Clinical characterisation of patients diagnosed with cancer following emergency self-referral.

BACKGROUND: Despite their frequency and potential impact on prognosis, cancers diagnosed via self-referral to the emergency department are poorly documented. We conducted a detailed analysis of cancer patients diagnosed following emergency self-referral and compared them with those diagnosed following emergency referral from primary care. Given the challenges associated with measuring intervals in the emergency self-referral pathway, we also aimed to provide a definition of the diagnostic interval for these cancers. METHODS: A retrospective observational analysis was performed on patients diagnosed with 13 cancers, either following emergency self-referral or emergency referral from primary care. We analysed demographics, tumour stage, clinical data (including 28 presenting symptoms categorised by body systems), and diagnostic intervals by cancer site, then testing for differences between pathways. RESULTS: Out of 3624 patients, 37 % were diagnosed following emergency self-referral and 63 % via emergency referral from primary care. Emergency self-referrals were associated with a higher likelihood of being diagnosed with cancers manifesting with localising symptoms (e.g., breast and endometrial cancer), whereas the likelihood of being diagnosed with cancers featuring nonspecific symptoms and abdominal pain (e.g., pancreatic and ovarian cancer) was higher among patients referred from primary care. Diagnostic intervals in self-referred patients were half as long as those in patients referred from primary care, with most significant differences for pancreatic cancer (28 [95 % CI -34 to -23] days shorter, respectively). CONCLUSION: These findings enrich the best available evidence on cancer diagnosis through emergency self-referral and showed that, compared with the emergency referral pathway from primary care, these patients had a significantly increased likelihood of presenting with symptoms that are strongly predictive of cancer. Since the starting point for the diagnostic interval in these patients is their emergency presentation, comparing it with that of those referred from primary care as an emergency is likely to result in biased data.

Outcomes of Combined Posterior Tibial Tendon Tendoscopy and Medializing Calcaneal Osteotomy for Stage IA Progressive Collapsing Foot Deformity.

BACKGROUND: Posterior tibial tendon (PTT) tendoscopy and medializing calcaneal osteotomy (MCO) are among the available techniques for patients presenting with symptomatic flexible hindfoot valgus (stage IA) progressive collapsing foot deformity (PCFD). The aim of this study was to determine clinical and radiographic outcomes of combined PTT tendoscopy and MCO for patients presenting with symptomatic stage IA PCFD. METHODS: A retrospective cohort study was performed in order to determine clinical and radiographic outcomes of 30 combined PTT tendoscopies and MCO on 27 patients presenting with symptomatic stage IA PCFD, with a minimum follow-up of 24 months. Patient satisfaction was assessed at last available follow-up as very satisfied, satisfied, and unsatisfied. Clinical assessment was performed evaluating preoperative and last available follow-up visual analog scale for pain (VAS-P), Foot and Ankle Outcome Score (FAOS), and the 36-Item Short Form Health Survey (SF-36). Magnetic resonance imaging (MRI) was performed preoperatively on all patients. Standard weightbearing anteroposterior, lateral, and long axial view radiographs of the foot and ankle were taken preoperatively, immediate postoperatively, at 6 weeks, 3 months, 6 months, 1 year postoperatively, and last follow-up evaluation available for each patient. RESULTS: The mean follow-up was 38.6 (range, 26-62) months. We registered 27 very satisfied, 1 satisfied, and 2 unsatisfied patients. There was statistically significant improvement on all clinical scores (VAS-P, FAOS and SF-36), as well as on lateral talo-first metatarsal and hindfoot alignment angles. We found low-grade PTT tears in 5 patients (16.67%) in whom preoperative MRI documented PTT tenosynovitis alone. CONCLUSION: We found that combined PTT tendoscopy and MCO provide significant clinical and radiographic improvement for patients presenting with symptomatic stage IAB PCFD. PTT tendoscopy should be considered in the treatment of all surgically addressed flexible valgus feet as it detects tendon tears which are frequently missed on an MRI. LEVEL OF EVIDENCE: Level IV, retrospective case series.

Anatomy of the Ankle and Subtalar Joint Ligaments: What We Do Not Know About It?

Understanding of the ankle and subtalar joint ligaments is essential to recognize and manage foot and ankle disorders. The stability of both joints relies on the integrity of its ligaments. The ankle joint is stabilized by the lateral and medial ligamentous complexes while the subtalar joint is stabilized by its extrinsic and intrinsic ligaments. Most injuries to these ligaments are linked with ankle sprains. Inversion or eversion mechanics affect the ligamentous complexes. A profound knowledge of the ligament's anatomy allows orthopedic surgeons to further understand anatomic or nonanatomic reconstructions.

Radiological and Anatomical Evaluation of First Metatarsal Pronation in Hallux Valgus Deformity: A Comparison Between Three Different Methods.

A frontal plane metatarsal rotational (pronation) has been documented in a high percentage of hallux valgus patients. Pathoanatomical concepts leading to pronation are still debated. Nevertheless, there is no consensus on how to measure this component of the deformity. The aim of the present study was to compare three commonly used radiographic methods to measure the frontal plane deformity in hallux valgus deformity, such as 1. Round sign of the lateral edge of the first metatarsal head on anterior-posterior radiograph, 2. Non-weightbearing CT-scan and 3. Bernard's axial projection of the first metatarsal head. Afterwards, feet were dissected, and a direct measurement of the pronation was done. Our data showed that alpha angle measurements made through the Bernard's axial projection were closer with those obtained during the dissection compared to those made through the CT-scan. The main finding of our study is that osteoarthritic changes at the metatarso-sesamoid joint play an important role in severe hallux valgus cases. The proposed radiographic methods allow surgeons to verify whether rotation can be corrected during Hallux Valgus procedures and to determine which procedure may be the best for each patient.

Outcomes of Posterior Arthroscopic Subtalar Arthrodesis for Medial Facet Talocalcaneal Coalition.

BACKGROUND: Medial facet talocalcaneal coalition can be a painful condition. This study aimed to determine clinical and radiographic outcomes of posterior arthroscopic subtalar arthrodesis (PASTA) for adult patients presenting with symptomatic medial facet talocalcaneal coalition and normal hindfoot alignment, with a minimal follow-up of 18 months. METHODS: Between June 2017 and July 2019, this procedure was performed on 8 feet (8 patients; mean age, 55 [42-70] years; mean BMI, 29.8 [24.4-45.0] kg/m2). Clinical assessment was performed using Visual Analog Scale for Pain (VAS-P), Foot and Ankle Outcome Score (FAOS) and the 36-Item Short-Form Health Survey (SF-36). Patient satisfaction was assessed at the last available follow-up as "very satisfied", "satisfied" or "unsatisfied". Radiographic analysis was performed using plain radiography, computed tomography (CT) scan and magnetic resonance imaging (MRI). The primary outcome was to determine both clinical and radiographic outcomes. RESULTS: The mean follow-up was 25.1 (18.2-34.2) months. The authors found statistically significant improvement on all clinical scores (VASP-P, FAOS and SF-36). They registered 6 "very satisfied" patients, 2 "satisfied" patients and no "unsatisfied" patient. Fusion of the subtalar joint was observed in all patients by 12 weeks and in 5 of them as soon as 8 weeks postoperatively (mean, 9.5 [8-12] weeks). There were no cases of delayed fusion or nonunion of the subtalar joint, superficial or deep infection, neurovascular damage, thromboembolic event, screw breakage, need for hardware removal or revision surgery. CONCLUSION: This study found that PASTA is a safe and reliable technique for adult patients presenting with symptomatic medial facet talocalcaneal coalition and normal hindfoot alignment, demonstrating and maintaining clinical improvement at an average follow-up of 2 years. LEVEL OF EVIDENCE: Level IV, case series.

Varus talar tilt combined with an internal rotation pivot stress assesses the supination instability vector in lateral ankle ligaments' injury - cadaver study.

BACKGROUND: The lack of consensus on the relevance of the varus talar tilt test (VTTT) might be due to the divergence between the insufficiency vector of lateral ankle instability and the direction of this clinical test. Our hypothesis is that the VTTT is more accurate to diagnose lateral ankle ligaments rupture when it's applied with a pre-positioning of the foot in internal rotation (IR). METHODS: We compared, in 12 cadaver ankles, the varus opening during a classic VTTT with the same test starting in an IR pivot, using a new arthrometer. RESULTS: The classic VTTT caused a 13° tilt after ATFL section and 23,8° after ATFL and CFL section. The application of a VTTT with an IR prepositioning caused a 21,2° tilt after ATFL section (p = 0,002) and 29,5° after ATFL and CFL section (p = 0,006). CONCLUSION: The VTTT is better to identify lateral ankle ligaments' insufficiency when it's applied with a pre-positioning of the foot in internal rotation. The resulting vector is similar to the supination trauma.

Irreducible Acute Patellar Dislocation due to a New Anatomical Variant - the Notched Patella.

Irreducible patella dislocations are rare and are usually associated with complex mechanisms. The authors report the clinical case of an irreducible lateral patellar dislocation due to an anatomical variant. The authors assisted a 16-year-old patient who presented with a lateral patella dislocation that was impossible to reduce by closed manipulation, even under general anesthesia. During the imaging study, the computed tomography (CT) exam showed a notch in the medial facet of the patella, impacted in the lateral condyle, which prevented the reduction. This anatomical variant was later confirmed during surgery. In a bilateral follow-up CT, this variant was also present in the contralateral, normal knee, excluding traumatic reshaping as the reason for this patellar notch. The authors used a medial parapatellar approach for open reduction of the dislocation and to repair the medial retinaculum. According to Wiberg, there are three different patella types. The authors describe a variation of type III patella with a notch in the medial border that is not included in the previous classification. They emphasize the importance of a CT study in the presence of an irreducible dislocation and the recognition of this anatomical variant of the patella, as further aggressive maneuvers have proven to be unsuccessful. Open reduction appears to be the best option in this scenario.

Irreducible Acute Patellar Dislocation due to a New Anatomical Variant - the Notched Patella / Dislocação patelar aguda irredutível devido a uma nova variante anatômica - a patela entalhada

Abstract Irreducible patella dislocations are rare and are usually associated with complex mechanisms. Theauthors report the clinical case of an irreducible lateral patellardislocationdueto an anatomical variant. The authors assisted a 16-year-old patient who presented with a lateral patella dislocation that was impossible to reduceby closedmanipulation, even under general anesthesia. During the imaging study, the computed tomography (CT) exam showed a notch in the medial facet of the patella, impacted in the lateral condyle, which prevented the reduction. This anatomical variant was later confirmed during surgery. In a bilateral follow-up CT, this variant was also present in the contralateral, normal knee, excluding traumatic reshaping as the reason for this patellar notch. The authors used a medial parapatellar approach for open reduction of the dislocation and to repair themedial retinaculum. According to Wiberg, there are three different patella types. The authors describe a variation of type III patellawith a notch inthemedial border that is not included in the previous classification. They emphasize the importance of a CTstudy in the presence of an irreducible dislocation and the recognition of this anatomical variant of the patella, as further aggressive maneuvers have proven to be unsuccessful. Open reduction appears to be the best option in this scenario.

Resumo As luxações irredutíveis da patela são raras e são geralmente associadas a mecanismos complexos. Os autores relatam o caso clínico de uma luxação patelar lateral irredutível devido a uma variante anatômica. Os autores atenderam um paciente de 16 anos que apresentou uma luxação lateral da patela de redução impossível por manipulação fechada, mesmo sob anestesia geral. Durante o estudo de imagem, a tomografia computadorizada (TC) mostrou um entalhe na faceta medial da patela, impactada no côndilo lateral, o que impediu a redução. Esta variante anatômica foi posteriormente confirmada durante a cirurgia. Em uma TC bilateral de acompanhamento, esta variante anatômica também estava presente no joelho contralateral, normal, excluindo o remodelamento traumático como o motivo deste entalhe patelar. Os autores utilizaramuma abordagem parapatelar medial para a redução aberta do deslocamento e para o reparo do retináculo medial. De acordo comWiberg, existem três tipos diferentes de patela. Os autores descrevem uma variação da patela de tipo III com um entalhe na margem medial que não está incluída na classificação anterior. Ressalta-se a importância de um estudo de TC na presença de luxação irredutível e o reconhecimento desta variante anatômica da patela, já quemanobras agressivas foram testadas sem sucesso. A redução aberta parece ser a melhor opção neste cenário. Abstract Irreducible patella dislocations are rare and are usually associated with complex mechanisms. The authors report the clinical case of an irreducible lateral patellar dislocation due to an anatomical variant. The authors assisted a 16-year-old patient

An anatomical study about the arthroscopic repair of the lateral ligament of the ankle.

BACKGROUND: The purpose of this anatomical study to was to determine the relationship of the structures involved in the arthroscopic repair of the anterior talofibular ligament. METHODS: Dissection of fifteen lower leg cadaveric specimens was made and distances in the anterior direction from the reference-point at the lateral malleolus origin of the anterior talofibular ligament were measured, to the talar insertion of the ligament, to the superficial peroneal nerve at 60° and 90° in relation to the lateral malleolus axis in the sagittal plane, and to the inferior extensor retinaculum. RESULTS: The mean±SD distance to superficial peroneal nerve from the reference-point was 25±6 (range 17-35) mm at 60°, and 32±9 (range 24-48) mm at 90° in relation to the lateral malleolus axis. The mean±SD distance to the inferior extensor retinaculum was 20±5 (range 14-29) mm. The mean±SD length of the anterior talofibular ligament was 21±4 (range 13-29) mm. CONCLUSIONS: The superficial peroneal nerve demonstrated the greatest variance in its anatomy. An accessory incision to include the inferior extensor retinaculum in the repair should not surpass the 22mm distance from the lateral malleolus in the anterior direction, due to the risk of damaging the nerve.

Bony landmarks available for minimally invasive lateral ankle stabilization surgery: a cadaveric anatomical study.

PURPOSE: The purpose of this study was to determine the clinical utility of three bony tubercles: fibular obscure tubercle, talar obscure tubercle and tuberculum ligamenti calcaneofibularis, to serve as anatomical landmarks for defining the precise location of the origins and insertions of the anterior talofibular ligament (ATFL) and calcaneofibular ligament (CFL). METHODS: Twelve lower extremity cadaveric specimens were procured. The detectability of the tubercles was tested using palpation and fluoroscopy with subsequent confirmation after dissection. If the tubercles were present, then distances from the identified tubercles to the footprint centres and the intersection of the ATFL and CFL were measured to allow precise localization of the ATFL and CFL origin and intersection sites. Further, if the tubercles were not detectable, then an attempt to provide an alternative means of localizing ATFL and CFL origin and insertion sites was made by measuring distances between alternative landmarks and other important structures. All the measurements were performed by two researchers, and the results were averaged. RESULTS: The fibular obscure tubercle existed and was detectable in all specimens. It was located 1.3 mm proximal to the articular tip of the fibula, 2.7 mm to the intersection of the ATFL and CFL, 3.7 mm distal to the ATFL and 4.9 mm proximal to the CFL origins. The talar obscure tubercle existed 58 % of specimens and was detectable in 57 %. The talar obscure tubercle was located 1.4 mm to the ATFL. The ATFL insertion point was located 60 % of the distance from the inferolateral corner to the anterolateral corner of the of talar body along the anterior border of the talar lateral articular facet. The tuberculum ligamenti calcaneofibularis existed in 33 % of specimens and was detectable in 8 %. The CFL inserted 17 mm on a perpendicular projected line distal from the subtalar joint. CONCLUSIONS: The fibular obscure tubercle was clinically relevant and reliable bony landmark of the ATFL and CFL origin location. However, the talar obscure tubercle was less reliable and the tuberculum ligamenti calcaneofibularis was rarely available and as such alternative landmarks for the ATFL and CFL insertion location should be utilized. The present study describes the utility of clinically relevant bony landmarks that may assist in identifying the origins and insertions of the ATFL and CFL to facilitate minimally invasive ankle stabilization surgery.