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.

HR-pQCT in vivo imaging of periarticular bone changes in chronic inflammatory diseases: Data from acquisition to impact on treatment indications.

Imaging is essential for the assessment of bone and inflammatory joint diseases. There are several imaging techniques available that differ regarding resolution, radiation exposure, time expending, precision, cost, availability or ability to predict disease progression. High-resolution peripheral quantitative computed tomography (HR-pQCT) that was introduced in 2004 allows the in vivo evaluation of peripheral bone microarchitecture and demonstrated high precision in assessing bone changes in inflammatory musculoskeletal diseases. This review summarizes the use of HR-pQCT for the evaluation of the hand skeleton in inflammatory joint diseases. We conducted a review of the literature regarding the protocols that involve hand joints assessment and evaluation of bone changes as erosions and osteophytes in chronic inflammatory diseases. Apart from measuring bone density and structure of the radius and the tibia, HR-pQCT has contributed to assessment of bone erosions and osteophytes, considered the hallmark of diseases as rheumatoid arthritis and psoriatic arthritis, respectively. In this way, there are some conventions recently established by rheumatic study groups that we just summarized here in order to standardize HR-pQCT measurements.

Management of split cord malformation in children: the Lyon experience.

INTRODUCTION: Split cord malformation (SCM) is a rare congenital spinal abnormality. Clinical presentation varies. Other congenital defects can be associated. Management is surgical. MATERIAL AND METHODS: We retrospectively reviewed all our SCM cases and reported our experience for its management. From 1990 to 2014, 37 patients were operated. Five situations lead to the diagnosis (orthopedic disorders (n = 8), orthopedic and neurological disorders (n = 16), pure neurological disorders (n = 5), no symptoms except cutaneous signs (n = 7), antenatal diagnosis (n = 1)). Scoliosis was the most common associated condition. The level of the spur was always under T7 except in one case. There were more type I (n = 22) than type II (n = 15) SCM. RESULTS: Patients with preoperative neurological symptoms (n = 21) were improved in 71.4%. Five out of nine patients that had preoperative bladder dysfunction were improved. Eleven patients needed surgical correction of the scoliosis. CONCLUSIONS: For us, the surgical procedure is mandatory even in case of asymptomatic discovery in order to avoid late clinical deterioration. In any case, the filum terminale need to be cut in order to untether completely the spinal cord. In case a surgical correction of a spinal deformity is needed, we recommend a two-stage surgery, for both SCM type. The SCM surgery can stop the evolution of the scoliosis and it may just need an orthopedic treatment with a brace.

Clinical Study of a Four-Step Program for the Treatment of Plantar Fasciitis with Bone Spurs.

OBJECTIVE: The most common causes of plantar and heel pain are plantar fasciitis and calcaneal spurs, and they often co-exist. Surgery is a recognized treatment for refractory plantar fasciitis. However, few studies have proposed treatment options for patients with metatarsophalangeal fasciitis with bone spurs. Accordingly, this study's purpose was to propose a four-step surgical regimen, and to improve the surgical outcome of plantar fasciitis with osteophytes and to establish a procedure for surgical treatment. METHODS: Retrospective analysis of 45 patients suffering from plantar fasciitis with bone spurs from 2020 to 2023. All patients underwent a four-step procedure, including plantar fascia release, calcaneal spur grinding, inflammatory tissue removal, and calcaneal burr decompression. The imaging parameters and functional scores were recorded before and after the operation. The objective evaluation included the measurement of calcaneal spur length on radiographs. Clinical evaluation included the American Orthopaedic Foot and Ankle Society (AOFAS), the Visual Analog Scale (VAS), and the Foot and Ankle Outcome Scale (FAOS). Measurement data that conformed to normal distribution were expressed as (x2 ± s), and pre-and postoperative AOFAS, FAOS, and VAS scores were compared using repeated-measures ANOVA, and preoperative and postoperative spur lengths were compared using paired t-tests. RESULTS: The 45 patients were followed up for 3 to 30 months, (17.72 ± 8.53) months, at final follow-up, the patient's AOFAS score improved from preoperative (74.93 ± 5.56) to (94.78 ± 3.98), FAOS score increased from preoperative (76.42 ± 3.37) to (96.16 ± 2.74), the VAS score decreased from (3.18 ± 0.54) to (1.07 ± 1.20) (p < 0.05), the length of spur decreased from (0.72 ± 1.81) cm to (0.23 ± 1.19) cm, and there were significant differences before and after operation (p < 0.05). CONCLUSION: The four-step surgical regimen is an appropriate and effective surgical procedure to treat plantar fasciitis with bone spurs.

Case report: A vertebral bone spur as an etiology for spinal cord herniation: case presentation, surgical technique, and review of the literature.

Objective: The pathophysiology of idiopathic spinal cord herniation remains unknown. However, several different factors have been postulated, such as congenital causes (ventral dura mater duplication, preexisting pseudomeningocele, or other congenital dural defects), inflammation, remote spinal trauma, or thoracic disc herniation. Herein, the diagnosis and surgical treatment of a patient with spinal cord herniation caused by an intraspinal bone spur is presented along with a relevant literature review. Case presentation: A 56-year-old male patient presented with a non-traumatic Brown-Sequard syndrome persisting for over 1 year. A magnetic resonance imaging of the spinal axis revealed a ventral spinal cord displacement in the level of T 6/7. A supplementary thin-sliced computed tomography of the spine revealed a bone spur at the same level. For neurosurgical intervention, T 6 and T 7 laminectomy was performed. The cranial and caudal end of the right paramedian ventral dural defect was visualized and enlarged. Following extradural spinal cord mobilization by denticulate ligament transection, the spinal cord was finally released. The spinal cord was rotated and the ventral closure of the dural defect was performed by continuous suture. The patient recovered from surgery without additional deficits. The patient's postoperative gait, sensory, and motor function deficits improved, and further neurological deterioration was prevented. Conclusion: Since the first description of spinal cord herniation by Wortzman et al. in 1974, approximately 260 cases have been reported in the literature. In addition to other causes, intraspinal bone spur is a possible cause of spinal cord herniation.

Association of Obesity and Plantar Fasciitis in Patients With Plantar Heel Spurs.

Background: Although its pathophysiology is not clear, the presence of a plantar heel spur has been considered a cause of heel pain in plantar fasciitis. This study investigated demographic and radiographic differences between a plantar fasciitis patient group with plantar heel spur and the age/sex-matched control group with plantar heel spur. Methods: Patients who visited the office under the diagnosis of plantar fasciitis and had a plantar heel spur were compared to an age/sex-matched control group who visited the office with other foot and ankle issues except for heel pain. All patients in both the control and case groups had radiographically proven presence of a plantar heel spur. Demographics and radiographic findings between the 2 groups were compared, and a multivariable logistic regression analysis was performed to identify independent risk factors that are associated with plantar fasciitis symptoms. Results: A total of 100 patients were included in the plantar fasciitis study group (PF+S) and age/sex-matched control group (C+S). BMI was higher in the study group than in the control group: 35.2 vs 30.9 (P = .002). The size of the plantar heel spur was larger in the study group than in the control group: 5.9 vs 4.6 mm (P = .017). A multivariable regression analysis identified that obesity (BMI > 30, odds ratio [OR] = 2.675) and the size of plantar heel spur >5.3 mm (OR = 2.642) were associated with PF+S. Conclusion: We found an association of both obesity and increased average plantar heel spur length on lateral radiographs in patients with painful plantar fasciitis compared to patients without plantar fasciitis but with plantar heel spurs. The presence of a plantar heel spur alone did not account for the symptoms of plantar fasciitis. Level of Evidence: Level III, comparative case study.

Spontaneous rupture of the extensor pollicis longus tendon after conservative treatment of a non-displaced distal radius fracture in an adolescent.

A spontaneous rupture of the extensor pollicis longus (EPL) tendon after a fracture of the distal radius is a known complication in adults. In contrast, there are a paucity of reports concerning EPL tendon ruptures in children and adolescents. The authors present a case of a spontaneous rupture of the EPL tendon in a 15-year-old girl after a non-displaced distal radius fracture. The patient had no predisposing factors including rheumatoid arthritis or steroid injection. During surgery, the EPL tendon was found to be ruptured at the extensor retinaculum (third compartment). Extensor indicis proprius (EIP) to EPL transfer was performed. At the 18-month follow-up, the patient was asymptomatic and showed satisfactory thumb function, with normal active extension.

La rotura espontánea del tendón del extensor largo del pulgar (EPL) tras una fractura distal del radio es una complicación conocida en adultos. En cambio, son escasos los informes sobre roturas del tendón del EPL en niños y adolescentes. Los autores presentan un caso de rotura espontánea del tendón del EPL en una niña de 15 años tras una fractura distal del radio no desplazada. La paciente no presentaba factores predisponentes como artritis reumatoide o inyección de esteroides. Durante la intervención quirúrgica, se descubrió que el tendón del EPL estaba roto a la altura del retináculo extensor (tercer compartimento). Se realizó una transferencia del extensor indicis proprius (EIP) al EPL. A los 18 meses de seguimiento, el paciente estaba asintomático y mostraba una función satisfactoria del pulgar, con una extensión activa normal.

Simultaneous Compression of the Neurovascular Bundle of Both Arms by a Bilateral Supracondylar Humeral Process: A Rare Case of Bilateral Nerve Entrapment of the Elbow in a Child.

The supracondylar process is a beak-shaped bone spur arising from the anteromedial area of the distal humerus and in the majority of cases, it is connected to the medial epicondyle with a band of connective tissue which is known as ligament of Struthers. The complex of bone spur and ligament creates a ring that may compress the median nerve causing soreness and paresthesia of the hand and fingers. We present a rare case of bilateral supracondylar process compressing the neurovascular bundles in both arms and causing simultaneous bilateral upper limb pain, numbness, and weakness in an otherwise healthy young child. Surgical excision of the bone spurs and release of Struthers' ligaments provided immediate pain relief and complete resolution of symptoms. Three years after the index surgery, no limitations of activities or signs of recurrence were reported. Median nerve compression neuropathy in a child or a young adult should always raise the suspicion of the presence of supracondylar process particularly when bilateral symptoms exist. Although there are limited data about the incidence of recurrence and the extent of bone resection, the supracondylar process should be excised together with the overlying periosteum to minimize the theoretical risk of local regrowth.

Spur-of-the-Moment: An Exacting Nasal Intubation.

Nasotracheal intubations are an important airway management technique in otolaryngologic surgeries and trauma distorting oropharyngeal structures. For those performing these procedures, nasal deformities are not uncommon. This case report highlights an example of recurrent cuff tears that occurred during nasotracheal intubation of a patient with an unknown nasal bone spur. A careful airway analysis with available imaging studies may predict the potential difficulty with nasotracheal intubation. A successful approach to nasotracheal intubation can then be attempted on the contralateral side if a nasal bone spur is present.

Morphological Features of the Coccyx in the Turkish Population and Interrelationships Among the Parameters: A Computerized Tomography-Based Analysis.

Introduction The coccyx is well-known to be a highly variable structure considering its morphology. To our knowledge, the relationship between the coccygeal types and other morphological features has not been studied yet. In addition to the interrelations among morphological parameters, this study investigated the morphology and morphometry of coccyx more extensively in the adult Turkish population using computerized tomography images. Methods Five hundred subjects who underwent pelvic computerized tomography were included in this study. In addition to coccyx type and the counts of coccygeal vertebrae and segments, the presence of coccygeal deviation, sacrococcygeal joint (SCJ) fusion, SCJ subluxation, intercoccygeal joint (ICJ) fusion, and coccygeal spicule were evaluated. The coccygeal length, sacrococcygeal angle, and intercoccygeal angle were measured on the digital workstation. The findings were subjected to statistical analyses. Results The coccygeal vertebra count ranged between three to five, with an average of 4.04 ± 0.48. The range of coccygeal segment count was between one and five, with an average of 2.53 ± 1.02. ICJ fusion in any segment, SCJ fusion, and SCJ subluxation were identified in 397 subjects (79.4%), 343 subjects (68.6%), and 17 subjects (3.4%), respectively. The coccyx types from the most common to the least common were as follows: type 2, type 1, type 3, type 4, and type 5. Coccygeal deviation to the left side was observed in 71 subjects (14.2%), while coccygeal deviation to the right side was observed in 61 subjects (12.2%). A coccygeal spicule was identified in 73 subjects (14.6%). The subjects' mean age demonstrated no significant difference considering the ICJ fusion (p=0.271), SCJ subluxation (p=0.51), coccygeal spicule (p=0.337), features of coccygeal deviation (p=0.83), and coccyx types (p=0.11). The subjects with SCJ fusion (50.7 ± 18.3 years) were significantly older than the subjects without SCJ fusion (46.5 ± 18.5 years) (p=0.016). The differences between the coccyx types considering the rate of SCJ fusion (p=0.002), ICJ fusion (p=0.04), and spicule presence (p<0.001) as well as the coccygeal vertebra count (p<0.001) were significant. Conclusion The presence of coccygeal spicule, a risk factor for coccydynia, is reported to be 14.6% in this study group that represents the Turkish population. This study indicates an association between the coccyx types and the frequency of SCJ fusion, ICJ fusion, and spicule presence and consequently suggests the significance of the coccyx type among the morphological features to cause susceptibility to coccydynia. Due to the multiplicity of the pain generators in the coccygeal region that is established by previous reports, the comparisons of different human populations and the knowledge on the interrelations between the morphologic parameters might facilitate the comprehension of the etiology of coccydynia. The clarification of interrelationship existence among the coccygeal morphological parameters requires further investigations.

Clinical Value of Ultrasonographic Assessment in Lateral Epicondylitis Versus Asymptomatic Healthy Controls.

BACKGROUND: Ultrasonography (US) is often used in the assessment of lateral epicondylitis (LE). The strength of evidence supporting its role is, however, not well-documented. PURPOSE: To describe and compare the US tendinopathic changes observed in patients with LE and the general population, including any correlation between patient characteristics and US outcomes. STUDY DESIGN: Cross-sectional study; Level of evidence, 3. METHODS: Tendon thickness, color Doppler activity, and bone spur were assessed by US in 264 participants with healthy elbows and 60 patients with chronic LE. In addition to patient characteristics, Patient-Rated Tennis Elbow Evaluation (PRTEE) score, pain, and disability were recorded. RESULTS: Depending on the measurement technique used, mean LE tendon thickness increased by 0.53 mm (10.2%) or 0.70 mm (14.5%) as compared with the contralateral arm and 0.40 mm (7.9%) or 0.41 mm (8.5%) as compared with the general population. Mean color Doppler activity (scale, 0-4) was 3.47 in the LE arm versus 0.13 in the contralateral asymptomatic arm and 0.26 in the general population. Bone spur was observed in 78% of the LE arms as opposed to 45% in the contralateral arms and 50% in the general population. In the LE group and the general population, the prevalence of bone spur increases with age. No correlations were observed with pain, disability, PRTEE, and disease duration. CONCLUSION: Increased common extensor tendon thickness is part of the tendinopathic changes observed in LE. However, given the marked variation in natural tendon thickness and small increases in tendon thickness in patients with LE, this technique cannot be used as a stand-alone diagnostic tool but rather as a supplement to the overall assessment. The contralateral elbow (if asymptomatic) is a better tendon thickness comparator than a general population mean value. Color Doppler activity is an indicator of ongoing tendinopathy and supports the LE diagnosis, but it is not pathognomonic for the condition. Absence of Doppler activity in a patient with suspected LE should raise suspicion of other diagnoses. Identification of a bone spur is of very limited clinical value given the high prevalence in the general population. The important outcomes of pain, disability, PRTEE, and disease duration did not correlate with any of the investigated US techniques.

Relationship of the Shape of Subacromial Spur and Rotator Cuff Partial Thickness Tear.

BACKGROUND: The present study was undertaken to evaluate the relationship between location of the rotator cuff tear and shape of the subacromial spur. METHODS: Totally, 80 consecutive patients who underwent arthroscopic repair for partial thickness rotator cuff tear were enrolled for the study. Bigliani's type of the acromion, type of subacromial spur, and location of partial thickness tear of the rotator cuff were evaluated using plain X-ray and magnetic resonance imaging. We then compared the groups of no spur with spur, and heel with traction spur. RESULTS: Of the 80 cases, 25 cases comprised the no spur group, and 55 cases comprised the spur group. There was a significant difference in type of tear (p=0.0004) between these two groups. Bursal side tears were significantly greater (odds ratio=6.000, p=0.0007) in the spur group. Subjects belonging to the spur group were further divided into heel (38 cases) and traction spur (17 cases). Comparing these two groups revealed significant differences only in the type of tear (p=0.0001). Furthermore, the heel spur had significantly greater bursal side tear (odds ratio=29.521, p=0.0005) as compared to traction spur. CONCLUSIONS: The heel spur is more associated to bursal side tear than the traction spur, whereas the traction spur associates greater to the articular side tear.

Large enthesophytes in teenage skulls: Mechanical, inflammatory and genetic considerations.

BACKGROUND: The literature implies that large enthesophytes are exclusive to genetically predisposed individuals and to Spondyloarthropathies sufferers. Accordingly, the aim of this investigation and report was to assess the involvement of genetic predisposition, inflammatory and/or mechanical influences in the development of large enthesophytes in a sample population of teenagers presenting with large enthesophytes emanating from the external occipital protuberance. METHODS: Analysis was based on four teenage males (13-16 year-old) possessing 14.5-30.5 mm enthesophytes projecting from the external occipital protuberance. This study included assessment of radiographs, MRI scans, blood-work, history, the SF-36 health survey, and the comparison of these data with the relevant literature to describe the interrelationships between the presence of enlarged external occipital protuberance, forward head protraction, active inflammation and/or genetic factors. FINDINGS: Known genetic markers (e.g. HLA-B27) were not detected by allele-specific primers and both ESR and CRP tests were negative. Additionally, MRI analyses failed to detect active localised inflammation at the external occipital protuberance and surrounding structures. The health survey yielded normal parameters for all participants. All participants displayed significantly large Forward Head Protraction values (>40 mm), and interviews with participants and their parents indicated that concerns related to posture were prevalent since early childhood. INTERPRETATION: This report suggests that mechanical load has an important role in enthesophyte development, irrespective the involvement of inflammatory or genetic factors.

The age dependent change in the incidence of calcaneal spur.

OBJECTIVE: The aim of the present study was to evaluate the association between the calcaneal spur incidence and age, gender and side. METHODS: Lateral ankle X-rays of 1335 patients (550 (41.2%) females and 758 (58.8) males; mean age: 46.5 ± 13.5 years) who referred to our hospital because of trauma were reviewed. Incidence of plantar calcaneal spur, posterior calcaneal spur and association of such incidences with age, gender and side were all evaluated. RESULTS: Incidences of plantar calcaneal spur and posterior calcaneal spur were detected as 32.2% (male: 31%, female: 34%) and 13.1% (male: 11%, female: 16%), respectively. Incidence of plantar calcaneal spur increased by age whereas there was not any association with gender and location. The highest incidence was detected as 41.8% over 70 years of age. Incidence of posterior calcaneal spur increased by age and female gender whereas no significant association was observed with location. The highest incidence was detected as 22.3% between 61 and 70 years of age. CONCLUSION: Incidences of plantar and posterior calcaneal spur were detected as 32.2% and 13.1%, respectively. Both plantar and posterior calcaneal spur incidence increases by age. Posterior calcaneal spur occurs significantly more frequently in females while, no difference is found between the males and females in incidence of the plantar calcaneal spur. LEVEL OF EVIDENCE: Level IV, diagnostic study.

Spontaneous rupture of the extensor pollicis longus tendon after conservative treatment of a non-displaced distal radius fracture in an adolescent / Rotura espontánea del tendón del extensor largo del pulgar tras el tratamiento conservador de una fractura no desplazada del radio distal en un adolescente

Abstract: A spontaneous rupture of the extensor pollicis longus (EPL) tendon after a fracture of the distal radius is a known complication in adults. In contrast, there are a paucity of reports concerning EPL tendon ruptures in children and adolescents. The authors present a case of a spontaneous rupture of the EPL tendon in a 15-year-old girl after a non-displaced distal radius fracture. The patient had no predisposing factors including rheumatoid arthritis or steroid injection. During surgery, the EPL tendon was found to be ruptured at the extensor retinaculum (third compartment). Extensor indicis proprius (EIP) to EPL transfer was performed. At the 18-month follow-up, the patient was asymptomatic and showed satisfactory thumb function, with normal active extension.

Resumen: La rotura espontánea del tendón del extensor largo del pulgar (EPL) tras una fractura distal del radio es una complicación conocida en adultos. En cambio, son escasos los informes sobre roturas del tendón del EPL en niños y adolescentes. Los autores presentan un caso de rotura espontánea del tendón del EPL en una niña de 15 años tras una fractura distal del radio no desplazada. La paciente no presentaba factores predisponentes como artritis reumatoide o inyección de esteroides. Durante la intervención quirúrgica, se descubrió que el tendón del EPL estaba roto a la altura del retináculo extensor (tercer compartimento). Se realizó una transferencia del extensor indicis proprius (EIP) al EPL. A los 18 meses de seguimiento, el paciente estaba asintomático y mostraba una función satisfactoria del pulgar, con una extensión activa normal.

Relationship of the Shape of Subacromial Spur and Rotator Cuff Partial Thickness Tear

BACKGROUND: The present study was undertaken to evaluate the relationship between location of the rotator cuff tear and shape of the subacromial spur. METHODS: Totally, 80 consecutive patients who underwent arthroscopic repair for partial thickness rotator cuff tear were enrolled for the study. Bigliani's type of the acromion, type of subacromial spur, and location of partial thickness tear of the rotator cuff were evaluated using plain X-ray and magnetic resonance imaging. We then compared the groups of no spur with spur, and heel with traction spur. RESULTS: Of the 80 cases, 25 cases comprised the no spur group, and 55 cases comprised the spur group. There was a significant difference in type of tear (p=0.0004) between these two groups. Bursal side tears were significantly greater (odds ratio=6.000, p=0.0007) in the spur group. Subjects belonging to the spur group were further divided into heel (38 cases) and traction spur (17 cases). Comparing these two groups revealed significant differences only in the type of tear (p=0.0001). Furthermore, the heel spur had significantly greater bursal side tear (odds ratio=29.521, p=0.0005) as compared to traction spur. CONCLUSIONS: The heel spur is more associated to bursal side tear than the traction spur, whereas the traction spur associates greater to the articular side tear.