Bony Pathology Research Articles

Impingement-type bony morphology was related to cartilage defects, but not pain in professional ballet dancers’ hips

ObjectivesProfessional ballet dancers may have hip bony morphology that predisposes them to cartilage or labral injury. However, the relationship between bony morphology and pathology has not been investigated in ballet. This study investigates associations between bony morphology, chondrolabral defects and hip pain in ballet dancers. DesignCross-sectional study. Methods33 male and female professional ballet dancers, (mean age 27 years (range 19–39)), completed questionnaires with hip pain measured on a visual analogue scale; and underwent 3.0-T magnetic resonance imaging (3T MRI) to measure lateral centre edge angles (LCEA), alpha angles in the anterior and superior position, femoral neck-shaft angles (NSA) and acetabular version angles; and to detect acetabular labral tear and articular cartilage defects. ResultsSeventeen dancers (51.5%) had impingement-type (alpha angle>50.5° or acetabular version <10° or >20°) and 19 (58%) had instability-type (LCEA<25° or NSA>135°) bony morphology. Cartilage defect prevalence was higher in dancers with impingement-type bony morphology (n=14) compared to those without impingement-type morphology (n=4, p=0.001). There was no relationship between instability-type bony morphology and cartilage defects (p>0.05). There was no relationship between labral tears and bony morphology (p>0.05). Neither chondrolabral pathology nor any morphological feature were associated with hip pain (p>0.05 for all). ConclusionsImpingement-type bony morphology was related to cartilage defects, but not labral tear. Hip pain was not associated with pathology or bony morphology. Longitudinal studies are warranted to determine if bony features, such as cam morphology, acetabular retroversion or anteversion, are precursors to symptomatic hip joint injury or osteoarthritis.

Predictors of Outcomes of Non-Surgical Management for Acetabular Labral Tears

Objectives:Acetabular labral tears are increasingly recognized as a source of hip pain in the younger, active population. Due to a significant focus on surgical intervention, there has been limited investigation on the predictive factors and natural history of non-surgical management of these injuries. Many reports recommend a trial of non-operative management with a variety of modalities including physical therapy, education, non-steroidal anti-inflammatories (NSAIDs), intra-articular injections, and activity modification. However, there is limited data supporting these claims as few studies have explored non-surgical management. Additionally, the authors were not able to find any studies on factors that portend outcomes of non-operative management. We hypothesized that patients with more significant bony FAI pathology or more severe osteoarthritis would have poorer outcomes.Methods:Eighty patients with acetabular labral tears, confirmed by MRI, receiving a minimum of one year of non-surgical management were identified. Subjects completed baseline patient reported outcome measures (PROMs: mHHS, HOS-ADL, HOS-SS, iHOT-33). Sixty five (81.25%) patients completed the same one-year follow-up functional outcomes measures in addition to a satisfaction questionnaire (37F, 28 M). Chart review was conducted to obtain demographic information and radiographic information (Tonnis grade, alpha angle, center edge angle, chondral damage, cartilage defects, cysts, and subchondral edema). Statistical significance (p<0.05) was determined t-test, anova, or Wilcoxon rank-sum.Results:Average follow up time was 24 months (R:18-30). The mean age was 41.7(R:18-57), average BMI was 26.2 (R18-39), and average Tonnis grade was 0.6 (R0-2). At follow-up, overall patients experienced a significant improvement in functional outcomes (mHHS: 66.6 vs 75.18, HOS-ADL: 75.7 vs 85.8, HOS-SS: 54 vs 69.7, iHOT-33: 47.9 vs 65.4). There was a positive correlation between baseline PROMs and follow-up PROMs as well as a negative correlation between baseline PROMs and change in PROMs over time. Tonnis grade, chondral damage, and cartilage defects portended significantly worse outcomes across all PROMs at follow-up. Presence of cysts or subchondral edema was also correlated with worse outcomes but these findings did not reach statistical significance. (Table 2). Alpha angle >55 (cam lesion) resulted in significantly worse outcomes across all PROMs although CEA>40 (pincer lesion) only reached significance for the HOS ADL and SSS. CEA< 25 (dysplasia) trended toward worse outcomes but did not reach significance. (Table1)Conclusion:Due to the limited healing potential of the labrum, the associated anatomical defects of FAI, and the potential for progression to osteoarthritis, there has been a focus on surgical intervention for FAI and labral tears. Despite a lack of evidence for its use, non-surgical management is frequently cited as the first step to treatment. As we found in a previous analysis, patients with symptomatic labral tears can experience functional improvement after minimum one year of non-surgical management. Those with signs of higher grade arthritis performed significantly worse that their less arthritic counterparts. Those with larger cam and pincer lesions also improved less than patients with less significant bony morphology. This study can help inform surgeons and their patients when they present with hip pain and inquire about non-surgical management.Change in patient reported outcome measures from baseline to follow-up for osseous morphologymHHSP ValueHOS-ADLP ValueHOS-SSSP ValueiHOT-33P value CEA<25 0.48140.07510.12140.3223No9.0 (14.8)11(19)17(30)18(25.4)Yes3.8(14.6)-5(13)-2(22)11.3(12.1) CEA>40 0.06840.01850.02160.0838No10(14.7)12(19)19(30)20(24)Yes0.9(13.2)1(12)-2(22)3.8(25.2) Alpha>55 0.00010.00790.0010.0001No12.1(14.1)13(19)21(29)25.1(20.6)Yes-4.0(9.0)-1(14)-4(20)-10.4(17.2)Change in patient reported outcome measures from baseline to follow-up for cartilage statusmHHSp valueHOS-ADLp valueHOS-SSSp valueiHOT-33p value Edema 0.09450.89950.83330.1312No10.2 (14.4)10 (20)16 (28)20.4 (21.9)Yes1.8 (14.7)10 (14)14 (37)4.6 (32.5) Cartilage Degeneration 0.00010.00010.00010.0001No18.0 (9.1)19(17)29(27)31.7(17.0)Yes-5.4(9.4)-3(12)-4(22)-4.0(17.9) Cartilage Defect 0.00010.00090.00890.0002No12.0(13.3)14(18)20(28)22.7(22.9)Yes-6.4 (11.2)-6 (11)-5 (26)-5.9 (18.4)

Foot and ankle tumours

Both benign and malignant tumours are encountered in the foot and ankle. Due to their rarity, however, diagnosis is often uncertain. Usual criteria such as tumour size, invasiveness or pain fail to differentiate benign from malignant neoplasias. Plain radiography and-due to the complex foot anatomy-CT are important in the diagnostic evaluation of primary bone tumours. In the case of soft tissue tumours, ultrasonography is used to identify ganglion cysts. Tumour evaluation and staging are then performed using MRI. Nuclear imaging comes into play when multifocal, metastatic or systemic spread of the disease is suspected or if abiopsy procedure is planned. For the role of dual-energy CT, please refer to partI. Whether dual-energy CT is suitable to assess bone marrow oedema patterns is still debated. Primary bone tumours generally present in the ankle or the hindfoot. Malignant bone tumours, e. g. chondrosarcoma, are primarily found in the latter. On the other hand, soft tissue tumours generally present in the mid- and forefoot regions. While the radiologic diagnostic evaluation of pedal bone tumours is quite reliable, caution is urgently needed in the case of soft tissue tumours because there are many confusing differential diagnoses. Proper X‑ray examination of the foot (at least in two plains) or with special views according to bony pathology is needed. All soft tissue masses that are not cysts should be evaluated further. MRI remains the diagnostic modality of choice but never stands alone! Caution: Size and well-defined margins of pedal soft tissue tumours are not considered criteria regarding whether a tumour is malignantor not.

Fully-endoscopic lumbar laminectomy for central and lateral recess stenosis: Technical note

Abstract Background Lumbar central and lateral recess stenosis that results from a degenerative bulging of the disc and overgrowth of the facet is a very common cause for lumbar claudication and radiculopathy in the elderly. The standard surgical treatment for symptomatic lumbar central and lateral recess stenosis often requires a laminectomy. The evolution of minimally invasive techniques have created advantages for patients undergoing surgery and the authors present here a novel technique for endoscopic access to the central and lateral recess pathology that is truly minimally invasive and offers several advantages to minimally invasive spine surgeon. Methods 14 cases were performed, 10 at L4–5 and 4 at L5-S1, for the treatment of central and lateral recess stenosis. The technique was similar to that performed for minimally invasive lumbar laminectomies with a tubular retractor except, after percutaneous access to the pathological level, a cannulated 11.5 mm tubular retractor was inserted and then a 10 mm outer diameter laminoscope with a 6 mm working channel and 15° lens was inserted. Specialized endoscopic drills, forceps, and kerrison rongeurs were used to remove bony pathology and ligamentum flavum under direct visualization. Results Following surgery, the patients' symptoms showed immediate regression with continued relief at 6 month and 1 year follow up visits. Conclusions The availability of endoscopes with larger working channels (laminoscopes) and larger endoscopic instruments and drills now makes treating significant central and lateral recess lumbar stenosis with endoscopic techniques more feasible.

Giant mediastinal parathyroid adenoma presenting as bilateral brown tumour of mandible: a rare presentation of primary hyperparathyroidism

Hyperparathyroidism (HPT) is becoming increasingly common endocrinopathy in clinical practice. Nowadays, it is mostly diagnosed in subclinical or early clinical stage. Bony involvement in HPT has seen significant fall in...

Comprehensive Clinical Evaluation of Femoroacetabular Impingement: Part 3, Magnetic Resonance Imaging

Radiologic imaging is an essential supplement to the physical examination in the evaluation of a patient with femoroacetabular impingement. Plain radiographs are the initial modality of choice for the evaluation of bony anatomy and pathology. Magnetic resonance imaging supplements the physical examination and standard radiographs by enabling qualitative and quantitative evaluation of both articular cartilage and soft tissues about the hip. Magnetic resonance imaging also provides improved 3-dimensional characterization of the bony anatomy owing to the multiplanar nature of this technique. This article describes a comprehensive approach to interpretation of magnetic resonance examination of the hip.

Molecular Mechanisms That Contribute to Bone Marrow Pain.

Pain associated a bony pathology puts a significant burden on individuals, society, and the health-care systems worldwide. Pathology that involves the bone marrow activates sensory nerve terminal endings of peripheral bone marrow nociceptors, and is the likely trigger for pain. This review presents our current understanding of how bone marrow nociceptors are influenced by noxious stimuli presented in pathology associated with bone marrow. A number of ion channels and receptors are emerging as important modulators of the activity of peripheral bone marrow nociceptors. Nerve growth factor (NGF) sequestration has been trialed for the management of inflammatory bone pain (osteoarthritis), and there is significant evidence for interaction of NGF with bone marrow nociceptors. Activation of transient receptor potential cation channel subfamily V member 1 sensitizes bone marrow nociceptors and could contribute to increased sensitivity of patients to noxious stimuli in various bony pathologies. Acid-sensing ion channels sense changes to tissue pH in the bone marrow microenvironment and could be targeted to treat pathology that involves acidosis of the bone marrow. Piezo2 is a mechanically gated ion channel that has recently been reported to be expressed by most myelinated bone marrow nociceptors and might be a target for treatments directed against mechanically induced bone pain. These ion channels and receptors could be useful targets for the development of peripherally acting drugs to treat pain of bony origin.

Surgical management of giant cell tumor of axis vertebra: review of fourteen cases in literature with a case illustration

Abstract Primary spinal giant cell tumor (PSGCT) considered as rare primary neoplasm, with predilection for subarticular location and commonly located at knee joint region, sacrum or distal radius, however, spinal involvent is uncommon and comparatively much rarer in the cervical spine. Further occurrence of giant cell tumor in the Axis vertebra is extremely uncommon and easily misdiagnosed and, thus, treatment is still debated and various treatment modalities and different surgical approaches were utilized during evolution of surgical management. Authors could collect only 14 cases of primary giant cell tumor affecting Axis vertebra in a detailed Pubmed and Medline search, out of which 12 cases were primary and rest two case was recurrent. So authors reviewed in total thirteen cases primary giant cell tumor of Axis managed surgically, including our case. Out of 13 PSGCT, twelve cases were managed with surgical resection and the rest one case was managed with monoclonal antibody using Denosomab monotherapy without any surgical intervention. In the surgical group (n=12), nine cases had two staged surgical procedure, first being posterior fixation followed by anterior approach with resection of tumor while, the rest three had one stage surgical resection including current case. Authors reports a unique case of spinal giant cell tumor developing in a- 38 - year male with history of renal transplant, presented with neck pain and difficulty in walking, neuroimaging revealed a osteolytic mass lesion involving body of axis vertebra with extension into right sided lamina, underwent two stage complete surgical intervention. Authors describes management of such rare locally recurring primary bony pathology affecting axis vertebra as it is not only interesting and challenging and different management modalities, various, surgical approaches and issue of renal osteodystrophy along with pertinent literature is also reviewed briefly.

Hip arthroscopy in patients less than 25 years of age in the treatment of labral tears: aetiology and clinical outcomes.

Hip arthroscopy has evolved into a well-established and rapidly growing field of orthopedic surgery for the management of labral tears. The purpose of this study was to review clinical outcomes of patients less than 25 years of age undergoing hip arthroscopy for treatment of a labral tear. From 2005 to 2013, 82 hips in 76 patients with mean age of 20.4 (16-25 range) underwent hip arthroscopy for treatment of labral-chondral damage. The Western Ontario McMaster Universities Osteoarthritis Index (WOMAC) and hip disability and osteoarthritis outcome score (HOOS) were recorded at latest follow-up. 36 of 86 hips (42%) had isolated labral pathology with no associated bony pathology (normal alpha and centre-edge angle; no retroversion). Beck score (intraoperative cartilage damage) of 3 or more was significantly associated with an alpha angle of more than 55 degrees (odds ratio [OR], 3.6; confidence interval [CI], 1.2-11.0) and presence of femeroacetabular impingement (OR, 4.5; CI, 1.3-15.2). HOOS pain, sports/recreation, and quality of life significantly improved from preoperative to one year after surgery (p<0.05). 8 patients had re-operations for persistent pain; 5 underwent arthroscopic labral repair; 2 underwent arthroscopy with subsequent periacetabular osteotomy (PAO); 1 had only a periacetabular osteotomy (PAO). Complications included 2 lateral femoral cutaneous nerve deficits and 1 deep vein thrombosis. Labral tears in patients less than 25 years of age occurs commonly without bony deformities, with those with normal head/neck contour demonstrating significantly less early cartilage damage than those with bony pathology. Hip arthroscopy in young patients can improve function and quality of life with minimal morbidity.

Intraoperative Radiation Exposure During Hip Arthroscopy.

Background:The frequency of hip arthroscopy for the treatment of acute and chronic chondrolabral pathology and femoroacetabular impingement (FAI) has increased exponentially over the past decade. While surgeon and patient radiation exposure has been well documented in other areas of the orthopaedic literature, little is known about the procedure-specific and cumulative doses affecting the hip arthroscopist.Purpose:To determine the mean annual radiation exposure to the hip arthroscopist and the mean surgeon exposure per case.Study Design:Case series; Level of evidence, 4.Methods:A total of 210 consecutive hip arthroscopies performed in 209 patients by a single surgeon at a single ambulatory surgical center in a cohort consisting of approximately 50% bony (cam and pincer) pathology were prospectively reviewed, documenting the specific procedures performed in each case and the readings from a radiation dosimeter worn by the surgeon during positioning and while performing the procedures. Radiation readings for deep dose–equivalent (DDE), lens dose–equivalent (LDE), and shallow dose–equivalent (SDE) were measured. These readings were compared with the annual radiation dose limit recommendations established by the International Commission on Radiological Protection (ICRP).Results:The total radiation doses for the operative surgeon during all 210 cases were 183 mrem (1.83 mSv) DDE, 183 mrem (1.83 mSv) LDE, and 176 mrem (1.76 mSv) SDE. The mean exposure per case was 0.871 mrem (0.00871 mSv) DDE, 0.871 mrem (0.00871 mSv) LDE, and 0.838 mrem (0.00838 mSv) SDE. The operative surgeon’s mean annual exposure, performing 70 hip arthroscopies per year with 55% involving bony work, was 61.0 mrem (0.610 mSv) DDE, 61.0 mrem (0.610 mSv) LDE, and 58.7 mrem (0.587 mSv) SDE. These results are well below the ICRP annual limits of 50,000 mrem (500 mSv) DDE, 2000 mrem (20 mSv) LDE, and 50,000 mrem (500 mSv) SDE.Conclusion:For an experienced hip arthroscopist utilizing fluoroscopy during setup and bony resection, the annual and per-patient exposure to radiation remains well below the recommended ICRP limits.Clinical Relevance:Considering the increasing annual frequency of hip arthroscopies being performed, information regarding procedure-specific and cumulative doses of radiation exposure affecting the hip arthroscopist may provide valuable safety information for the orthopaedic community.

Systematic review of oral manifestations related to hyperparathyroidism.

We sought to identify oral symptoms found in hyperparathyroidism and compare their rate of occurrence, as well as potential variations in sequelae between primary, secondary, and tertiary hyperparathyroidism. Database searches were performed through EMBASE and PubMed, with a continual handsearch for relevant articles. PRISMA guidelines were followed. Two hundred five articles including 245 patients were analyzed with data extraction. The average age was 34.02years old (age range 1-83), with 91 male and 154 female patients (1:1.7 M/F ratio). Patients presented with symptoms including facial asymmetry or swelling (167/214 cases; 78.0%), oral pain (30/214; 14.0%), systemic symptoms (25/214; 11.7%), referrals or incidental findings (16/214; 7.5%), and neuropathy (6/214; 2.8%) independently and in combination together. Bony pathology occurred most often in the mandible (100/245 cases; 40.8%), while 72 cases were in the maxilla (29.4%) and 73 cases in both jaw bones (29.8%). Our data collection identifies a wide variation in the presentation of hyperparathyroidism. In order to be more certain of oral maladies from hyperparathyroidism, studies with large patient populations need to be conducted at healthcare centers to clarify the oral outcomes of hyperparathyroidism. What was thought to be a characteristic finding of HPT, mandibular radiolucency occurred in only a minor portion of cases. Furthermore, the pathognomonic sign of HPT on radiograph, loss of lamina dura, was only the third most common presentation. Bone pathology was most commonly reported in literature, but should not be assumed the only oral sequelae of hyperparathyroidism.

Mechanically sensitive Aδ nociceptors that innervate bone marrow respond to changes in intra-osseous pressure.

Sensory neurons that innervate the bone marrow provide the CNS with information about pain associated with bone disease and pathology, but little is known of their function. Here we use a novel in vivo bone-nerve electrophysiological preparation to study how they respond to noxious mechanical stimulation delivered by increasing intra-osseous pressure. We provide evidence that sensory neurons that innervate the bone marrow respond to high threshold noxious mechanical stimulation, have response properties consistent with a role in nociception, provide information about different features of an intra-osseous pressure stimulus and express the Piezo2 mechano-transducer molecule. Our findings show how some bone marrow nociceptors signal pain in bony diseases and pathologies that involve a mechanical disturbance or increased intra-osseous pressure, and that the Piezo2 mechano-transducer may be involved. Whilst the sensory neurons and nerve terminals that innervate bone marrow have a morphology and molecular phenotype consistent with a role in nociception, little is known about their physiology or the mechanisms that generate and maintain bone pain. In the present study, we provide evidence that Aδ nociceptors that innervate the bone marrow respond to high threshold noxious mechanical stimulation, exhibit fatigue in response to prior stimulation and in some cases can be sensitized by capsaicin. They can be classified on the basis of their response properties as either phasic-tonic units that appear to code for different intensities of intra-osseous pressure, or phasic units that code for the rate of change in intra-osseous pressure. Three different subclasses of mechanically sensitive Aδ units were observed: phasic units that were sensitized by capsaicin, phasic units that were not sensitized by capsaicin and phasic-tonic units (that were not sensitized by capsaicin). These could also, in part, be distinguished by differences in their thresholds for activation, mean discharge frequency, latency to peak activation and peak-to-peak action potential amplitude. The majority of small-diameter myelinated sensory neurons projecting to the bone marrow expressed Piezo2. Our findings indicate that Aδ mechano-nociceptors are likely to play an important role in generating and maintaining pain in response to bony pathologies that involve a mechanical disturbance or increased intra-osseous pressure, and imply that Piezo2 signalling may be involved in mechano-transduction in these receptors.

Proximal Phalanx Osteoid Osteoma: A Case Report and Literature Review.

Summary:Osteoid osteoma is a rare clinical entity often mistaken for osteomyelitis, enchondroma, osteochondroma and other bony pathologies. Cardinal features include localized swelling and nocturnal pain often relieved by nonsteroidal antiinflammatory drugs. Definitive treatment requires surgical removal of the lesion by curettage or en bloc excision. The following case report details the diagnosis and management of a recurrent case of osteoid osteoma in a long finger proximal phalanx. Included with this case report is a literature review of osteoid osteomas on the hand and the anatomic distribution of 289 cases published in the last 30 years.

Imaging Findings at the Quadrangular Joint in Carpal Boss

A carpal boss was initially described as a bony, sometimes painful mass at the quadrangular joint. Clinical examination and plain radiography will usually reveal the diagnosis. US and CT may add information. MRI may illustrate a variable bony morphology and additional bony and soft tissue pathologies. Bone marrow edema shows a significant correlation with a painful carpal boss. Hence, MRI may be of additional diagnostic value in patients with persistent pain and preoperatively. This paper presents a review of the anatomy and pathology in carpal boss. The merit of each imaging modality – in particular MRI – is mentioned.

Reliability and Relationship Between HIP Osteoarthritis Synovitis-Effusion Measurements Using Different MRI Sequences

Purpose: Hip osteoarthritis (OA) is a complex disease and imaging can provide important insight into pathophysiology. For example, magnetic resonance imaging (MRI) can demonstrate bony and soft tissue pathology such as synovitis/effusion in a noninvasive test, with the unique ability to use various sequences to enhance or decrease signals from fat, fluid, and other tissues. However, there is currently little evidence as to which MRI sequences should be used to optimally image synovitis/effusion, and whether the use of contrast agent, which carries risks, is necessary at the hip. Though there are multiple areas to assess in hip OA pathophysiology, in this study we focused on scoring inflammation, particularly measurements of effusion-synovitis. The objective of this study was to compare effusion-synovitis measurements obtained using various MR sequences in terms of reader reliability and inter-sequence correlations Methods: With informed consent and institutional ethics approval, we recruited 97 patients with highly symptomatic hip OA just prior to their clinically requested fluoroscopically guided joint injection, and obtained sagittal hip MRI using Proton Density Fat Saturation (PD FS), T2 Fat Saturation (T2 FS), and post-gadolinium-enhanced VIBE sequences. PD FS was optimal for overall anatomic detail, while T2 FS emphasized fluid signal to directly visualize effusion, and VIBE was performed post gadolinium contrast injection to enhance hyperemic areas, such as in synovitis. To assess inflammation two readers AS and LS, both fellowship trained musculoskeletal radiologists with 8 and 6 years imaging experience respectively, separately measured i) effusion only, as the maximal depth of joint fluid including bright voxels only, on PDFS and T2FS sequences, and ii) synovitis/effusion, as distance from the bone surface to the outer edge of the joint capsule (i.e., effusion plus synovial thickness), on PDFS and post-gadolinium VIBE sequences. Note that the synovium is not well seen on T2FS and effusion is not readily directly visualized without synovium on VIBE. Measurements were performed at the point of widest effusion at the femoral neck (on any slice on which femoral neck marrow was visible). Results: Reliability: Measurements were highly reliable at the femoral neck on all sequences, with inter-observer intraclass correlation coefficients (ICC(3,1)) 0.843 (95% CI 0.798,0.879) for post-gadolinium VIBE synovitis/effusion, 0.873 (0.836,0.902) for PDFS effusion only, 0.846 (0.802,0.881) for PDFS synovitis/effusion, and 0.917 (0.892,0.937) for T2FS effusion only. Correlations: Measurements of effusion correlated highly to each other (PDFS vs. T2FS effusion only, r=0.883, p<0.0001), as did measurements of effusion-synovitis (PDFS vs. VIBE, r=0.762, p<0.0001). The correlation between effusion only and effusion-synovitis was very high on PDFS at r=0.930, p<0.0001). Conclusions: Hip joint effusion/synovial thickness can be measured with high reliability at the largest fluid pocket at the femoral neck. Measurements correlate highly between non-augmented and post-gadolinium sequences, and were more reliably performed on non-augmented PDFS scans than post-gadolinium VIBE. This may be due to higher in-plane resolution on PDFS scans. Future work includes correlation to clinical and imaging outcomes, and to ultrasound measurements of effusion. Overall, the data shows a promising degree of consistency among readers for several sagittal MRI sequences, highlights the importance of high resolution imaging in assessing hip OA with MRI, and raises doubt as to whether gadolinium adds value.

Soft tissue techniques in hallux valgus surgery

The hallux valgus represents combined bony and soft tissue pathology. In addition to known bony surgical procedures, addressing the soft tissue with regard to the anatomical structures, the surgical technique and the extent of correction are discussed.The goal of the operation is the restoration of the physiological balance between the active and passive stabilizing factors of the MTP-I-joint. The joint capsule, the ligaments and the tendons of the first ray act directly as stabilizing structures, whereas the hind foot and the position of the upper ankle have an indirect influence on the MTP-I-joint.The present work gives an overview of the pathoanatomy of the MTP-I-joint in the hallux valgus pathology. The individual anatomical structures are presented with regard to their physiological and pathological influence and the possible therapeutic options.

Clinical presentation and management of arterial thoracic outlet syndrome

ObjectiveArterial thoracic outlet syndrome (TOS) is a rare condition characterized by subclavian artery pathology associated with a bony abnormality. This study assessed contemporary clinical management of arterial TOS at a high-volume referral center. MethodsA prospectively maintained database was used to conduct a retrospective review of patients undergoing primary or reoperative treatment for arterial TOS during an 8-year period (2008 to 2016). Presenting characteristics, operative findings, and clinical and functional outcomes were evaluated. ResultsForty patients underwent surgical treatment for arterial TOS, representing 3% of 1401 patients undergoing operations for all forms of TOS during the same interval. Patients were a mean age of 40.3 ± 2.2 years (range, 13-68 years), and 72% were women. More than half presented with upper extremity ischemia/emboli (n = 21) or posterior stroke (n = 2), including eight that had required urgent brachial artery thromboembolectomy. The presentation in 17 (42%) was nonvascular, with 11 having symptoms of neurogenic TOS and six having an asymptomatic neck mass or incidentally discovered subclavian artery dilatation. All patients underwent thoracic outlet decompression (25 supraclavicular, 15 paraclavicular), of which there were 30 (75%) with a cervical rib (24 complete, 6 partial), 5 with a first rib abnormality, 4 with a clavicle fracture, and 1 (reoperation) with no remaining bone abnormality. Subclavian artery reconstruction was performed in 70% (26 bypass grafts, 1 patch, 1 suture repair), and 30% had mild subclavian artery dilatation (<100%) requiring no arterial reconstruction. Mean postoperative length of stay was 5.4 ± 0.6 days. During a mean follow-up of 4.5 ± 0.4 years (range, 0.9-8.1 years), subclavian artery patency was 92%, none had further dilatation or embolism, and chronic symptoms were present in six (4 postischemic/vasospasm, 2 neurogenic). Functional outcomes measured by scores on the 11-item version of the Disability of the Arm, Shoulder and Hand Outcome Measure improved from 39.1 ± 3.8 to 19.2 ± 2.7 (P < .0001). ConclusionsThis relatively large single-institution series demonstrates the diverse clinical presentation of arterial TOS coincident with a spectrum of bony and arterial pathology. Current surgical protocols can achieve excellent outcomes for this rare and often complicated condition.

Role of Cross Sectional Imaging in Isolated Chest Wall Tuberculosis.

Isolated chest wall tuberculosis though a rare entity, the incidence of it has been on rise among immunocompromised population making it an important challenging diagnosis for the physicians. Its clinical presentation may resemble pyogenic chest wall abscess or chest wall soft tissue tumour. Sometimes it is difficult to detect clinically or on plain radiograph. The present study was conducted with an aim to evaluate the common sites and varying appearances of isolated chest wall tuberculosis. A hospital based cross-sectional retrospective study was conducted in Assam Medical College and Hospital, a tertiary care centre in North East India. The study group comprise of 21 patients (n=15 male and n=6 females) with isolated chest wall tuberculosis without associated pulmonary or spinal involvement who were subjected to Computed Tomography/Magnetic Resonance Imaging (CT/MRI) of the thorax following initial Ultrasonogram (USG) evaluation of the local site. Pathological correlation was done from imaging guided sampling of the aspirate or surgery. Variable sites of involvement were seen in the chest wall in our patients (n=21), with chest wall abscess formation being the most common presentation and rib being the most common bony site affected in the thoracic cage. Bony sclerosis was noted in 11 patients (52.4%), periosteal reaction in 10 patients (47.6%) and sequestration in five patients (23.8%). CT/MRI not only localized the exact site and extent of the abscesses which facilitated guided aspirations, but also helped in detecting typical bony lesions thereby, differentiating from pyogenic osteomyelitis besides ruling out associated pulmonary or pleural involvement in such patients. Cross-sectional imaging plays an important role by giving a wholesome picture of both soft tissue and bony pathology. It is important to have adequate understanding of the radiologic manifestations of the chest wall involvement and complications of tuberculosis to facilitate diagnosis and in assessing response to treatment on follow up in patients.

CSM 2017 Orthopaedic Section Platform Presentations (Abstracts OPL1–OPL64)

CSM 2017 Orthopaedic Section Platform Presentations (Abstracts OPL1–OPL64)

Anatomic and functional imaging in the diagnosis of spine metastases and response assessment after spine radiosurgery.

Spine stereotactic radiosurgery (SSRS) has recently emerged as an increasingly effective treatment for spinal metastases. Studies performed over the past decade have examined the role of imaging in the diagnosis of metastases, as well as treatment response following SSRS. In this paper, the authors describe and review the utility of several imaging modalities in the diagnosis of spinal metastases and monitoring of their response to SSRS. Specifically, we review the role of CT, MRI, and positron emission tomography (PET) in their ability to differentiate between osteoblastic and osteolytic lesions, delineation of initial bony pathology, detection of treatment-related changes in bone density and vertebral compression fracture after SSRS, and tumor response to therapy. Validated consensus guidelines defining the imaging approach to SSRS are needed to standardize the diagnosis and treatment response assessment after SSRS. Future directions of spinal imaging, including advances in targeted tumor-specific molecular imaging markers demonstrate early promise for advancing the role of imaging in SSRS.