Correlation between radiological assessment of acute ankle fractures and syndesmotic injury on MRI

Item does not contain fulltextOBJECTIVE: Owing to the shortcomings of clinical examination and radiographs, injury to the syndesmotic ligaments is often misdiagnosed. When there is no indication requiring that the fractured ankle be operated on, the syndesmosis is not tested intra-operatively, and rupture of this ligamentous complex may be missed. Subsequently the patient is not treated properly leading to chronic complaints such as instability, pain, and swelling. We evaluated three fracture classification methods and radiographic measurements with respect to syndesmotic injury. MATERIALS AND METHODS: Prospectively the radiographs of 51 consecutive ankle fractures were classified according to Weber, AO-M�ller, and Lauge-Hansen. Both the fracture type and additional measurements of the tibiofibular clear space (TFCS), tibiofibular overlap (TFO), medial clear space (MCS), and superior clear space (SCS) were used to assess syndesmotic injury. MRI, as standard of reference, was performed to evaluate the integrity of the distal tibiofibular syndesmosis. The sensitivity and specificity for detection of syndesmotic injury with radiography were compared to MRI. RESULTS: The Weber and AO-M�ller fracture classification system, in combination with additional measurements, detected syndesmotic injury with a sensitivity of 47\% and a specificity of 100\%, and Lauge-Hansen with both a sensitivity and a specificity of 92\%. TFCS and TFO did not correlate with syndesmotic injury, and a widened MCS did not correlate with deltoid ligament injury. CONCLUSION: Syndesmotic injury as predicted by the Lauge-Hansen fracture classification correlated well with MRI findings. With MRI the extent of syndesmotic injury and therefore fracture stage can be assessed more accurately compared to radiographs

Psychopathology predicts the outcome of medial branch blocks with corticosteroid for chronic axial low back or cervical pain: a prospective cohort study

<p>Abstract</p> <p>Background</p> <p>Comorbid psychopathology is an important predictor of poor outcome for many types of treatments for back or neck pain. But it is unknown if this applies to the results of medial branch blocks (MBBs) for chronic low back or neck pain, which involves injecting the medial branch of the dorsal ramus nerves that innervate the facet joints. The objective of this study was to determine whether high levels of psychopathology are predictive of pain relief after MBB injections in the lumbar or cervical spine.</p> <p>Methods</p> <p>This was a prospective cohort study. Consecutive patients in a pain medicine practice undergoing MBBs of the lumbar or cervical facets with corticosteroids were recruited to participate. Subjects were selected for a MBB based on operationalized selection criteria and the procedure was performed in a standardized manner. Subjects completed the Brief Pain Inventory (BPI) and the Hospital Anxiety and Depression Scale (HADS) just prior to the procedure and at one-month follow up. Scores on the HADS classified the subjects into three groups based on psychiatric symptoms, which formed the primary predictor variable: <it>Low</it>, <it>Moderate</it>, or <it>High </it>levels of psychopathology. The primary outcome measure was the percent improvement in average daily pain rating one-month following an injection. Analysis of variance and chi-square were used to analyze the analgesia and functional rating differences between groups, and to perform a responder analysis.</p> <p>Results</p> <p>Eighty six (86) subjects completed the study. The <it>Low </it>psychopathology group (n = 37) reported a mean of 23% improvement in pain at one-month while the <it>High </it>psychopathology group (n = 29) reported a mean worsening of -5.8% in pain (p < .001). Forty five percent (45%) of the <it>Low </it>group had at least 30% improvement in pain versus 10% in the <it>High </it>group (p < .001). Using an analysis of covariance, no baseline demographic, social, or medical variables were significant predictors of pain improvement, nor did they mitigate the effect of psychopathology on the outcome.</p> <p>Conclusion</p> <p>Psychiatric comorbidity is associated with diminished pain relief after a MBB injection performed with steroid at one-month follow-up. These findings illustrate the importance of assessing comorbid psychopathology as part of a spine care evaluation.</p

Reconstruction techniques and clinical results of patellar tendon ruptures: Evidence today

Background: The analysis of the different operative reconstructions of patellar tendon ruptures has not been reported. A critical review of the existing literature was performed to identify the different operative techniques and the post-operative outcomes in acute, chronic and post-total knee arthroplasty (TKA) patellar tendon rupture repairs. Methods: Using PRISMA guidelines, a review of the English-written literature published after 1947 was performed using the MEDLINE, PubMed and Cochrane libraries in November 2013 to retrieve case series with the keywords “Patellar tendon” AND “Rupture” AND “Repair” in their title or abstract. Results: Forty-one manuscripts, reporting on 503 patients were analysed. Three-hundred-and-fifty-four acute repairs described eight different operative techniques. One-hundred-and-forty-nine chronic repairs described eight different operative techniques. Sixty-eight post-TKA repairs described nine different operative techniques. Six acute, four chronic and seven post-TKA repair operative techniques reported failures. In acute repair, using a primary repair method augmented with cerclage wire, Dall–Miles cable or non-absorbable sutures reported the best clinical results, with a 2% failure rate. Alternatively, for chronic and post-TKA repair, autogeneous grafts were significantly better than primary repair (p = 0.0252, 0.0038 respectively). Conclusion: Acute surgical repair of a patellar tendon rupture using augmented primary repair is associated with the best post-operative outcomes. In chronic and post-TKA repair, autogeneous grafts produce best post-operative outcomes. Immediate post-operative mobilisation should be considered in all repairs. Future papers reporting on patellar operative repairs should have a standardised scoring method of functional outcome to allow more comprehensive comparison and evaluation

Preoperative embolization of bone metastases from renal cell carcinoma

The purpose of this study was to correlate the effectiveness of preoperative embolization with the blood loss and transfusion requirement during surgery for bone metastases from renal cell carcinonoma. Twenty-eight preoperative embolizations in 26 patients with renal cell carcinoma metastatic to bone were retrospectively evaluated and divided into two groups: Group A included the embolizations that resulted in complete devascularization of the lesion as defined by the post-embolization arteriograms, and group B included those with an incomplete result. The two groups were compared with regard to blood loss and transfusion requirement during surgery, by unpaired two-tailed Student’s t-test. Where complete embolization was effected (group A, 10 cases), there was a mean blood loss of 535 +/- 390 ml. When a less than complete embolization was achieved (group B, cases), the mean blood loss was 1.247 +/- 1.047 ml (p = 0.049). The red blood cell transfusion in group A was 1.3 +/- 1 units, whereas in group B it was 2.4 +/- 1.2 (p = 0.03). Preoperative embolization of bone metastases from renal cell carcinoma with subsequent complete devascularization leads to significant reduction of blood loss during surgery. Interventional radiologists should pursue and embolize every feeder to the metastasis, because any less than complete devascularization increases the amount of blood loss and the amount of red blood cell transfusion during surgery