Tibial Retro-Malleolar Groove Morphology in Patients With Posterior Tibialis Tendon Dysfunction.

The posterior tibial tendon is a gliding tendon which courses around the medial malleolus and fails in posterior tibialis tendon dysfunction (PTTD) leading to a flat foot deformity. Distal tibial bone spurs have been identified as a secondary sign of PTTD although they have not been quantified in detail. The aim of this study was to assess the association of tendon dysfunction with the bony morphology of the tibial retro-malleolar groove. We performed a retrospective review of the clinical presentation, plain radiographs, and 103 magnetic resonance imaging (MRI) scans in 82 consecutive patients with PTTD compared with a non-PTTD group. We carried out a quantitative and qualitative assessment of the presence of plain radiographic bone spurs, stage of PTTD and MRI imaging of the morphology of the tibial bony malleolar groove. Plain radiographic bone spurs, as a secondary sign of PTTD, were present in 21.3% of ankle radiographs. MRI bone spurs were identified in 26/41 (63.4%) for all high-grade partial and complete tears and 7/41 (17.1%) for isolated complete tears compared with only 3.9% of the non-PTTD group. There was a significant association between the presence of bone spurs on MRI imaging and high-grade partial and complete tibialis posterior tears (p < .001; odds ratio of 4.98). Eleven of 103 (10.7%) of spurs were large and in 4/103 (3.9%) were substantial enough to create a tunnel-like hypertrophic groove not previously reported. There is variation in the bony structure of the malleolar groove in PTTD not observed in the non-PTTD group. Further investigation over time may elucidate whether the groove morphology may lead to mechanical attrition of the tibialis posterior tendon and contribute to failure of healing and progressive tendon degeneration.

Transcanal Excision of Exostoses: Large Series Comparing Bone Removal Methods.

OBJECTIVE: External auditory exostosis (EAE) is a condition of progressive temporal bone growth into the external auditory canal most commonly from repeat cold water and wind exposure. Several tools have been utilized for EAE excision with varying implications for intra- and postoperative complications. However, comparisons of osteotome and microdrill are made difficult due to the few published cases and intervariability between surgeons. Furthermore, evidence is needed to analyze the safety of novel supplemental tools such as the piezoelectric bone-cutting device. STUDY DESIGN: Retrospective chart review. SETTING: Medical clinic and surgery center. METHODS: A total of 413 subjects representing 472 ears met the inclusion criteria. Of which 159 ears were operated on using osteotome alone (OA), 271 using osteotome with a drill (OD), and 42 with osteotome with piezoelectric (OP). Charts were analyzed for the most reported intraoperative complications and postoperative symptoms and complications. RESULTS: There were no significant differences in the rate of tympanic membrane perforations nor in total intraoperative complications between OA, OD, or OP. The OD group contained the only nonperforation intraoperative event. OA had the lowest or near lowest incidence of all symptoms analyzed. OA showed a significantly lower incidence of tinnitus when compared to OD and OP. CONCLUSION: We found that OA performed the best, though not statistically significant in most measures, with regard to mitigating rates of complications postsurgery. Our findings suggest OA provides lower risk intraoperatively and postoperatively for patients undergoing transcanal exostosis excision.

Complication Rates in Osteotome and Drill Techniques in External Auditory Canal Exostoses: A Systematic Review and Meta-Analysis.

OBJECTIVES: To assess and compare complication rates of symptomatic external auditory canal (EAC) exostoses treated with drill versus osteotome canalplasty. DATABASES REVIEWED: PubMed/Medline, OVID, EMBASE, Web of Science, Google Scholar. METHODS: A systematic review and meta-analysis in accordance with PRISMA guidelines and standardized bias assessment using the JBI critical appraisal checklist was performed. Studies containing original outcome data on drill and osteotome canalplasty were included. The primary study outcome was complication rates. RESULTS: Fifteen studies were included, encompassing 1399 total patients (1788 ears) with 530 and 1258 ears in the osteotome and drill groups, respectively. Ten studies used a drill, 2 used an osteotome, and 3 used both. The most frequently reported complications were tympanic membrane (TM) perforation (osteotome group: 5.3% [95% CI: 1.7%-10.9%]; drill group: 3.8% [1.5%-7.1%]), sensorineural hearing loss (SNHL) (0.69% [0.07%-1.9%]; 4.3% [2.2%-7.0%]), and postoperative stenosis (1.1% [0.0005%-4.3%]; 4.1% [1.9%-7.0%]). Use of the osteotome was associated with a lower rate of SNHL (P < .05) and stenosis (P < .05), and a higher rate of TM perforation (P < .05). Heterogeneity of the studies included in the analyzed complications ranged from moderate to high. Level of evidence in the included studies ranged from 2b to 4 and all studies had an overall low risk of bias. CONCLUSION: While an osteotome technique may increase the risk of TM perforation, drill canaloplasty may increase the risk of SNHL and postoperative stenosis in EAC exostectomy. The exact quantity of hearing loss could not be definitively evaluated. Additional research with participant randomization is needed to assess clinical efficacy. LEVEL OF EVIDENCE: Level 8.

Hemothorax caused by costal exostosis injuring diaphragm: a case report and literature review.

BACKGROUND: Osteochondromas, also known as exostoses, are the most common benign tumors of bone and can be classified into isolated and multiple osteochondromas. A great majority of osteochondromas is asymptomatic, painless, slow-growing mass, and incidentally found. However, osteochondromas occurring in adolescence or in adult patients can grow in size and become symptomatic as a result of mechanical irritation of the surrounding soft tissues or peripheral nerves, spinal cord compression, or vascular injury. CASE PRESENTATION: We present a case of a 13-year-old girl with spontaneous hemothorax, the cause of which was identified by limited thoracotomy with the aid of video-assisted thoracic surgery to be bleeding from a diaphragmatic laceration incurred by a costal exostosis on the left sixth rib. Preoperative chest computed tomography (CT) depicted a bony projection arising from the rib and bloody effusion in the intrathoracic cavity, but was unable to discern the bleeding cause from the lung or the diaphragm. This case will highlight our awareness that costal exostosis possibly results in bloody pleural effusion. Meanwhile, English literatures about solitary costal exostosis associated with hemothorax were searched in PubMed and nineteen case reports were obtained. Combined our present case with available literature, a comprehensive understanding of this rare disease entity will further be strengthened. CONCLUSIONS: Injury to the diaphragm is the primary cause of hemothorax caused by costal osteochondroma, including the present case. Thoracic CT scan can help establish a diagnosis of preoperative diagnosis of costal osteochondroma. Surgical intervention should be considered for those patients with symptomatic osteochondroma of the rib. Combined with our case and literature, prophylactic surgical removal of intrathoracic exostosis should be advocated even in asymptomatic patients with the presentation of an inward bony spiculation.

Hallux anatomy: much ado about shoes-an attempt to prove that constrictive V-shaped toe-box shoes deform the hallux.

PURPOSE: A question still remains as to whether constrictive toe-box shoes (TBS) cause disability only due to pain on pressure points or if they can cause permanent changes in the hallux anatomy. The aim of this study is to compare the hallux morphology in 3 groups classified according to their use of constrictive or open TBS. METHODS: 424 patients were classified into 3 groups: group A used open TBS daily; group B used constrictive TBS daily; group C used both open and constrictive TBS. Hallux's angles, presence of exostoses and shape of the distal phalanx (DP) were analyzed on dorsoplantar weight-bearing radiographs and compared amongst groups. RESULTS: The intermetatarsal (IMA), metatarsophalangeal (MTPA), DASA, PASA, interphalangeal (IPA), obliquity (AP1), asymmetry (AP2) and joint deviation (JDA) angles for group A were 10°, 8°, 5°, 4°, 9°, 3°, 5°, 3°; for group B were 9°, 19°, 5°, 6°, 12°, 2°, 8°, 2°; and for group C were 10°, 10°, 4°, 4°, 12°, 3°, 8°, 1°. Only the differences in the MTPA, IPA and AP2 were statistically significant (p < 0.05). The prevalence of exostoses on the tibial side of the DP was 22, 36, and 29% in groups A, B and C, respectively (p < 0.05). We found similar distributions of the different DP shapes in the three groups. CONCLUSIONS: Our results suggest that the use of constrictive TBS, even if used only occasionally, could change hallux anatomy from a young age increasing MTPA, IPA and AP2. Moreover, we have found that DP exostoses are present as a "normal variation" in patients who wear an open TBS, but their prevalence is higher in those wearing constrictive toe-box shoes. This could be due to a reactive bone formation secondary to the friction caused by the inner border of the shoe. LEVEL OF CLINICAL EVIDENCE: 3.

Exercise induced neuropathic lower leg pain due to a tibial bone exostosis.

Objectives: The differential diagnosis of chronic exercise induced lower leg pain in sporters includes compartment syndrome and medial tibial stress syndrome. However, severe discomfort may also be caused by nerve entrapment.Methods: Here we present a marathon runner who reports pain day and night in the lower leg. Deep palpation suggested the presence of a bony tumor deep in the calf musculature, and digital pressure on the soleal sling was painful and elicited paresthesias in the foot. A swab test indicated a hypo-esthetic sole of the foot. Imaging revealed the presence of a tibial exostosis that was hypothesized to narrow the soleal tunnel and irritate the tibial nerve.Results: Via a medial infragenual approach, the soleal tunnel was opened. A bony prominence was found in direct contact to the tibial nerve. Resection of the exostosis with tibial nerve neurolysis completely abolished all of his symptoms.Conclusion: An awkward lower leg discomfort that is present at night and worsens during exercise combined with altered foot sole skin sensation in the presence of a tibial bone exostosis may suggest tibial nerve neuropathy. If conservative therapies fail, resection and neurolysis is advised.

Dorsal Medial Cuneiform Bony Outgrowth-Apophysis or Exostosis: A Case Report.

CASE: Three female children (11-15 years) presented with painful dorsomedial medial cuneiform masses that did not improve after conservative treatment. Findings were consistent with a diagnosis of medial cuneiform apophysis. After surgical resection, no patients had recurrence, although one continued to have pain from a deep peroneal nerve sensory branch that was resected. One patient had an intramass physis identified. CONCLUSION: When surgically removing dorsomedial cuneiform masses, surgeons should decompress overlying sensory nerve branches, detach and subsequently repair muscular attachments, and remove the entire stump to prevent regrowth because some of these masses may be apophyses and not exostoses.

Giant torus mandibularis causing submandibular duct obstruction and sialadenitis.

Torus mandibularis is a benign osseous overgrowth arising from the lingual surface of the mandible. It is a common, incidental finding on imaging due to its relatively high prevalence. In the majority of cases, mandibular tori are asymptomatic. We report a novel presentation of a giant torus mandibularis causing bilateral obstruction of the submandibular ducts and consequent sialadenitis. Our patient presented with progressive pain centered in the floor of his mouth and had bilateral submandibular glandular enlargement on exam. Computed tomography showed a giant right torus mandibularis, which was causing obstruction and dilation of the bilateral submandibular ducts. Although conservative management was attempted, he ultimately underwent surgical resection of his torus with symptomatic improvement. This patient highlights a novel complication of torus mandibularis and illustrates successful treatment. Though not previously described, this complication may be underreported and should be considered in the appropriate clinical setting.

Hypertension in Potocki-Shaffer syndrome: A case report.

Potocki-Shaffer syndrome (PSS) is a rare contiguous gene deletion syndrome caused by heterozygous deletion of 11p11.2p12. Typical features described in patients with PSS include developmental delay, intellectual disability, multiple cartilaginous exostoses, biparietal foramina, craniofacial abnormalities, and genitourinary anomalies. While hypertension has been noted in three patients with PSS, it has not been described in most patients with this syndrome. This report details the evaluation and treatment of a teenager with PSS who presented on several occasions during childhood with elevated blood pressure measurements. The renin level was elevated, likely indicating a secondary cause for the HTN. The patient's BP responded to monotherapy with Angiotensin Converting Enzyme Inhibitor (ACEI).

Cervical Cord Compression by Exostosis.

A 51-year-old woman presented to physical therapy with complaints of weakness in her left arm, progressive numbness in both hands, and mild progressive neck pain radiating into the left upper arm. She reported that her condition had started after playing in an amateur tennis tournament 4 weeks prior and progressed to inability to play tennis. Following examination by the physical therapist, the patient was referred to her physician, who ordered magnetic resonance imaging of the spine, which showed a bony exostosis at C1-2 with myelopathy. J Orthop Sports Phys Ther 2019;49(2):112. doi:10.2519/jospt.2019.7942.

Torus palatinus / Torus Palatinus

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Torus mandibularis affects the severity and position-dependent sleep apnoea in non-obese patients.

OBJECTIVE: Various anatomical structures of upper airway and physical differences are known to be risk factors for obstructive sleep apnoea (OSA). Torus mandibularis is a structure that can appear on the inside of the mandible. Therefore, it is possible for tori to influence airway volume by occupying the space for tongue and cause sleep apnoea. The purpose of this study is to investigate the effect of torus mandibularis on the severity of OSA as one of the craniofacial risk factors. DESIGN: Retrospective case-control study. SETTING: University-based tertiary medical centre. PARTICIPANTS: Adult patients over 19-years-old who visited outpatient clinics with complaints of sleep-disordered breathing symptoms between January 2010 and December 2017 were investigated. MAIN OUTCOME MEASURES: The presence of torus mandibularis in oral cavity was confirmed by physical examination or CT image. We analysed demographic findings including age, sex, medical history, previous operation history, physical findings of upper airway and result of polysomnography. To evaluate the effect of torus mandibularis on OSA, polysomnography data of the two groups according to presence or absence of torus mandibularis were compared and analysed. RESULTS: Two-hundred and thirty-two OSA patients with BMI <25 were divided into two groups, according to either the presence or absence of torus mandibularis. We analysed 138 patients of control group and 94 of torus mandibularis group. Apnoea-hypopnoea index (AHI) was 18.8 ± 14.9 in control group and 25.1 ± 18.4 in torus mandibularis group (P = 0.006). Respiratory disturbance index (RDI) was 23.1 ± 14.7 in control group and 27.9 ± 18.4 in torus mandibularis group (P = 0.035). Supine AHI showed 26.6 ± 20.3 in control group and 32.5 ± 22.6 in torus mandibularis group (P = 0.039). Patients with torus mandibularis had a trend of increase in proportion according to the severity of sleep apnoea, such as AHI (P = 0.007) or RDI (P = 0.034). CONCLUSIONS: We newly found that the presence of torus mandibularis affects not only severity of OSA and also position-dependent OSA. These results support the necessity of torus mandibularis evaluation in OSA patients, and further study is also required to investigate its consequence in the surgical outcome.

Medial and lateral exostoses of the distal phalanx of the hallux: A potentially painful bunion-like structure. Part 1: Incidence and clinical application.

BACKGROUND: Exostoses at the base of the distal phalanx of the great toe are usually asymptomatic. The literature has not generally considered them as the origin of a possible problem resulting from a pressure conflict between hallux and shoe (medial aspect) or second toe (lateral aspect) nor a potential complication of surgical correction of hallux valgus deformity. No studies, to our knowledge, have evaluated its possible correlation with other foot disorders. When one of these neglected exostoses became painful after surgical correction of hallux valgus, we decided to start a study to determine their possible origin, prevalence in daily practice and histo-pathological morphology. METHODS: Two hundred and fifty-four feet of patients (average age 41.7y.) were enrolled in the study from January 2007 to June 2009. Dorsoplantar weight-bearing radiographs were used to analyze the presence of exostoses and their correlation with the distal phalanx morphology, metatarsal formula (or transverse plane orientation of the metatarsal heads parabola) and hallux valgus angles. Patients were classified according to their age and main symptom for consultation. Four exostoses removed from cadaver feet were also analyzed microscopically. RESULTS: Osseous excrescences arising on the medial or lateral aspect at the proximal part of the terminal phalanx of the hallux were observed in 132 feet (51.9%). Thirty-five feet out of these 132 (13.7%) had exostoses on both sides of the phalanx.A statistically significant positive correlation was found between the presence of a medial exostosis of the phalanx and the severity of HVA. Patients with higher IPH and asymmetry angles have a lower prevalence of medial exostoses (p<0.05). Amongst the different morphologies of the second phalanx, exostoses were most likely found in the standard form. CONCLUSIONS: Prevalence of exostoses at the base of the distal phalanx is high (51.9% of the studied feet). Histological findings would suggest that these exostoses could be considered a mechanical reactive process, produced by a chronic irritation by shoes. We encourage surgeons to be aware of its potential clinical implications. Direct resection is very simple and the most appropriate treatment for symptomatic cases.

Surgical Correction of Haglund's Triad Using a Central Tendon-Splitting Approach: A Retrospective Outcomes Study.

We evaluated the surgical outcomes of Haglund's triad using a central tendon-splitting approach, with Achilles tendon partial detachment and debridement, excision of the retrocalcaneal bursa, resection of Haglund's prominence, and reattachment of the Achilles tendon. The medical records of 22 patients (22 heels) who had undergone surgical correction of Haglund's triad from January 2010 to December 2015 were reviewed retrospectively. The visual analog scale pain score, American Orthopaedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot scale score, and 36-item Short-Form Health Survey physical and mental component scores were prospectively collected preoperatively, 6 months postoperatively, and at the last visit. The scores of a subjective question involving satisfaction were prospectively collected at the last visit. Possible risk factors were also evaluated. We reviewed the data from 12 females and 10 males, with the mean age of 59.2 ± 7.3 years and a mean follow-up duration of 15.1 ± 4.6 months. Significant improvement was found in the mean visual analog scale pain score, average American Orthopaedic Foot and Ankle Society Ankle-Hindfoot scale score, and 36-item Short-Form Health Survey physical component scale score. The overall satisfaction rate was 77.3% (17 of 22). Postoperative complications included 2 cases of delayed wound healing and 1 case of sensation loss over the heel wound. No Achilles tendon rupture or wound infection developed. Gender and body mass index did not affect the surgical outcomes. The surgical technique we used for Haglund's triad provided effective pain relief, function improvement, and overall enhancement of patients' health condition. More research is required to further evaluate the outcomes of our surgical approach to treat Haglund's triad and the possible risk factors.

Surgical Emphysema Following Canalplasty for Aural Exostoses.

OBJECTIVE: To describe the presentation and management of surgical emphysema involving the temporomandibular joint and deep neck following exostoses removal. PATIENT: A 60-year-old male surfer presented with hearing loss and recurrent infections in the right ear. An examination revealed obstructing bony exostoses in the right external auditory canal. He underwent right canalplasty using a postauricular approach. At 5 weeks after surgery, he presented with right otalgia, swelling of the right face and neck, and complaints of a squeaking noise in the right ear with mandibular excursions. An otomicroscopic examination demonstrated a focal area of prolapsing soft tissue along the anterior bony external auditory canal with mandibular movement. The examination also revealed palpable crepitus of the right face and neck. Computed tomography was obtained of the temporal bones and neck confirming a focal anterior canal wall defect allowing communication between the glenoid fossa and external auditory canal with subcutaneous emphysema tracking around the temporomandibular joint into the masticator, parotid, and parapharyngeal spaces. INTERVENTION: Maxillomandibular fixation for 2 weeks with revision canalplasty using a split tragal cartilage graft. RESULTS: At 6 weeks after revision surgery, the patient reported complete resolution of all symptoms. Repeat imaging demonstrated complete resolution of subcutaneous and deep neck emphysema, and the otomicroscopic examination revealed a fully epithelialized external auditory canal with no further evidence of soft tissue prolapse. CONCLUSION: Maxillomandibular fixation with autologous cartilage graft is an effective management strategy for complications of canalplasty resulting in exposure of the temporomandibular joint capsule and surgical emphysema.

Dermoscopy of Subungual Exostosis: A Retrospective Study of 10 Patients.

INTRODUCTION: Subungual exostosis (SE), the most common nail tumor of young adults, is a benign bony proliferation of the distal phalanx occurring beneath the nail. Misdiagnosis or late diagnosis frequently occurs and no dermoscopy features of this tumor were previously outlined. MATERIAL AND METHODS: To describe the dermoscopic appearance of SE, 10 patients with radiologically and histologically confirmed SE were retrospectively retrieved from our tertiary referral centers. Data regarding age, gender, time to diagnosis, clinical presentation, dermoscopic features, involved nail and history of trauma were recorded for each patient. RESULTS: In our patients, clinical findings were similar to previous reports. Among the dermoscopic features, vascular ectasia was the most common finding (70%), followed by hyperkeratosis (60%), onycholysis (40%), and ulceration (30%). CONCLUSION: Dermoscopy could be a useful technique aimed at creating diagnostic suspicion of this benign nail condition, although X-ray examination and histopathology are mandatory for the diagnosis.