Posterior tibial tendon dysfunction: secondary MR signs.

We evaluated four potential secondary magnetic resonance imaging signs to aid in clinical diagnosis of posterior tibial tendon (PTT) tears. Seventy-one ankles (25 PTT tears and 46 controls) were evaluated for the following secondary signs: (1) PTT sheath fluid, (2) a distal tibial spur located just anterior to the PTT, (3) unroofing of the talus, and (4) "bone bruise"--like medullary lesions. Two musculoskeletal radiologists rated their confidence using a scale and were compared for level of agreement. The presence of PTT sheath fluid had modest specificity and fair to moderate sensitivity. Tibial spurring and unroofing of the talus had excellent specificity and fair sensitivity. Bone bruise-like lesions were commonly seen in cases and controls. Examination of divergence of opinion between the two radiologists revealed pitfalls in interpretation of PTT sheath fluid and bone bruise-like lesions, which were commonly the result of adjacent vessels and inhomogeneous fat saturation, respectively. We conclude that secondary signs of PTT tears with high specificities include unroofing of the talus, tibial spurring, and PTT sheath fluid.

Lisfranc arthrodesis for chronic pain: a cannulated screw technique.

Nine patients with injury to the tarsometatarsal joint underwent fusion with cannulated screw fixation after conservative treatment had failed. Symptoms consisted of localized pain, forefoot abduction, and progressive collapse of the medical column. Early diagnosis and treatment were associated with a better functional outcome. The technique involved either a single or double incisional approach, resection of joints, reduction and fixation with cannulated cancellous screws. A total of 43 joints were fused: 37 tarsometatarsal joints and 6 tarsal joints. A partial Lisfranc joint complex fusion (medial three joints) was performed in four patients and a total joint complex fusion was performed in five patients. Intertarsal fusion was performed when pathologic change was evident. A cannulated screw was used to fixated 40 of the 43 joints fused. Reduction was performed prior to arthrodesis, when significant fracture-dislocation had occurred. The cannulated self-tapping cancellous screw technique provides a method of reduction that decreases technical difficulty while providing compression across the fusion site. After an average follow-up of 29 months (range 20 to 36 months), seven patients (78%) rated their outcome as good. One patient had a fair result (11%), and one patient had a poor result (11%).

In pursuit of sisterhood: adult siblings as a resource for combined individual and family therapy.

Therapists traditionally view brothers and sisters as rivalrous and self-seeking. Under carefully arranged conditions, however, siblings can learn to cooperate with each other to resolve important conflicts in family relationships. This case documents a dramatic change in the relationship between a 29-year-old woman and her father, the outcome of a three-step therapeutic intervention in which sibling dynamics were selectively used by the psychotherapist. As part of her individual therapy, the therapist first aroused the woman's discontent with her status as the neglected "baby of the family." Next, a series of meetings were held with the woman and her three sisters that permitted resolution of their previous anger and misunderstandings, thus helping them to become a more cohesive group of sisters. The third step brought the sisters, now as allies both of the identified patient and of the therapist, into a constructive confrontation with the parents. This resulted in lasting personal change for the identified patient and improved relationships throughout the entire family.

Osteoid osteoma of the great toe.

Osteoid osteoma is a benign tumor which most commonly affects adolescents and young adults. Although this lesion occurs predominantly in the lower extremities, it has been described in the great toe only once before in medical literature. This bone lesion causes acute localized pain, worse at night, and it is relieved by aspirin or other anti-inflammatory medications. Treatment of choice is en bloc excision of the lesion. The prognosis with appropriate diagnosis and treatment is excellent.