Medial sesamoid position in moderate to severe hallux valgus: Correlation between three radiographic measurements.

BACKGROUND: In hallux valgus surgery, it is essential to accurately assess the position of the sesamoids both pre- and postoperatively. Weight-bearing foot anteroposterior, tangential sesamoid, and semi-weight-bearing computed tomography axial views are radiographic methods used to assess the medial sesamoid position. This study aimed to measure the medial sesamoid position and evaluate the correlation between these three radiographic methods. METHODS: This retrospective study comprised 59 feet from 49 patients who underwent hallux valgus surgery. The mean age of patients was 54.6 (range, 22-70) years. We took preoperative and postoperative measurements using the weight-bearing anteroposterior, tangential sesamoid, and semi-weight-bearing computed tomography axial views to assess the medial sesamoid position. RESULTS: The mean grades of the medial sesamoid position preoperatively and 6 months postoperatively were 2.5 and 0.8, 1.6 and 0.4, and 1.3 and 0.3 points based on the anteroposterior, tangential sesamoid, and computed tomography axial views, respectively (P < 0.001). Preoperatively, there was a strong positive correlation between the computed tomography axial and tangential sesamoid views (P < 0.001, r = 0.645) and anteroposterior and computed tomography axial views (P < 0.001, r = 0.468). In contrast, the tangential sesamoid and anteroposterior views showed a weak positive correlation (P = 0.03, r = 0.283). Six months postoperatively, there was a positive correlation between the computed tomography axial and tangential sesamoid views (P < 0.001, r = 0.473), anteroposterior and computed tomography axial views (P < 0.001, r = 0.470), and tangential sesamoid and anteroposterior views (P < 0.001, r = 0.480). CONCLUSIONS: We observed that the anteroposterior view exhibited a higher degree of medial sesamoid position displacement than the computed tomography axial and tangential sesamoid views. For the preoperative evaluation of the medial sesamoid position, the correlation between the computed tomography axial and tangential sesamoid views was stronger than that between the tangential sesamoid and anteroposterior views. However, all three views showed strong correlations postoperatively.

Diagnostic value of necrotic lesion boundary in bone collapse of femoral head osteonecrosis.

PURPOSE: Our research developed a novel approach to quantitatively evaluate the boundary of necrotic lesions in osteonecrosis of the femoral head (ONFH) and to explore its diagnostic value in predicting bone collapse of the femoral head. METHODS: A retrospective cross-sectional study was conducted in our institution, and 146 hips (121 cases) identified as ONFH were recruited. The anterior and lateral boundaries of each enrolled subject were measured in standard anteroposterior (AP) view and frog-leg (FL) view of plain radiographic images, the intact rate of which was then calculated and presented as the anteroposterior view intact ratio (APIR) and frog-leg view intact ratio (FLIR), respectively. Univariate and multivariate logistic regression analyses were performed to identify risk factors for collapse. A receiver operating characteristic (ROC) curve analysis was performed to determine the sensitivity, specificity and cutoff value of the APIR and FLIR. A Kaplan-Meier (K-M) analysis was applied to calculate the survival rate of the femoral head, and bone collapse of the femoral head was regarded as the endpoint. RESULTS: Femoral head collapse was observed in 61 hips during the follow-up period. Patients with or without femoral head collapse were categorized into the collapse group and non-collapse group, respectively. The mean follow-up time was 3.7 years (2-9) for the collapse group and 7.7 years (5-20) for the non-collapse group. Univariate and multivariate logistic regression analysis and ROC analysis showed that APIR (< 25.61%) and FLIR (< 24.43%) were significantly associated with femoral head collapse. The K-M survival curves indicated that the overall survival rate of APIR (≥ 25.61%) was 94.8% at 7.5 years and 76.6% at 10 years, while that of FLIR (≥ 24.43%) was 87.3% at 7.5 years and ten years. CONCLUSION: The present study demonstrates that APIR and FLIR are of high diagnostic value in the early and middle stages of ONFH. APIR and FLIR can be used to predict the occurrence of femoral head collapse in patients with JIC classification types B and C1. The measurement of these two parameters in plain radiography images may contribute to the selection of a proper hip preservation strategy.

The impact of the fluoroscopic view on radiation exposure in pelvic surgery: organ involvement, effective dose and the misleading concept of only measuring fluoroscopy time or the dose area product.

INTRODUCTION: Minimally invasive fluoroscopy-guided screw fixation is an established technique to stabilize fractures of the posterior pelvic ring in orthopaedic surgery. However, safe placement of the screws may be associated with prolonged intervention time and extensive fluoroscopy is a concern. In the current literature, the dose area product (DAP) and fluoroscopy time are often used to describe radiation exposure of the patient. It was the aim of the study to compare DAP to organ doses and the effective dose for four standard views commonly used in pelvic surgery. METHODS: An anthropomorphic cross-sectional dosimetry phantom, representing the body of a male human (173 cm/73 kg), was equipped with metal-oxide-semiconductor field-effect transistors (MOSFET) in different organ locations to measure radiation exposure. Anteroposterior (APV), lateral (LV), outlet (OLV) and inlet (ILV) of the phantom were obtained with a mobile C-arm, and effective dose and organ doses were calculated. DAP was measured in the built-in ionisation chamber beyond the collimator of the C-arm. The measurements were repeated with a fat layer to simulate an obese patient. RESULTS: Overall, the highest organ dose was measured in the stomach for ILV (0.918 mSv/min). Effective dose for ILV showed the highest values by far (1.85 mSv/min) and the lowest for LV (0.46 mSv/min). The DAP pattern was completely different to the effective dose with similar values for LV and ILV (12.2 and 12.3 µGy·m2/s). Adding a fat layer had no major effect on the measurements. CONCLUSION: The exposure to radiation varies considerably between different orthopaedic standard views of the pelvis. About the fourfold amount of the effective dose was measured for ILV compared to LV. DAP and irradiation time do not respect either the body region in the field of radiation or the radiosensitivity of the affected organs. Thus, they do not allow a reliable interpretation of the radiation burden the patient is exposed to.

Simple classification of carotid bifurcation: is it possible to predict twisted carotid artery during carotid endarterectomy?

BACKGROUND: The internal carotid artery (ICA) usually runs posterolaterally to the external carotid artery (ECA), but occasionally we encounter the twisted carotid bifurcation, a variant in which the ICA courses medially to the ECA during carotid endarterectomy (CEA). Prediction of this anomaly in the preoperative evaluation is mandatory, although descriptions in the literature are limited. We reviewed the clinical features of patients who underwent CEA and analyzed preoperative cerebral angiography, especially the anteroposterior (AP) view to determine whether it could be a predictive modality. METHODS: In 58 consecutive CEA cases, we simply classified them into three groups; type 1 (the ICA runs laterally and the ECA runs medially), type 2 (the ICA and ECA run to overlap each other), and type 3 (the ICA runs medially and the ECA runs laterally), based on the findings of AP view of cerebral angiography. We compared the clinical features and intraoperative findings of these groups. RESULTS: Of 58 cases, types 1-3 were 24, 30, and four cases, respectively. Twisted carotid bifurcations were recognized in seven cases (12.4 %), including three cases in type 2 and four in type 3, and all twisted cases were found on the right side. Twisted carotids and right-sided lesion were significantly frequent in type 3, but no statistical differences of coexisting diseases were recognized among the three groups. CEAs of twisted carotid bifurcations were performed successfully with correction of the carotid position in three and as it was in four cases. CONCLUSIONS: Twisted carotid bifurcations were observed during operation in 10 % in type 2 and 100 % in type 3. CEA of twisted carotid bifurcations can be performed safely with or without correction of the carotid position. AP view of cerebral angiography could be useful for preoperative evaluation.

Intraoperative anteroposterior and oblique fluoroscopic views for detection of mediolateral pedicle screw misplacement in the lumbar spine: a randomized cadaveric study.

BACKGROUD CONTEXT: Pedicle screws are commonly used for posterior fixation of the lumbar spine. Inaccuracy of screw placement can lead to disastrous complications. PURPOSE: As fluoroscopic assisted pedicle screw instrumentation is the most frequently used technique, the aim of this study was to assess the specificity, sensitivity and accuracy of intraoperative fluoroscopy to detect mediolateral screw malpositioning. We also analyzed whether the addition of an oblique view could improve these parameters. STUDY DESIGN: On 12 human cadavers, 138 pedicle screws were placed intentionally either with 0 to 2 mm (75 screws), with 2 to 4 mm (six medial and 12 lateral screws) and with >4 mm (22 medial and 23 lateral screws) breach of the pedicle from Th12 to L5. METHODS: Three experienced spine surgeons evaluated the screw positioning in fluoroscopic AP views and 4 weeks later in AP views and additional oblique views. The surgeons' interpretation was compared with the effective screw position on postoperative CT scans. RESULTS: Pedicle breaches greater than 2 mm were detected in 68% with AP views and in 67% with additional oblique views (p=.742). The specificity of AP views was 0.86 and 0.93 with additional oblique views (p=<.01). The accuracy was 0.78 with AP views and 0.81 with AP + oblique views (p=.114). There was a substantial inter-reader agreement (Fleiss's kappa: 0.632). CONCLUSIONS: Fluoroscopic screening of pedicle screw misplacement has a limited sensitivity. Adding an oblique view improves specificity but not sensitivity and accuracy in detecting screw malpositions. CLINICAL SIGNIFICANCE: When in doubt of a screw malpositioning, other modalities than a fluoroscopic assisted pedicle screw instrumentation such as intraoperative CT imaging or an intraoperative exploration of the screw trajectory must be evaluated.

Morphometric Analysis of Glenopolar Angle of the Scapula in Indian Population.

BACKGROUND: The glenopolar angle (GPA), usually ranges from 30° to 45°. GPA measures the tilt of the plane of the glenoid cavity in relation to the axis of the body of the scapula passing from the superior pole of the glenoid cavity to the inferior angle of the scapula. It is essential to assess the results of surgeries for dislocated shoulders. Worse long-term outcomes can arise from glenoid misalignment in scapular neck fractures. When evaluating prognosis and planning therapy for shoulder injuries including scapular fractures, GPA assessment is essential. Still, there is a dearth of data on the normal range of GPA and its contributing elements, which calls for more study. The purpose of this study is to determine typical GPA values by utilizing radiographs and a sizable sample of scapular bone specimens. METHODS: In this study, the GPA was assessed in 50 chest radiographs of anteroposterior (AP) view and Neer's view of individuals as well as 100 dried scapulae of any gender. The mean GPA obtained using the various methods was then statistically compared. FINDINGS: All scapulae had an average GPA of 42.6°. Twenty-nine scapulae had GPA observations higher than 45°, with an average of 47.2°. Twenty-seven scapulae had GPA measurements below 40°, averaging 37.3°. Right-sided 62 scapulae with an average GPA of 43.1° were present. Thirty-eight of left-side scapulae had a GPA of 41.7° on average. It was determined that the 1.6° mean difference in GPA between the two groups was not statistically significant. The Kolmogorov-Smirnov test verified that the GPA data had a normal distribution. The homogeneity of variances across various measuring techniques was confirmed using Levene's test. The average GPA measured using the dry scapula approach was 42.6°, the average GPA measured using the AP view was 39.8°, and the average GPA measured using the Neer I view was 42.3°. The GPA means from these three approaches differed considerably (p=0.0014) according to a one-way Analysis of Variance (ANOVA). Fisher's least significant difference post hoc testing showed that the scapular bone specimens and the Neer I view revealed significantly higher GPA values than AP shoulder radiographs. The GPA values obtained from the osteological group and the Neer I perspective had a mean difference of 0.21°, which was practically identical and suggested that there was no statistically significant difference between these approaches. IN SUMMARY: In order to diagnose and treat a variety of shoulder joint diseases, this study estimates the normal values of scapular GPA. Furthermore, it offers support for improved implant design in the context of Indian shoulder joint replacement and repair. Using every measurement technique, the GPA values on the right and left sides did not differ significantly. GPA results from various measuring methods varied significantly, which emphasizes the significance of methodological consistency in clinical and research settings.

Radiographic parameters of the normal ankle syndesmosis: Comparison between hindfoot alignment view and anteroposterior view.

OBJECTIVE: To compare the parameters associated with the normal ankle syndesmosis between the hindfoot alignment view (HAV) and anteroposterior (AP) view and determine which view is more accurate for comparing the left and right ankles. METHODS: This study involved 61 subjects without syndesmosis injury who had radiographs of both ankles. The tibiofibular clear space (TFCS), tibiofibular overlap (TFO), and medial clear space (MCS) were measured in each view. Intraclass correlation coefficients were used to assess the agreement between the two ankles. Difference ratios for the measured parameters between the ankles were also compared. RESULTS: The agreement for TFCS showed wide disparity between the two ankles (AP view, 0.576; HAV, 0.858). The highest degree of agreement was seen for TFO (AP view, 0.733; HAV, 0.926). The agreement for MCS was low in both groups. The mean difference ratio for TFCS was also lower in the HAV group (9.9%) than in the AP view group (16.4%); a similar result was observed for TFO (16.4% vs. 25.8%). CONCLUSIONS: For evaluation of the syndesmosis, use of the HAV showed increased accuracy and few measurement errors when comparing the left and right ankles relative to use of the AP view.

A Randomized Controlled Trial of Fluoroscopically-Guided Sacroiliac Joint Injections: A Comparison of the Posteroanterior and Classical Oblique Techniques.

OBJECTIVE: The sacroiliac joint can be a primary source of pain or part of multifactorial syndromes. As there is no single historical, physical examination-based, or radiological feature that definitively establishes a diagnosis of sacroiliac joint pain, diagnostic blocks are regarded as the gold standard. The primary aim of this randomized trial was to compare the posteroanterior approach with the classic oblique approach for sacroiliac joint injection based on an assessment of procedure times and patient-reported pain outcomes in subjects scheduled for fluoroscopically-guided sacroiliac joint injections. METHODS: Thirty patients were randomized into 2 groups of 15 patients each. The endpoints measured included the total length of procedure time, fluoroscopic time, needling time (length of time the needle was maneuvered), and pre- and postprocedure visual analogue scale pain scores. RESULTS: The posteroanterior approach was significantly shorter in terms of procedure time (p=0.03) and needling time (p=0.01) than the oblique approach. Adjusting for body mass index, the mean procedure and needling times were significantly shorter in the posteroanterior group than in the oblique group. CONCLUSION: This study of the posteroanterior approach for fluoroscopic-guided sacroiliac joint injection observed shorter times for fluoroscopy, needling, and the overall procedure than were recorded for the widely prevalent oblique approach. This may translate to lower radiation exposure, lower procedural costs, and enhanced ergonomics of fluoroscopicallyguided sacroiliac joint injections.