Can the Achilles tendon regenerate completely following percutaneous tenotomy in older children with clubfoot?

PURPOSE: The aims of the study were to document the outcomes of percutaneous Achilles tenotomy (pAT) performed in older children with clubfoot, by assessing the clinical, functional and ultrasonographic evidence of Achilles tendon regeneration. METHODS: A retrospective case series of older children with clubfoot treated between August 2011 and July 2020 was studied. Clinical assessment of ankle range of motion and calf strength, functional assessment of triceps surae muscle endurance by single leg heel-rise test, and ultrasonographic assessment of Achilles tendon echotexture and dimensions to assess tendon regeneration were performed. RESULTS: Percutaneous Achilles tenotomy was performed on 31 children (48 clubfeet) at a mean age of 5.24 ± 2.14 years (1-10.2 years). At a mean follow-up of 4.86 ± 1.97 years, all children demonstrated normal calf strength with mean dorsiflexion range of 13.64° (0-25°) and mean plantarflexion range of 37.95° (10-40°). The heel-rise endurance test was completed by 27 children with mean 25.85 heel rises/minute (range 17-30) and mean height of heel rise of 6.29 cm (range 4-10 cm). Normal fibrillar tendinous echotexture with homogenous echogenicity was seen on ultrasonography in 41 feet (85.4%) with mean tendon width of 9.7 mm (3.3-16 mm) and thickness of 5.1 mm (1.8-15 mm), comparable with unaffected feet. CONCLUSIONS: Clinical, functional and ultrasonographic parameters unequivocally demonstrate complete regeneration of the Achilles tendon, when pAT is performed in older children with delayed-presenting idiopathic clubfoot treated using Ponseti principles.

Accuracy of the kissing sign on lumbar spine MRI in cases of axillary disc herniation and the surgical correlation: an Indian multi-center study / Precisão do sinal do beijo na RM da coluna lombar em casos de hérnia do disco axial e a correlação cirúrgica: um estudo multicêntrico indiano

ABSTRACT Objectives: Magnetic resonance imaging has proven to be a valuable tool in the assessment of disc abnormalities. Two types of disc extrusion can be described according to the direction of herniated disc material: shoulder type and axillary type. Axillary disc herniation is described when the extruded disc fragment lies in the recess between the lateral border of cauda equina and medial to the nerve roots, while in the shoulder type the disc lies lateral to the nerve roots. It is very important to describe the type of disc herniation, as the surgical approach differs in each type. To the best of the authors' knowledge, no definite signs have been described in literature to date. This study aimed to address the accuracy of the kissing sign on MRI for he diagnosis of axillary disc herniation. Methods: The MRIs of 72 patients undergoing spinal surgery were prospectively evaluated for axillary disc herniation by a senior radiologist and experienced spinal surgeon using the kissing sign on MRI. The kissing sign was considered positive when the herniated disc material was in direct contact with the lamina and/or ligamentum flavum on axial images. Subsequently, all surgeries were performed by two independent surgeons and the actual type of disc herniation was documented. The accuracy of the results was statistically assessed. Results: The kissing sign on MRI was found to be 66.66% sensitive, 92.59% specific, and 76.38% accurate in detecting axillary disc herniation with significant correlation with the surgical findings. Conclusion: The type of disc herniation is an important parameter for patient selection in different surgical approaches. The kissing sign on MRI can be considered as an important tool for diagnosing axillary disc herniation due to its high specificity and accuracy.

RESUMO Objetivos: A ressonância magnética provou ser uma ferramenta valiosa na avaliação das anormalidades do disco. Dois tipos de extrusão de disco podem ser descritos de acordo com a direção do disco herniado: lateral e axilar. A hérnia de disco axilar é definida quando o fragmento do disco extruso encontra-se no recesso entre a borda lateral da cauda equina e medial às raízes do nervo, enquanto na hérnia lateral o disco posiciona-se lateralmente às raízes do nervo. A descrição do tipo de hérnia de disco é extremamente importante, pois a abordagem cirúrgica difere em cada tipo. Tanto quanto é do conhecimento dos autores, nenhum sinal definido foi descrito na literatura até o momento. Este estudo teve como objetivo abordar a precisão do sinal do beijo na RM no diagnóstico de herniação de disco axilar. Métodos: As RM de 72 pacientes submetidos à cirurgia da coluna vertebral foram avaliadas prospectivamente em relação à presença de hérnia de disco axilar por um radiologista sênior e cirurgião da coluna experiente com o sinal do beijo na RM. O sinal do beijo foi considerado positivo quando o material do disco herniado estava em contato direto com a lâmina e/ou ligamento amarelo em imagens axiais. Posteriormente, todas as cirurgias foram feitas por dois cirurgiões independentes e o tipo real de hérnia de disco foi documentado. A precisão dos resultados foi avaliada estatisticamente. Resultados: O sinal do beijo na RM apresentou 66,66% de sensibilidade, 92,59% de especificidade e 76,38% de precisão na detecção de hérnia de disco axilar com correlação significativa com os achados cirúrgicos. Conclusão: O tipo de hérnia de disco é um parâmetro importante para a seleção de pacientes em diferentes abordagens cirúrgicas. O sinal do beijo na RM pode ser considerado uma ferramenta importante para o diagnóstico de hérnia de disco axilar devido à sua alta especificidade e precisão.

Accuracy of the kissing sign on lumbar spine MRI in cases of axillary disc herniation and the surgical correlation: an Indian multi-center study.

OBJECTIVES: Magnetic resonance imaging has proven to be a valuable tool in the assessment of disc abnormalities. Two types of disc extrusion can be described according to the direction of herniated disc material: shoulder type and axillary type. Axillary disc herniation is described when the extruded disc fragment lies in the recess between the lateral border of cauda equina and medial to the nerve roots, while in the shoulder type the disc lies lateral to the nerve roots. It is very important to describe the type of disc herniation, as the surgical approach differs in each type. To the best of the authors' knowledge, no definite signs have been described in literature to date. This study aimed to address the accuracy of the kissing sign on MRI for he diagnosis of axillary disc herniation. METHODS: The MRIs of 72 patients undergoing spinal surgery were prospectively evaluated for axillary disc herniation by a senior radiologist and experienced spinal surgeon using the kissing sign on MRI. The kissing sign was considered positive when the herniated disc material was in direct contact with the lamina and/or ligamentum flavum on axial images. Subsequently, all surgeries were performed by two independent surgeons and the actual type of disc herniation was documented. The accuracy of the results was statistically assessed. RESULTS: The kissing sign on MRI was found to be 66.66% sensitive, 92.59% specific, and 76.38% accurate in detecting axillary disc herniation with significant correlation with the surgical findings. CONCLUSION: The type of disc herniation is an important parameter for patient selection in different surgical approaches. The kissing sign on MRI can be considered as an important tool for diagnosing axillary disc herniation due to its high specificity and accuracy.

OBJETIVOS: A ressonância magnética provou ser uma ferramenta valiosa na avaliação das anormalidades do disco. Dois tipos de extrusão de disco podem ser descritos de acordo com a direção do disco herniado: lateral e axilar. A hérnia de disco axilar é definida quando o fragmento do disco extruso encontra-se no recesso entre a borda lateral da cauda equina e medial às raízes do nervo, enquanto na hérnia lateral o disco posiciona-se lateralmente às raízes do nervo. A descrição do tipo de hérnia de disco é extremamente importante, pois a abordagem cirúrgica difere em cada tipo. Tanto quanto é do conhecimento dos autores, nenhum sinal definido foi descrito na literatura até o momento. Este estudo teve como objetivo abordar a precisão do sinal do beijo na RM no diagnóstico de herniação de disco axilar. MÉTODOS: As RM de 72 pacientes submetidos à cirurgia da coluna vertebral foram avaliadas prospectivamente em relação à presença de hérnia de disco axilar por um radiologista sênior e cirurgião da coluna experiente usando o sinal do beijo na RM. O sinal do beijo foi considerado positivo quando o material do disco herniado estava em contato direto com a lâmina e/ou ligamento amarelo em imagens axiais. Posteriormente, todas as cirurgias foram realizadas por dois cirurgiões independentes e o tipo real de hérnia de disco foi documentado. A precisão dos resultados foi avaliada estatisticamente. RESULTADOS: O sinal do beijo na RM apresentou 66,66% de sensibilidade, 92,59% de especificidade e 76,38% de precisão na detecção de hérnia de disco axilar com correlação significativa com os achados cirúrgicos. CONCLUSÃO: O tipo de hérnia de disco é um parâmetro importante para a seleção de pacientes em diferentes abordagens cirúrgicas. O sinal do beijo na RM pode ser considerado uma ferramenta importante para o diagnóstico de hérnia de disco axilar devido à sua alta especificidade e precisão.

Short term results of cementless total hip arthroplasty in sicklers.

BACKGROUND: Sickle cell (SC) disease leading to endarteritis induces skeletal changes in the form of osteitis, sclerosis of femoral canal and osteonecrosis of the femoral head. All these make total hip arthroplasty (THA) difficult and prolonged. There is increased risk of infection, SC crisis and increased complication rate. Our paper aims to highlight preoperative, intraoperative and postoperative hurdles encountered in performing THA in sicklers and the short term outcome using cementless implants. MATERIALS AND METHODS: Thirty-nine patients with SC disease, who had osteonecrosis of the femoral head, were operated between 2007 and 2011. The mean age of patients was 22 years (range 13-49 years). There were twenty eight females and 11 males. Bilateral cementless total hip replacement (THR) was performed in 11 patients (22 hips) and in the rest unilateral (28 hips). Preoperative and postoperative modified Harris hip score was evaluated. The average followup was 3.8 years (range 2-6 years). RESULTS: The average operating time was 96 min (range 88-148 min). The average blood loss was 880 ml (range 650-1200 ml). The average intraoperative blood transfused was 2.3 units (range 2-5 units). All patients showed an improvement in Harris hip score from 42 points preoperatively to 92 points at latest followup. Intraoperatively, one patient had a periprosthetic fracture. Six patients developed acute SC crisis and were managed in intensive care unit. Three patients developed wound hematoma. Three patients developed limb length discrepancy less than 1 cm. None had early or late dislocations, infection, heterotopic ossification, sciatic nerve palsy and aseptic loosening. CONCLUSION: THA in sicklers involves considerable challenge for the orthopedic surgeon. Management requires a multidisciplinary approach involving the anesthetist, hematologist and the orthopedic surgeon. Contrary to previous reports, THA in sicklers now has a predictable outcome especially with the use of cementless implants.

Ipsilateral intertrochantric and femoral head fracture without dislocation of the hip. Potentially misleading radiograph: a case report and review of literature.

BACKGROUND: Traumatic femoral head fracture without dislocation with ipsilateral intertrochanteric fracture is an extremely rare injury and has not been reported in the literature. CASE REPORT: We reported a case of simultaneous ipsilateral femoral head and intertrochantric fracture without dislocation of the hip in a 74-year-old woman. The patient presented with a history of road traffic accident. Radiographs and computerised tomography scans revealed a right intertrochantric fracture and femoral head fracture without dislocation of the hip. CONCLUSIONS: The case was managed by uncemented modular bipolar arthroplasty using LINK reconstruction prosthesis. In the case report we described this unusual pattern, mechanism of injury, and management of such cases.

Fracture of the outer metallic head of the bipolar hip prosthesis: an unusual bearing surface failure.

Fracture of the bearing surface is an infrequent cause of failure of a hip arthroplasty. Although well documented with ceramic heads, fracture of the metallic head is much rarer. We report a case of a fracture of the outer metallic head of a modular cemented bipolar hemiarthroplasty 2 years after the index procedure. Over time, the outer head lost its intended motion and assumed a vertical position. We hypothesized that this position caused asymmetrical loading with stress concentration at the poles, compounded by repeated impingement between the skirted inner cobalt-chromium (Cr-Co) head and the outer stainless steel head of this particular prosthesis. These were supported by the finite element studies. In addition, scanning electron microscopy and energy dispersive x-ray studies showed metallurgical defects that seemed to have initiated and/or accelerated the fracture. Although rare, this mode of failure calls for increased awareness, periodic follow-up, and quality control.

Brodie's abscess of the femoral neck simulating osteoid osteoma.

Subacute osteomyelitis (Brodie's abscess) is essentially a problem of diagnosis, and there may be considerable difficulty in distinguishing it from other benign and malignant bone lesions. Though reported in the metaphyseal region of the femur, Brodie's abscess is rarer in the femoral neck. The authors present a case of Brodie's abscess in the femoral neck, which clinico-radiologically simulated an osteoid osteoma. Retrospectively, the presence of a cortical sinus tract should have aroused suspicion.

Extraskeletal osteochondroma of the thigh: a case report.

A case of histopathologically proven extraskeletal osteochondroma of the thigh is presented along with its radiographic, CT and MRI findings. This is the first such case reported, to the best of our knowledge. The diagnosis of extraskeletal osteochondroma should be considered when a discrete ossified mass is localised in the soft tissue.