Unilateral Adolescent Pes Planus After a Bimalleolar Ankle Fracture: A Case Report.

We present the case of a 14-year-old female who presented with unilateral pes planus 30 months after a bimalleolar ankle fracture dislocation. At surgery, the tibialis posterior tendon was encased in fracture callus within the syndesmosis and required reconstruction using flexor digitorum longus transfer. Dislocation of the tibialis posterior tendon and entrapment within the tibiofibular syndesmosis has been previously reported. To our knowledge, this is the first case report tibialis posterior tendon syndesmotic entrapment presenting with unilateral pes planus.

Congenital absence of superficial posterior compartment calf muscles.

Although various congenital abnormalities have been described, congenital absence of calf musculature is extremely rare, with only one report on its complete absence. We are the first to describe a case of congenital absence of muscles of the superficial posterior compartment of the calf presenting in a toddler. The child presented with a history of a painless limp, however no significant difference was found in functional gait analysis. We suggest that such cases should be monitored and parents can be reassured that no immediate treatment is required.

Skin-derived tenocyte-like cells for the treatment of patellar tendinopathy.

BACKGROUND: Recent research of lateral elbow tendinopathy has led to the use of laboratory-amplified tenocyte-like cells. HYPOTHESIS: Ultrasound-guided injection of autologous skin-derived tendon-like cells are effective compared with other injectable therapies for the treatment of refractory patellar tendinosis. STUDY DESIGN: Randomized controlled trial; Level of evidence, 1. METHODS: From 60 patellar tendons in 46 patients with refractory patellar tendinopathy, a 4-mm skin biopsy was sampled to grow tenocyte-like collagen-producing cells. Patients were allocated into 2 groups: (1) injection with laboratory-prepared, amplified collagen-producing cells derived from dermal fibroblasts and suspended in autologous plasma from centrifuged autologous whole blood or (2) injection with autologous plasma alone. Injections were made into the sites of hypoechogenicity, intrasubstance tears, and fibrillar discontinuity within the patellar tendon. The Victorian Institute of Sport Assessment (VISA) score was used to assess pain, severity, and functional disability. Ultrasound was performed to assess structural and blood flow changes, evaluating 4 criteria: tendon thickness, hypoechogenicity, intrasubstance tears, and neovascularity. RESULTS: In the cell group, mean VISA scores improved from 44 ± 15 before treatment to 75 ± 17 at 6 months; in the plasma group, from 50 ± 18 to 70 ± 14. Estimated average difference between groups was 8.1, a significantly higher score in the cell group. Patients treated with collagen-producing cells also had significantly faster improvement and a highly significant effect of treatment, with the difference between groups estimated as 2.5 per unit increase in 1/√time. One patient treated with cell therapy had a late rupture and progressed to surgery; histopathology showed normal tendon structure. CONCLUSION: Ultrasound-guided injection of autologous skin-derived tendon-like cells can be safely used in the short term to treat patellar tendinopathy, with faster response of treatment and significantly greater improvement in pain and function than with plasma alone.

Persistent symptoms following non operative management in low grade MCL injury of the knee - The role of the deep MCL.

Incomplete injuries (grade I or II) to the medial collateral ligament (MCL) of the knee are common and usually self limiting. Some patients complain of chronic medial knee pain following injury. We highlight the importance of anatomical investigation of these patients and evaluate a successful treatment technique. A consecutive case series of 34 patients with chronic pain following grade I/II MCL injury were reviewed. Injury prevented sporting activity, and examination revealed thickening and tenderness of the MCL. The knee was assessed by MRI. All patients had radiological evidence of injury to the superficial and deep MCL, with thickening, scarring and tearing. Patients were treated with ultrasound guided injection of local anaesthetic and steroid into the deep MCL and clinically reassessed. They were allowed to return to sport immediately. They were assessed for recurrence of symptoms with a postal questionnaire. Four were excluded from follow up. Four were lost. All patients reported an immediate and sustained resolution their medial knee pain. At mean follow up of 20.4 months (range 11-38 months) all were back to their pre-injury level of work. Twenty five (96%) had immediate and sustained return to sporting activity. Twenty one (81%) reported no change in level of sporting function. In patients with persistent medial joint pain following grade I/II MCL sprain, pain from the deep MCL must be considered. MRI will confirm the diagnosis, exclude coexistent pathology and localise the lesion within the deep MCL. A single corticosteroid injection provides an excellent clinical outcome 20 months post injection.

Fluid-fluid levels in bone neoplasms: variation of T1-weighted signal intensity of the superior to inferior layers--diagnostic significance on magnetic resonance imaging.

The diagnostic relevance of the relative T1-weighted (T1W) and T2-weighted (T2W)/short tau inversion recovery (STIR) MRI signal intensity characteristics of the superior to inferior fluid layers within fluid-fluid levels (FFLs) found in bone tumours was investigated. A retrospective analysis was performed of MRI studies of 2,568 patients presenting with a suspected bone tumour over an 8-year period. Final diagnosis was made by biopsy/surgical resection or characteristic imaging/clinical findings. Subjects were divided by the absence/presence of FFLs and benign/malignant histology. Cases with FFLs were sub-categorised by the relative signal intensity of the superior/inferior layer as high/low or low/high on T1W and T2W/STIR sequences. Out of the total of 2,568 cases, 214 (8.3%, CI 7.3-9.5%) had FFLs and 2,354 (91.7%, CI 90.5-92.7%) had no FFLs. All 214 cases with FFLs had T2W/STIR sequences available, all demonstrating high/low signal intensity characteristics; 135/214 (63.1%, CI 56.2-69.6%) were benign and 79/214 (36.9%, CI 30.4-43.8%) were malignant. Out of the 214 patients, 151 had T1W sequences performed; 52 showed high/low signal intensity, of which 30 (57.7%, CI 34.2-71.3%) were benign and 22 (42.3%, CI 28.7-56.8%) were malignant (P = 0.06 compared with no FFL group); 50 showed low/high signal intensity, of which 40 (80%, CI 66.3-90.0%) were benign and ten (20%, CI 10.0-33.7%) were malignant (P = 0.0000, compared with the no FFL group). The low/high and high/low groups had a significantly greater proportion of benign and malignant lesions, respectively (P = 0.015). In conclusion, all FFLs showed high/low signal intensity characteristics on T2W/STIR sequences. Low/high signal on T1W was significantly associated with benign disease. Malignancy may occur slightly more frequently with high/low signal on T1W.

MR imaging appearances of acromioclavicular joint dislocation.

The key structures involved in dislocation of the acromioclavicular joint (ACJ) are the joint itself and the strong accessory coracoclavicular ligament. ACJ dislocations are classified with the Rockwood system, which comprises six grades of injury. Treatment planning requires accurate grading of the ACJ disruption, but correct classification can be difficult with clinical assessment. Magnetic resonance (MR) imaging has a well-established role in evaluation of ACJ pain. MR imaging performed in the coronal oblique plane parallel to the distal clavicle allows assessment of the acromioclavicular and coracoclavicular ligaments owing to its in-plane orientation in relation to these structures. This technique enables distinction between grade 2 and grade 3 injuries, which can be difficult with conventional clinical and radiographic evaluation. In addition, diagnosis of grade 1 injuries is possible by demonstration of a ruptured superiodorsal acromioclavicular ligament. Resultant thickening of the acromioclavicular or coracoclavicular ligament allows identification of chronic ACJ injuries.

MR imaging evaluation of the bone marrow and marrow infiltrative disorders of the lumbar spine.

The use of MR imaging in assessing lumbar bone marrow first requires an understanding of the bone marrow's normal composition and the various imaging sequences available for use. One of the most useful sequences is the T1-weighted spin-echo sequence. This sequence may be combined with other sequences such as T2-weighted or diffusion-weighted sequences; techniques such as fat suppression, chemical shift imaging, and contrast-enhanced imaging are discussed. The varying features of normal lumbar marrow related to the normal physiologic changes that occur with aging and with changes in hematopoietic demand are important to understand and are described. The appearances of infiltrative marrow disease are explained on the basis of marrow composition and whether disease causes proliferation, replacement, or depletion of normal marrow components.

Intra-urinoma rendezvous using a transconduit approach to re-establish ureteric integrity.

Ureteric discontinuity following injury has been traditionally treated surgically. With the advent of improved interventional instrumentation it is possible to stent these lesions percutaneously, retrogradely or failing that using a combined (rendezvous) technique. We describe an intra-urinoma rendezvous procedure combining a percutaneous antegrade-transconduit retrograde technique of stent insertion to successfully re-establish ureteric integrity that was used following the failure of a percutaneous retrograde approach. We illustrate its usefulness as an alternative to surgery.