The whole leg radiograph: standing versus supine for determining axial alignment

The whole leg radiograph (WLR), the standard technique for determining axial alignment, is usually taken in a standing position, although some prefer the supine position. To determine the difference between these two positions, we performed a standing and a supine WLR in 20 patients with a varus alignment. We found an average of 2 degrees more varus deviation in the standing position than in the supine position.     

Large transverse fasciocutaneous leg flap: whole leg flap.

Large defects of leg and sole often need massive tissue transfer. As an alternative to microvascular transfer, we have developed a fasciocutaneous flap in which almost the whole of the skin of the opposite leg is transferred based just on the septocutaneous perforators of the posterior tibial artery. The flap has been used as a cross-leg fasciocutaneous flap with potential for use as a free flap by taking a segment of the posterior tibial artery. Our experience with 11 cases is presented. Two patients suffered marginal necrosis while donor site problems were seen in another two patients. We have found this flap to be safe, technically easy and with minimal donor-site morbidity.     

The whole leg radiographStanding versus supine for determining axial alignment

The whole leg radiograph (WLR), the standard technique for determining axial alignment, is usually taken in a standing position, although some prefer the supine position. To determine the difference between these two positions, we performed a standing and a supine WLR in 20 patients with a varus alignment. We found an average of 2 degrees more varus deviation in the standing position than in the supine position.     

脊柱全长X线片对非矩形化腰椎骶化的诊断价值

目的:探讨脊柱全长X线片对非矩形化腰椎骶化的诊断价值。方法:2008年8月～2009年7月共153例腰腿痛并颈部或胸背部不适的患者接受脊柱全长X线片检查,男84例,女69例,年龄14～82岁,平均47.9±13.7岁。观察其脊柱全长X线片,明确是否有腰椎X线平片难辨出的腰椎骶化。结果:共发现7例腰椎X线平片难辨出的非矩形化完全型腰椎骶化,男5例,女2例,年龄21～60岁,平均39.7±13.7岁。所有骶化的椎体均为正常S1椎体矩形化表现,下方椎间隙为正常S1/2椎间融合表现。合并颈肋2例,第12肋骨缺如4例。结论:脊柱全长X线片能确诊单纯腰椎X线平片难以明确的非矩形化腰椎骶化。     

Computed tomography scanogram compared to long leg radiograph for determining axial knee alignment

Background and purpose

Supine computed tomography scanogram (CTS) is a commonly used alternative to weight bearing long leg plain radiograph (LLR) in measuring knee alignment. No published studies have validated its use in the native knee and the post-unicompartmental replacement knee (UKR). We quantified the difference in measurements obtained from CTS and LLR for knee alignment.

Patients and methods

Supine CT scanograms and weight bearing long leg plain anteroposterior radiographs were obtained for 40 knees (in 25 patients), 17 of which were native, and 23 of which were post-UKR. The mechanical and anatomical axes of the tibio-femoral joint were measured. Bland-Altman plots were used to calculate the 1.96 standard deviation limits of agreement between CTS and LLR. Intraclass correlation was used to assess intra-rater and inter-rater reliability (where values > 0.81 indicate very good reliability).

Results

CTS and LLR were equally reliable in measurement of the mechanical and anatomical axes of the tibio-femoral joint (intraclass correlation coefficient (ICC) > 0.9 for all parameters). Statistically significant and clinically relevant differences were found between CTS and LLR in measurement of the mechanical axis (limits of agreement: UKR −3.2° to 6.3°; native −3.2° to 5.6°) and the anatomical axis (limits of agreement: UKR −3.7° to 8.7°; native −2.0° to 8.8°).

Interpretation

Although it is a reliable tool, CTS is not necessarily an accurate one for measurement of knee alignment when compared to LLR. We recommend that CTS should not be used as a substitute for LLR in measurement of the mechanical or anatomical axes of the knee.Measurement of knee alignment is useful in planning of operative intervention including high tibial osteotomy (HTO), uncompartmental knee replacement (UKR), and total knee replacement (TKR), and in the assessment of postoperative outcomes (Hernigou and Deschamps 2004, Hardeman et al. 2012, Kyung et al. 2013, Pietsch et al. 2013, Chen et al. 2014). The degree of accuracy required is thought to be ± 5° for native knees (Sharma et al. 2011), ± 3° after TKR (Bathis et al. 2004), and ± 2.5° after UKR (Gulati et al. 2009, Weale et al. 2000).The weight bearing long leg anteroposterior radiograph (LLR) shows loss of cartilage space and ligament laxity, and is therefore thought to be the best method for the measurement of coronal alignment of the knee (Babazadeh et al. 2013). However, some feel that the supine LLR is more suitable for planning in HTO (Ogata et al. 1991, Brouwer et al. 2003).Several recent papers have used the 2-D supine CT scanogram/scout film (CTS) to assess knee alignment (Moon et al. 2012, Kyung et al. 2013, Bugbee et al. 2013). Clinicians are also using this modality in clinical practice. CTS is severely limited by being a non-weight bearing modality in addition to having the same limitations as LLR (i.e. influence of rotational malalignment and flexion deformity). Brouwer et al. (2003) compared standing and supine LLR, but patients were excluded if they were unable to stand on one leg, if they had had previous surgery, or if they had a clinical malalignment. Gbejuade et al. (2014) compared CTS and LLR after TKR; however, weight bearing may not be as important a factor in measurement of alignment after TKR.The present study is the first to determine the differences in knee alignment measurement between CTS and LLR in native knees and after UKR.     

Effect of whole body vibration on intracompartmental pressure in the lower leg

Background

Whole body vibration has important effects on neuromuscular functions. It seems to be a promising tool in the conservative treatment and rehabilitation of compartment syndrome. In the present study we investigated the effect of whole body vibration on intracompartmental pressure in the lower leg during a strenuous static exercise program.

Methods

We conducted a cross-over pilot study in which fifteen healthy male subjects participated. They twice performed a 20.5-min static exercise program on the Fitvibe Medical whole body vibration device, once with 27 Hz vibrations and once without. The intracompartmental pressure was measured by two examiners at the superficial posterior compartment of the left and right lower leg, at rest and during the exercise programs.

Results

A general linear model for repeated measures showed a significant difference between the exercise program with vibrations and that without (P = 0.001) and a significant difference in intracompartmental pressure for the factor time of measurement (P < 0.001). Mean intracompartmental pressure was at any point in time lower in the vibrating than in the non-vibrating exercise conditions, though not always significant. In the program with vibrations the exercise pressures showed a non-significant trend to decrease (from 23.5 mmHg to 21.3 mmHg) as the program advanced, while in the non-vibration program, there was a trend to increase (from 24.1 to 27.9 mmHg).

Conclusions

The mean intracompartmental pressure was lower when whole body vibration at 27 Hz was superimposed. Therefore, whole body vibration seems to be a possible tool to lower intracompartmental pressure. Further research is needed to confirm whether these findings are also applicable in patients, athletes, and in dynamic exercises.     

The plain abdominal radiograph in acute appendicitis.

Although the radiological features of acute appendicitis have been well documented, the value of the plain abdominal radiograph has not been fully appreciated. This article summarises the role of radiology in acute appendicitis, especially in atypical cases and extremes of age, where there is often delay in diagnosis.     

Interpreting the chest radiograph

Presented is an approach to a chest radiograph, paying particular attention to features commonly seen in the intensive care unit (ICU) with regards to iatrogenic lines and tubes, together with common pathologies that may be encountered. This is accompanied by helpful images to use as an aide memoire when reviewing ICU chest x-rays. Pitfalls in interpreting these often complex x-rays are also discussed.     

Interpreting the chest radiograph

This article provides information about interpreting chest radiographs, with particular attention to the needs of anaesthetists. A routine for looking at each film is suggested, with comments on the assessment of the quality of the film, including rotation and penetration. Mention is made of each anatomical area (bones, soft tissues, mediastinum, lung fields) and the pathological changes seen in each is discussed. The differences between the findings in alveolar and interstitial pathology are emphasized. The lateral film is discussed and special attention is paid to the particular difficulties presented by chest radiographs taken in the ITU. There are discussions on the appearances related to vascular lines and the use of CT in the ITU.     

Interpreting the chest radiograph

Presented is an approach to a chest radiograph, paying particular attention to features commonly seen in the intensive care unit (ICU) with regards to iatrogenic lines and tubes, together with common pathologies that may be encountered. This is accompanied by helpful images to use as an aide memoire when reviewing ICU chest X-rays. Pitfalls in interpreting these often complex X-rays are also discussed.     

Interpreting the chest radiograph

A methodical system for looking at every chest radiograph is suggested. Readers are encouraged to decide whether an opacity on a chest radiograph is due to pleural, alveolar or interstitial pathology and then to consider the cause. Lung and pleural masses are considered and contrasted and the features of asbestos exposure listed. Special consideration is given to the problems of interpretation of the chest radiograph in the intensive care unit, and the various appearances of lines and tubes are outlined.     

The forty-five-degree posteroanterior flexion weight-bearing radiograph of the knee

Posteroanterior weight-bearing radiographs, made with the knee in 45 degrees of flexion, were compared with conventional radiographs for fifty-five patients who had surgical treatment for a lesion causing pain in one knee. Narrowing of the cartilage space of two millimeters or more was defined as indicative of major degeneration (grade III or IV). Comparison of the intraoperatively observed degeneration with the narrowing that was seen on the radiographs revealed that the posteroanterior weight-bearing radiographs that were made with the knee in 45 degrees of flexion were more accurate (p less than 0.01), more specific (no false-positives) (p less than 0.01), and more sensitive (fewer false-negatives) than the conventional extension weight-bearing anteroposterior radiographs.