presented in the recent literature. Probably as many questions as answers have been generated by these publications. The taut transverse metatarsal ligament appears to play a critical role compressing the interdigital nerve but the exact pathomechanics producing the neuroma and the role of the intermetatarsal bursa remain unclear. Electrodiagnostic techniques for this condition are in the early development stage and may be clinically applicable in the near future. Support for and recommendation against the preoperative injection of the intermetatarsal bursa and interdigital nerve area have been discussed. The necessity of interdigital neurectomy has been questioned but currently in North America, simple transverse metatarsal ligament division has not been widely utilized. Continued studies along these lines should improve our understanding of Morton's metatarsalgia, increase our diagnostic accuracy, and facilitate more effective management.

Aggressive fibromatosis of the plantar aspect of the foot. A case report.

Distinguishing superficial plantar fibromatosis from deep fibromatosis of the plantar aspect of the foot is difficult both clinically and histologically. An illustrative case is presented. Clinical factors suggestive of aggressive fibromatosis include presentation at an age younger than 20 years, tumor dimension exceeding 3 cm (without prior surgical excision), and multicentric occurrence in the affected limb. On histological review, the absence of nodule formation favors the diagnosis of deep aggressive fibromatosis.