Radiation Dose Practice Audit of 6,234 Fluoroscopically-Guided Spinal Injections.

BACKGROUND: Fluoroscopic imaging guidance is frequently used in performing spinal interventional techniques. Reference level standards are a quality improvement tool to help reduce radiation dose and serve as benchmarks for physicians and their technologists to achieve reasonable radiation exposure while performing fluoroscopically-guided spinal procedures. There are limited data describing radiation dose for musculoskeletal injections - in particular, spinal injections without any published reference standards. OBJECTIVE: The purpose of this study is to perform a practice audit of radiation doses of fluoroscopically-guided spinal injections to establish preliminary reference levels as a quality improvement tool for potential use in future radiation reduction measures. STUDY DESIGN: Retrospective, observational study. SETTINGS: An academic-based subspecialty, high volume pain medicine practice. METHODS: A retrospective analysis of 6,234 spinal injections of 9 different types performed by experienced practitioners between January and December 2012 was conducted under an institutional review board's approval with HIPAA compliance and waiver of informed consent. Cumulative radiation dose (in mGy) and exposure time (in seconds) distributions (percentiles) as displayed on the C-arm were calculated per injection for each type of fluoroscopically-guided spinal injection. Confidence intervals for the dose distributions were determined by using bootstrap resampling and were used to determine preliminary reference levels. RESULTS: Proposed preliminary reference levels of cumulative radiation dose (in mGy) and exposure time (in seconds) for fluoroscopically-guided spinal interventional procedures are provided for lumbar transforaminal (13 mGy, 30 s), cervical transforaminal (6 mGy, 49 s), caudal epidural (12 mGy, 23s), cervical facet injection (3 mGy, 36 s), lumbar facet injection (9 mGy, 20s), interlaminar (13mGy, 39s), lumbar radiofrequency denervation (7 mGy, 17s), lumbar sympathetic block (21 mGy, 39s), cervical medial branch block (2 mGy, 25 s), lumbar medial branch block (4 mGy, 12s) and sacroiliac joint injections (18 mGy, 37s). LIMITATIONS: Study performed at a single subspecialty institution using only one type of C-arm which limits generalizability. CONCLUSIONS: Radiation doses and preliminary reference levels of fluoroscopically-guided interventional spine procedures performed by experienced practitioners are made available without correction for body habitus or field of view, magnification or subtraction techniques or continuous vs pulsed mode. A registry of radiation-dose data for fluoroscopically-guided interventional spine procedures would be the next step to refine this data. KEY WORDS: Spinal procedures, radiation dose, patient safety.

Evaluation of two appropriateness criteria for total knee replacement.

OBJECTIVE: Insurance expansion under the Affordable Care Act will amplify a projected 6-fold increase in total knee replacement (TKR) utilization by 2030 but will not fully address TKR disparities. Promoting appropriate use of TKR would help reduce disparities and improve outcomes. There are currently no validated appropriateness criteria (AC) for TKR in the US. We evaluated the performance of 2 non-US AC in a cohort of US TKR patients. METHODS: AC1 was developed in Spain using the modified Delphi method with 624 patient scenarios. AC2 was developed in Canada using the overall Western Ontario and McMaster Universities Osteoarthritis Index score of >39 as the cutoff point for surgery. These criteria were applied to a random sample of TKR patients enrolled in our institutional registry. Preoperative clinical, radiographic, and patient-reported survey data were used in classifying patients. The rate of appropriateness was compared for the 2 AC. Inappropriate cases were further investigated to determine other mitigating factors beyond the criteria influencing the decision to operate. RESULTS: In total, 508 TKR procedures were evaluated. All patients had osteoarthritic radiographic changes. On the basis of AC1, 7.7% of cases were classified as inappropriate and 11.6% uncertain. On the basis of AC2, 31.5% were classified as inappropriate. Only 4.7% of the cases were classified as inappropriate by both ACs; however, there was poor agreement between the 2 AC (κ = -0.08). Beyond the criteria, failure of nonsurgical treatment and clinically significant valgus/varus deformities influenced the decision for surgery. CONCLUSION: There was poor agreement between 2 validated AC for TKR when tested in a US population. Culturally specific AC are needed to promote rational use of TKR.

Comparison of deformity with respect to the talus in patients with posterior tibial tendon dysfunction and controls using multiplanar weight-bearing imaging or conventional radiography.

BACKGROUND: Posterior tibial tendon dysfunction varies in location and severity. Weight-bearing radiographs have been validated to assess posterior tibial tendon dysfunction, yet their two-dimensional nature and the inability of the patients to achieve full weight-bearing during acquisition are limitations. Multiplanar modified sectional weight-bearing imaging is a novel modality, yielding computed tomography-like images compared with radiographs, yet with true weight-bearing, shorter acquisition time, and lower radiation. The aim of this study was to test two hypotheses: first, multiplanar weight-bearing imaging would localize deformity with respect to the talus in patients with posterior tibial dysfunction compared with controls, and second, multiplanar weight-bearing imaging would correlate with specific radiographic parameters of posterior tibial tendon dysfunction on weight-bearing radiographs. METHODS: Weight-bearing radiographs and multiplanar modified sectional weight-bearing images of the foot and ankle were made for twenty-three patients with flexible posterior tibial tendon dysfunction. Ten patients with imaging for unrelated pathological conditions served as controls. Thirteen radiographic parameters on the transverse, sagittal, and coronal views of multiplanar weight-bearing imaging in the study group were evaluated and compared with those in the control group. The same parameters on standing weight-bearing radiographs of patients in the study group were compared with those in the control group. RESULTS: Significant differences between study and control groups were found on multiplanar weight-bearing imaging for six of thirteen radiographic parameters (p < 0.05), notably the sagittal talonavicular angle as well as sagittal and transverse talar-first metatarsal angles (p = 0.027, p = 0.003, and p = 0.004, respectively). However, only one parameter on weight-bearing radiographs (lateral talar-first metatarsal angle) reached significance (p < 0.05). Correlation showed excellent, very good, and good agreement between both imaging modalities for three, two, and five parameters, respectively. CONCLUSIONS: Deformity with respect to the talus in posterior tibial tendon dysfunction is multifactorial, but was notably seen at the talonavicular joint in the sagittal plane with both modalities. Good to excellent agreement was found between weight-bearing radiographs and multiplanar weight-bearing images for many parameters; however, a greater number of significant differences was found between the flatfoot and control groups for multiplanar weight-bearing images. This implies a potential role for multiplanar modified sectional weight-bearing imaging as a more informative tool to assess posterior tibial tendon dysfunction in the physiological, full weight-bearing position.

Risedronate in children with osteogenesis imperfecta: a randomised, double-blind, placebo-controlled trial.

BACKGROUND: Children with osteogenesis imperfecta are often treated with intravenous bisphosphonates. We aimed to assess the safety and efficacy of risedronate, an orally administered third-generation bisphosphonate, in children with the disease. METHODS: In this multicentre, randomised, parallel, double-blind, placebo-controlled trial, children aged 4-15 years with osteogenesis imperfecta and increased fracture risk were randomly assigned by telephone randomisation system in a 2:1 ratio to receive either daily risedronate (2·5 or 5 mg) or placebo for 1 year. Study treatment was masked from patients, investigators, and study centre personnel. Thereafter, all children received risedronate for 2 additional years in an open-label extension. The primary efficacy endpoint was percentage change in lumbar spine areal bone mineral density (BMD) at 1 year. The primary efficacy analysis was done by ANCOVA, with treatment, age group, and pooled centre as fixed effects, and baseline as covariate. Analyses were based on the intention-to-treat population, which included all patients who were randomly assigned and took at least one dose of assigned study treatment. The trial is registered with ClinicalTrials.gov, number NCT00106028. FINDINGS: Of 147 patients, 97 were randomly assigned to the risedronate group and 50 to the placebo group. Three patients from the risedronate group and one from the placebo group did not receive study treatment, leaving 94 and 49 in the intention-to-treat population, respectively. The mean increase in lumbar spine areal BMD after 1 year was 16·3% in the risedronate group and 7·6% in the placebo group (difference 8·7%, 95% CI 5·7-11·7; p<0·0001). After 1 year, clinical fractures had occurred in 29 (31%) of 94 patients in the risedronate group and 24 (49%) of 49 patients in the placebo group (p=0·0446). During years 2 and 3 (open-label phase), clinical fractures were reported in 46 (53%) of 87 patients in the group that had received risedronate since the start of the study, and 32 (65%) of 49 patients in the group that had been given placebo during the first year. Adverse event profiles were otherwise similar between the two groups, including frequencies of reported upper-gastrointestinal and selected musculoskeletal adverse events. INTERPRETATION: Oral risedronate increased areal BMD and reduced the risk of first and recurrent clinical fractures in children with osteogenesis imperfecta, and the drug was generally well tolerated. Risedronate should be regarded as a treatment option for children with osteogenesis imperfecta. FUNDING: Alliance for Better Bone Health (Warner Chilcott and Sanofi).

Imaging of rheumatoid arthritis.

Increased awareness of the need for early diagnosis of rheumatoid arthritis and advances in the ability to effectively treat rheumatoid arthritis have made disease remission and maintenance of function a reality for many patients. However, identification of patients who are at risk for erosive disease remains a challenge. As more is learnt about risk factors for disease severity and the role of imaging techniques such as ultrasound and magnetic resonance imaging, the ability to prevent disease progression in the form of joint damage and its attendant deformity and functional limitation will further improve.

Preoperative templating before spinal fusion using a fluoroscopic multiplanar imaging system is as accurate as CT scan and uses substantially less radiation.

BACKGROUND: Many surgeons utilize preoperative multiplanar imaging for surgical planning before fusion surgery using pedicle screw instrumentation. Computed tomographic (CT) scan is often used but limited by non-weight-bearing images and high-ionizing radiation. The purpose of this study was to compare pedicle length and width measurements using a multiplanar fluoroscopic imaging system and CT with gross measurements to validate the accuracy of multiplanar fluoroscopic imaging and compare relative radiation exposure between techniques. METHODS: Thirteen intact cadaveric lumbar spine segments were imaged using multiplanar fluoroscopic imaging and conventional CT scan using a low-dose pediatric protocol. At each level and each imaging modality, the 26 pedicles were measured digitally for width and pedicle screw length in accordance with typical presurgical planning procedures. All images were independently measured by 3 observers. After measurement, the specimens were sectioned using a microsurgical saw to facilitate anatomic measurements using calipers. Measurements of the multiplanar fluoroscopic imaging and CT were compared with direct anatomic measurements to quantitate and compare measurement accuracy of CT and fluoroscopic imaging. At the time of image acquisition, radiation exposure from each modality was quantified to allow for comparison of radiation exposures. RESULTS: CT and multiplanar fluoroscopy had similar agreement with gross measurements with respect to pedicle width and length, with κ values for comparison of CT and fluoroscopy with gross measurements falling between 0.61 and 0.73. Both modalities underestimated pedicle width (by 1.9 mm for both modalities) and length (5.5 mm for CT, 6.6 mm for fluoroscopy). Interobserver reliability was higher for fluoroscopy versus CT. High-dose fluoroscopic imaging used 31% of the radiation exposure for CT. CONCLUSIONS: Multiplanar fluoroscopic imaging provides comparable diagnostic preoperative planning to CT scan in an experimental cadaveric model. The use of multiplanar fluoroscopic imaging resulted in between 69% and 85% less radiation exposure than conventional CT scan using pediatric settings. CLINICAL EVIDENCE: This study demonstrates similar results from simulated preoperative templating using fluoroscopic imaging compared with CT scan but with less radiation exposure.

Comparison of a fluoroscopic 3-dimensional imaging system and conventional CT in detection of pars fractures in the cadaveric lumbar spine.

STUDY DESIGN: Cadaveric Study. OBJECTIVE: To compare a fluoroscopic imaging system with computed tomography (CT) and radiographs in detection of spondylolysis and radiation exposure in a cadaver model. SUMMARY OF BACKGROUND DATA: Lumbar spondylolysis is defined as a defect or fracture of the pars interarticularis and occurs with or without anterior spondylolisthesis. CT scan is the gold standard imaging study for spondylolysis but is limited by the supine position, which may cause reduction of anterolisthesis and by ionizing radiation, which limits the frequency of follow-up scans. METHODS: Thirteen intact cadaveric lumbar spine segments with 26 pars were randomized to be left intact or to undergo simulated fracture using a 1.3 mm oscillating microsurgical saw. Fifteen pars underwent simulated fracture and 11 pars were left intact. Lumbar spine segments were imaged using plain radiographs, multiplanar fluoroscopic imaging, and conventional CT scan. The images were interpreted by 3 observers blinded to the number and location of defects. Radiation exposure and doses were recorded from all imaging units. RESULTS: Average radiation doses were 0.0025 mSv for each radiograph, 0.23 mSv (low dose) and 0.47 mSv (high dose) for fluoroscopic imaging, and 1.5 mSv for conventional CT imaging (pediatric dose setting). Evaluation of radiographs for spondylolysis had sensitivity of 98% and specificity of 97%. Evaluation using low-dose fluoroscopic images, high-dose fluoroscopic images, and CT scan images correctly identified the status of all pars based on multiplanar images; sensitivity and specificity were 100%. Kappa analysis demonstrated a value of 0.89 for radiographic interpretation indicating excellent agreement. Kappa values describing agreement for image interpretation for fluoroscopic imaging and CT scan were equal to 1.0, representing perfect agreement. CONCLUSIONS: Three-dimensional fluoroscopic imaging provides comparable diagnostic imaging with CT scan in an experimental cadaveric model of spondylolysis using up to 85% less radiation than conventional CT scan.

Incidence of plantar lateral foot pain before and after the use of trial metal wedges in lateral column lengthening.

BACKGROUND: One of the major concerns with lateral column lengthening (LCL) in symptomatic flatfoot deformity treatment is the risk of postoperative plantar lateral foot discomfort. We evaluated whether this risk can be minimized by using trial metal wedges. Using our study's evaluation tools, the incidence of postoperative plantar lateral foot discomfort before and after using trial metal wedges was determined. MATERIALS AND METHODS: The incidence of planter lateral foot pain after LCL was retrospectively assessed in 122 consecutive patients (132 feet) after they had undergone flatfoot reconstruction with LCL between 2001 and 2007. To determine if the incidence could be reduced, levels of pain or revision were compared before and after the use of trial metal wedges. The ratio of wedge size to preoperative radiographic calcaneal length was also determined. RESULTS: The overall incidence of plantar lateral discomfort was 11.2%. The incidence of pain or revision was lower after the introduction of trial metal wedges (6.3% compared to 14.7%), but did not reach significance (p = 0.084). There was no significant difference found in the ratio of the size of bone graft wedge to calcaneal length between the two groups (p = 0.805). CONCLUSION: The incidence of plantar lateral foot discomfort overall was 11.2% after LCL. We believe this risk may be reduced using trial metal wedges, properly judging eversion stiffness and carefully assessing the position of the foot intraoperatively.

The non-surgical and surgical treatment of tarsal navicular stress fractures.

Stress fractures of the tarsal navicular, first described in 1970, were initially thought to be rare injuries. Heightened awareness and increased participation in athletics has resulted in more frequent diagnosis and more aggressive treatment. The vascular supply of the tarsal navicular results in a relatively avascular zone in the central one-third, which experiences severe compressive forces during explosive manoeuvers such as jumping and sprinting. Repetitive activities can result in stress reactions or even fracture. Patients often initially complain of vague midfoot pain localized to the medial border of the foot. The pain is usually exacerbated by activity and relieved with rest. The diagnosis of tarsal navicular stress fracture is challenging because of the high false negative rate of plain radiographs. Additional diagnostic testing with bone scan, CT and MRI are often required for diagnosis. The proper treatment of tarsal navicular stress fractures has become a topic of debate as surgical intervention for these injuries has increased. In a recent meta-analysis, Torg et al. found that 96% of tarsal navicular stress fractures treated with non-weight-bearing (NWB) conservative treatment for 5 weeks went on to successful outcomes. However, only 44% of patients treated with weight-bearing (WB) conservative treatment had successful outcomes. Surgical treatment resulted in successful outcome in 82% of patients. Interestingly, the meta-analysis also found that fracture type did not correlate with outcomes, regardless of treatment. The meta-analysis also found no difference in time to return to activity between patients treated surgically and those who underwent NWB conservative treatment. The recent literature indicates that patients are undergoing surgery or are receiving WB conservative management as a first-line treatment option with the expectation that they will return to their activity more quickly. Although surgical treatment seems increasingly common, the results statistically demonstrate an inferior trend to conservative NWB management. Conservative NWB management is the standard of care for initial treatment of both partial and complete stress fractures of the tarsal navicular. WB conservative treatment and surgical intervention are not recommended.

Symptoms associated with compartmental radiographic disease in hip arthroplasty patients.

We compared symptoms to radiographic disease in the medial (less weight bearing) and axial and superolateral (greater weight bearing) compartments in total hip arthroplasty patients. Western Ontario and McMaster Universities Osteoarthritis Index scores (0 [best] to 100 [worst]) were better for patients with more medial than axial radiographic disease for pain (41 vs 53; P =.002), stiffness (43 vs 56; P =.003), and function (49 vs 58; P =.03). Similarly, patients with more medial than superolateral disease had fewer symptoms. Patients with disease principally in the less weight-bearing medial compartment had milder symptoms than their radiographs suggested. Patients with disease principally in the greater weight-bearing axial and superolateral compartments had more severe symptoms than their radiographs suggested. The association between symptoms and radiographic disease depended on which compartment of the hip was most affected.

Thromboembolic Complications Following Spine Surgery Assessed with Spiral CT Scans: DVT/PE Following Spine Surgery.

Spine surgery is associated with a significant risk of postoperative pulmonary embolism (PE) and/or deep vein thrombosis (DVT). The goal of this study was to determine which symptoms and risk factors were associated with spiral CT scans positive for PE and/or DVT in the postoperative spine surgery patient. We conducted a retrospective review of all spine patients who underwent a postoperative CT to rule out PE during the period of March 2004-February 2006. The type of surgical procedure, risk factors, symptoms prompting scan ordering, anticoagulation, and treatment were recorded. Logistic regression models were used to determine significant predictors of a positive CT in this patient population. Of the 3,331 patients that had spine surgery during the study period, 130 (3.9%) had a spiral CT scan to rule out PE and/or proximal DVT. Thirty-three of the 130 (25.4%) CT scans were positive for PE only, five (3.8%) for PE and DVT, and three (2.3%) for DVT only. Only 24.5% (32) patients had risk factors for thromboembolic disease, and of these, a history of PE and/or DVT was the only significant risk factor for a positive scan (p = 0.03). No presenting symptoms or demographic variables were noted to have a significant association with PE and/or DVT. The type of surgical procedure (i.e., anterior, posterior, and percutaneous) was not associated with an increased risk for PE and/or DVT. Patients who are undergoing spine surgery with a history of thromboembolic disease should be carefully monitored postoperatively and may benefit from more aggressive prophylaxis.

Results of anatomic lateral ankle ligament reconstruction with tendon allograft.

Chronic ankle instability can be addressed surgically through direct lateral ligament repair, non-anatomic reconstruction, or anatomic reconstruction. The goal of this study was to assess the radiographic, functional, and clinical results of patients undergoing an anatomic lateral ankle ligament reconstruction using an anterior tibial tendon allograft. Eleven patients (12 feet; mean age, 48.9 ± 11.4 years) undergoing lateral ankle ligament reconstruction were followed at a mean of 3.5 ± 1.7 years after surgery (range, 1.2 to 5.0 years). Indications for surgery were previous failed repair (i.e., Broström; one case), hyperlaxity (seven cases), and high-demand patients (four cases). Subjective outcomes including the Foot and Ankle Outcome Score (FAOS), SF-36, and activity level were assessed. Mortise and lateral ankle stress radiographs were performed. The FAOS daily activity and sports activity subscores were 93.4 (range, 77.9 to 100) and 78.6 (range, 30 to 100), respectively. The SF-36v2 physical health and mental health components were 50.4 (range, 30.6 to 65.7) and 45.0 (range, 24.8 to 68.0), respectively. Four patients (five feet) reported no restriction; six patients reported mild restrictions, and one patient reported moderate activity restrictions. Tibiotalar tilt improved significantly from 20.2° to 4.6° after surgery (p < 0.01). The radiographic anterior displacement of the talus from the tibia was 6.5 mm postoperatively. The technique described restores mechanical stability in patients with chronic lateral ankle instability and may be considered in a select group of patients.

Comparison of PACS and hard-copy 51-inch radiographs for measuring leg length and deformity.

BACKGROUND: The picture archiving and communication system (PACS) eventually will replace the use of standard hard-copy radiographs. It is unknown whether measurements of limb length discrepancy (LLD) and deformity on PACS compare in accuracy and reproducibility with those from hard-copy radiographs. QUESTIONS/PURPOSES: We compared the reproducibility and reliability of LLD and deformity measurements for each of these two media. METHODS: We retrospectively reviewed 51-inch standing lower extremity images obtained for LLD or deformity analysis from 40 patients to compare the measurements and their reliability on hard-copy film with those performed on soft-copy PACS. Two observers independently performed measurements twice using each system at 1-week intervals to minimize interobserver or intraobserver bias. Intraclass correlation coefficients (ICCs) were determined to test intraobserver and interrater reliability of Rater 1 and Rater 2. RESULTS: Interrater reliability of measurements made on hard copy ranged from 0.69 to 0.99 and PACS-derived measurements ranged from 0.66 to 0.98. Intraobserver reliability for Rater 1 for measurements made on hard copy ranged from 0.853 to 0.999 and PACS-derived measurements ranged from 0.80 to 0.996. Intraobserver reliability for Rater 2 for measurements made on hard copy ranged from 0.931 to 0.999 and PACS-derived measurements ranged from 0.962 to 0.999. CONCLUSIONS: Each system yielded comparable reliability for measurements, therefore, transition to PACS to perform measurements in patients with LLD or deformity can be made with confidence. LEVEL OF EVIDENCE: Level III, diagnostic study. See the Guidelines for Authors for a complete description of levels of evidence.

Deltoid ligament reconstruction with peroneus longus autograft in flatfoot deformity.

BACKGROUND: Stage IV posterior tibial tendon insufficiency is characterized by the presence of valgus talar tilt in the setting of a flatfoot deformity which results from attenuation of the deltoid ligament. Correcting valgus tilt at the time of flatfoot reconstruction may prevent future collapse and the need for joint sacrificing procedures. The purpose of this study was to report the intermediate-term results of patients who underwent deltoid ligament reconstruction using a peroneus longus tendon transfer. MATERIALS AND METHODS: Five patients (mean age, 67 years ± 5.3 years) who underwent flatfoot reconstruction along with deltoid ligament reconstruction using a peroneus longus autograft were evaluated at a mean of 8.9 ± 1.7 years after surgery. The FAOS, SF-36v2, and VAS surveys were administered. The correction of valgus talar tilt was determined with weightbearing radiographs of the ankle. Ankle range of motion along with standing hindfoot alignment was assessed. RESULTS: The postoperative average FAOS and SF-36v2 were 68.3 (range, 55.2 to 85.0) and 75.7 (range, 40 to 92), respectively. The valgus talar tilt improved from 7.7 degrees preoperatively to 2.1 degrees postoperatively. Mean ankle range of motion was 47 degrees (range, 40 degrees to 55 degrees). Mean hindfoot alignment was 4 degrees valgus (range, 1 degree varus to 8 degrees valgus). CONCLUSION: Deltoid ligament reconstruction using a peroneus longus tendon transfer was a useful technique for reducing tibiotalar tilt in the setting of stage IV flatfoot deformity. Correction and function were maintained at intermediate-term followup.

Reconstruction of the spring ligament using a peroneus longus autograft tendon transfer.

BACKGROUND: The spring (calcaneonavicular) ligament provides one of the main static supports of the medial arch of the foot. The purpose of this study was to retrospectively assess the results of patients having undergone reconstruction of the spring ligament using a peroneus longus tendon autograft left at its distal attachment and passed through the navicular followed by either a calcaneal or tibial drill hole, a technique not previously reported. MATERIALS AND METHODS: Thirteen consecutive patients (14 feet) (mean age, 63.5 +/- 12.3 years) undergoing flatfoot surgery with spring ligament reconstruction for cases in which lateral column lengthening failed to correct talonvavicular deformity were reviewed. The AOFAS, FAOS, and SF-36 were assessed along with standard weightbearing radiographs at a followup visit at a mean of 8.9 +/- 1.8 years after surgery. Hindfoot alignment and eversion strength were measured. RESULTS: The AOFAS ankle-hindfoot score increased from 43.1 to 90.3 (\hbox{p}\leq 0.001). The postoperative FAOS pain subscale and overall SF-36 were 83.7 (range, 67.9 to 100), and 77.3 (range 37.8 to 95.6) respectively. The AP first tarsometatarsal angle (p = 0.015), talonavicular coverage angle (p = 0.003), lateral calcaneal pitch (p = 0.002), and lateral talonavicular angle (p = 0.017) improved significantly and were within normal ranges postoperatively. The mean hindfoot alignment measured 2.7 degrees of valgus. All but one patient had normal (5/5) eversion strength. CONCLUSION: Reconstruction of the spring ligament resulted in few complications and might be considered as an alternative to arthrodesis in patients with ruptures of the spring ligament and deformity that does not correct fully with bony procedures alone.

Assessment of lateral hindfoot pain in acquired flatfoot deformity using weightbearing multiplanar imaging.

BACKGROUND: The etiology of lateral hindfoot pain in flatfoot deformity can be difficult to assess on plain radiographs. We hypothesized that multiplanar measurements obtained in a fully upright, weightbearing position would reliably demonstrate an increase in lateral hindfoot arthrosis and/or impingement in a cohort of flatfoot patients with lateral hindfoot pain compared to a cohort without pain. MATERIALS AND METHODS: Ten consecutive patients with flexible flatfoot deformity and lateral hindfoot pain (mean age, 55.5 +/- 13.9) were compared to 10 consecutive patients with flexible deformity but no pain (mean age, 61.0 +/- 8.6). Conventional radiographs and weightbearing multiplanar images were performed on all patients before surgical reconstruction. Flatfoot, hindfoot impingement, and arthrosis parameters were interpreted in a blinded fashion by two musculoskeletal radiologists. Interrater reliability was determined with intraclass correlation coefficients (ICC). All parameters were compared between groups with a Wilcoxon rank sum test (p < 0.05). RESULTS: A significant increase in posterior facet subtalar arthrosis (p = 0.006) and combined anterior and posterior facet subtalar arthrosis (p = 0.022) was evident in the pain group. Calcaneofibular impingement and calcaneocuboid arthritis were increased in the pain group, but did not reach significance (p = 0.057 and p = 0.067 respectively). The multiplanar imaging parameters demonstrated good (ICC = 0.60 to 0.73) to excellent (ICC >or= 0.74) reliability for most impingement and arthrosis parameters and for many of the standard flatfoot parameters. CONCLUSION: The results indicate that weightbearing, multiplanar imaging provides a reliable means of assessing lateral pain in patients with flexible flatfoot deformity.

Using magnetic resonance angiography to measure abnormal synovial blood vessels in early inflammatory arthritis: a new imaging biomarker?

OBJECTIVE: To ascertain whether magnetic resonance angiography (MRA) can reliably detect synovial neovascularization in subjects with early inflammatory arthritis. METHODS: Subjects with 6 weeks to 6 months of clinical evidence of inflammatory hand arthritis had a radiograph, power Doppler ultrasound (PDU) scan, magnetic resonance imaging (MRI), and contrast enhanced MRA performed on the more symptomatic hand. Ultrasound examination of the wrist and 2nd-5th metacarpophalangeal (MCP) joints was scored for erosions, synovial thickening, and synovial blood flow. MRI were assessed using the OMERACT Rheumatoid Arthritis MRI Score (RAMRIS). MRA was used to assess the number of abnormal vessels in the 2nd-5th MCP and in the wrist. RESULTS: Of 30 subjects, 66.7% showed abnormal vasculature on MRA in the MCP and/or wrist; mean number of abnormal vessels was 5.24 (range 0-22). Number of abnormal vessels on MRA was strongly correlated with degree of blood flow seen in the corresponding area on PDU (r = 0.79, p

Transtibial versus anteromedial portal drilling for anterior cruciate ligament reconstruction: a cadaveric study of femoral tunnel length and obliquity.

PURPOSE: To compare the obliquity and length of femoral tunnels prepared with transtibial versus anteromedial portal drilling for anterior cruciate ligament (ACL) reconstruction and identify potential risks associated with the anteromedial portal reaming technique. METHODS: We used 18 human cadaveric knees (9 matched pairs) without ACL injury or pre-existing arthritis for the study. Femoral tunnels for ACL reconstruction were prepared by either a transtibial (n = 6) or anteromedial portal (n = 12) technique. For the anteromedial portal technique, a guidewire was advanced through the medial portal in varying degrees of knee flexion (100 degrees [n = 4], 110 degrees [n = 4], or 120 degrees [n = 4]) as measured with a goniometer. By use of a 6-mm femoral offset guide, two 6-mm femoral tunnels were reamed with the guide placed (1) as far posterior and lateral in the notch as possible and (2) as far medial and vertical in the notch as possible to define the range of maximal and minimal achievable coronal obliquity for each technique. All knees were imaged with high-resolution, 3-dimensional fluoroscopy to define (1) coronal tunnel obliquity relative to the lateral tibial plateau, (2) sagittal tunnel obliquity relative to the long axis of the femur, (3) intraosseous tunnel length, and (4) the presence of posterior cortical wall blowout. Data analysis was performed with a paired t-test and repeated-measures analysis of variance, with P < .05 defined as significant. RESULTS: Preparation of a vertical tunnel was possible with both transtibial and anteromedial portal drilling. The maximal achievable coronal obliquity, however, was significantly better with an anteromedial portal compared with transtibial drilling. However, 7 of 36 tunnels (19.4%) showed violation of the posterior tunnel wall, and all of these cases occurred with the anteromedial portal drilling technique. In addition, 1 of 6 oblique femoral tunnels (16.7%) drilled with the transtibial technique and 5 of 12 oblique femoral tunnels (41.7%) drilled with the anteromedial portal had an intraosseous length less than 25 mm. Increasing knee flexion with anteromedial portal drilling was associated with a significant reduction in tunnel length, increase in coronal obliquity, increase in sagittal obliquity, and increased risk of posterior wall blowout (P < .05). CONCLUSIONS: The anteromedial portal technique allows for slightly greater femoral tunnel obliquity compared with transtibial drilling. However, there is a substantially increased risk of critically short tunnels (<25 mm) and posterior tunnel wall blowout when a conventional offset guide is used. Increasing knee flexion with anteromedial portal drilling allows for greater coronal obliquity of the femoral tunnel but is accompanied by a greater risk of critically short tunnels and posterior wall compromise. CLINICAL RELEVANCE: Our findings provide insight into the potential risks and advantages of a transtibial versus an anteromedial femoral tunnel drilling technique in ACL reconstruction.

Sonographic evaluation and sonographic-guided therapeutic options of lateral ankle pain: peroneal tendon pathology associated with the presence of an os peroneum.

Clinical implications of acute injuries of the os peroneum have been described, with the recommendation in some cases being the excision of the bone fragments. We describe the spectrum of sonographic appearances associated with pain in the region of the os peroneum, document associated peroneal tendon pathology, and describe the use of sonography to direct and guide therapeutic and/or diagnostic injections. All sonographic examinations in our ultrasound database from Jan 1, 2001-Jan 30, 2007 with the words "os peroneum" were reviewed. Patients were cross-referenced in our radiology database to find relevant foot or ankle radiographs for correlation. There were 47 patients (18 men and 29 women, age range 16 to 83) referred for sonographic evaluation of lateral foot and/or ankle pain who had an os peroneum identified during the sonographic evaluation. Eighteen patients were referred specifically for targeted injection of the lateral ankle, including peroneal tendon sheath injections (N = 10), calcaneocuboid joint injections (N = 1), and injections around symptomatic os peroneum (N = 7). All 47 patients had tendinosis of the peroneus longus, in varying degrees of severity. Radiographs were available for correlation in 28 patients. The causes of lateral ankle pain with a co-existent os peroneum are multifactorial and may not directly relate to the presence of an os peroneum. Ultrasound can be of value in separating out the specific etiology for pain, as well as provide a method for problem solving by the performance of targeted diagnostic or therapeutic injections in the lateral ankle.