High tibial osteotomy: evolution of research and clinical applications—a Canadian experience

Purpose

This narrative review describes experiences at the Fowler Kennedy Sport Medicine Clinic (FKSMC) with high tibial osteotomy (HTO) for patients with varus gonarthrosis, with particular focus on research published from the unit that has guided practice.

Methods

The goals of surgery are to improve alignment of the weight bearing axis of the lower limb to lessen the load on the medial tibiofemoral compartment and thereby decrease these important risk factors for disease progression. The overall aims are to improve knee function and delay or even prevent the eventual need for arthroplasty. To achieve these aims, a medial opening wedge osteotomy is utilised, deliberately avoiding an over correction of the lower limb, but tailoring the angle of correction to an individual patient’s characteristics. With such an approach, patients with a broad range of characteristics (including age, BMI and lateral compartment involvement) can benefit from the procedure. In addition, the HTO can be used with concomitant procedures to address specific presentations, such as large deformities and instability.

Results

The results suggest that correction to a slight valgus alignment produces approximately 50 % reduction in medial compartment loads during gait with large, clinically important improvements in patient-reported outcomes at 2-years postoperatively. In patients with substantial bilateral varus deformity, unilateral surgery can lead to increased dynamic knee joint loads on the nonoperative limb after surgery. This means that such patients require the close monitoring of both limbs and consideration of a staged, bilateral procedure if necessary. In patients requiring bilateral surgery, similar results after bilateral HTO to those after unilateral surgery have been reported. For patients requiring large corrections, the need for a concomitant tibial tubercle osteotomy to reduce the potential for iatrogenic patella infera is considered. Finally, HTO procedures can also be used in patients with instability, either to alter both sagittal and coronal alignment to correct instability in complex ligament deficiencies or to undertake simultaneous HTO and ACL reconstruction.

Conclusions

HTO is being used both alone and in conjunction with concomitant procedures with good clinical results. While continued investigation into patient selection and outcomes are required, current research indicates that HTO offers at least a partial solution for the patient with varus gonarthrosis to prolong the life of their native knee joint.

Level of evidence

V.     

Measuring tongue volumes and visualizing the chewing and swallowing process using real-time TrueFISP imaging—initial clinical experience in healthy volunteers and patients with acromegaly

This study assessed both two-dimensional (2D) TrueFISP imaging for quantifying tongue volume and real-time TrueFISP imaging for evaluating chewing and swallowing in healthy volunteers and patients with acromegaly. In 50 healthy volunteers, tongue volumes were measured using a 2D TrueFISP sequence. Chewing and swallowing were visualized using a real-time TrueFISP sequence. Ten patients with acromegaly were examined twice with the same magnetic resonance imaging protocol: once prior to therapy and a second time 6 months after therapy. Prior to therapy, healthy volunteers had an average tongue volume of 140 ml for men and 90 ml for women, and patients with acromegaly had an average tongue volume of 180 ml for men and 145 ml for women. However, 6 months after therapy the mean tongue volumes in patients with acromegaly had decreased to 154 ml in the men and to 125 ml in the women. The chewing and swallowing process was normal in all volunteers. Prior to therapy, just two patients showed a chewing and swallowing pathology, which disappeared after therapy. Patients with acromegaly had larger tongue volumes than healthy volunteers, and TrueFISP imaging proved feasible for visualizing chewing and swallowing in real time and is capable of detecting possible pathologies. Furthermore, TrueFISP imaging can be used to monitor therapeutic approaches in patients with acromegaly.     

Closing the gap between coil and balloon in the neurointerventional armamentarium? Initial clinical experience with a nitinol vascular occlusion plug

INTRODUCTION: The use of vascular plug devices for the occlusion of high-flow lesions is a relatively new and successful procedure in peripheral and cardiopulmonary interventions. We report on the use and efficiency of the Amplatzer vascular plug in a small clinical series and discuss its potential for occlusion of large vessels and high-flow lesions in neurointerventions. METHODS: Between 2005 and 2007 four patients (mean age 38.5 years, range 16-62 years) were treated with the device, in three patients to achieve parent artery occlusion of the internal carotid artery, in one patient to occlude a high-flow arteriovenous fistula of the neck. The application, time to occlusion, and angiographic and clinical results and the follow-up were evaluated. RESULTS: Navigation, positioning and detachment of the device were satisfactory in all cases. No flow-related migration of the plug was seen. The cessation of flow was delayed by a mean of 10.5 min after deployment of the first device. In the procedures involving vessel sacrifice, two devices had to be deployed to achieve total occlusion. No patient experienced new neurological deficits; the 3-month follow-up revealed stable results. CONCLUSION: The Amplatzer vascular plug can be adapted for the treatment of high-flow lesions and parent artery occlusions in the head and neck. In this small series the use of the devices was uncomplicated and safe. The rigid and large delivery device and the delayed cessation of flow currently limit the device's use in neurointerventions.     

MDCT imaging of Alloderm biologic mesh spacers in the abdomen and pelvis — preliminary experience

The purpose of this study was to assess the attenuation characteristics of the Alloderm Biologic Mesh Spacer (ABMS) in the abdomen and pelvis. Of nine patients with ABMS, five underwent multidetector computed tomographic scans at 1, 4, and 7 months postsurgery. Two patients underwent positron emission tomography–computed tomography (PET–CT). The pre- and postcontrast images were evaluated for attenuation characteristics of ABMS. The PET–CT scans were reviewed for [18F]-fluorodeoxyglucose (FDG) uptake. We observed increase in the attenuation characteristics of the spacers on follow-up imaging (P< .05). No FDG uptake was noted on PET–CT. To conclude, ABMS demonstrates soft tissue attenuation on noncontrast CT and shows increase attenuation on serial CT scans.     

Cancer Concepts and Principles: Primer for the Interventional Oncologist—Part II

This is the second of a two-part overview of the fundamentals of oncology for interventional radiologists. The first part focused on clinical trials, basic statistics, assessment of response, and overall concepts in oncology. This second part aims to review the methods of tumor characterization; principles of the oncology specialties, including medical, surgical, radiation, and interventional oncology; and current treatment paradigms for the most common cancers encountered in interventional oncology, along with the levels of evidence that guide these treatments.     

Periportal oedema of the liver—Correlation with clinical and paraclinical parameters in polytraumatic patients

PurposeTo clarify the occurrence of periportal edema in polytraumatic patients.Materials and MethodsRetrospective analysis of computed tomography (CT) scans from 74 polytraumatic patients (12 females, 62 males; 14–88 years old, median 32 years) performed shortly after the trauma. Periportal oedema was found in 22 patients. The existence and extent of the periportal oedema were studied with regard to the injury type, sex, weight and age, heart frequency, arterial blood pressure, as well as the lactate, pH value, and base excess (BE) directly after the admission of the patient to the intensive care unit.ResultsThere is a relevant statistical correlation between the existence of periportal oedema and the abdominal trauma (P<.0001), independent of the type of abdominal injury. No relevant correlation between periportal oedema and existence of liver rupture, liver haematoma, other abdominal organ injury, abdominal vessel injury, fracture in the skeletal system, or intracerebral bleeding was found. Periportal oedema occurs more commonly in females than in males, more in light weight patients than in the others, and more frequent in young patients than in older ones. There is no correlation with arterial blood pressure, heart rate, pH value, lactate, and BE.ConclusionThe existence of periportal oedema is one sign of abdominal trauma and is independent of liver injury. Although it correlates with the sex, weight, and age of the patient, there is no correlation with arterial blood pressure, heart rate, pH value, lactate, and BE.     

Disorders of glucose metabolism: post mortem analyses in forensic cases–part II

In continuation to part I, a literature review is presented concerning biochemical problems of forensic post mortem cases of unclear hyperglycaemia or hypoglycaemia. Clinical parameters for this purpose were recently reviewed. Particular attention was paid to the detection of diabetic ketoacidosis, of hyperosmolar coma, insulinoma, insulin-induced or oral diabetic-induced hypoglycaemia. The second part of the review discusses the analytes ketone bodies, synthetic insulins, human insulin, C-peptide, proinsulin and insulin antibodies. Special interest is given to post mortem matrices for those analytes to reference concentrations, stability data, analytic interferences and analytical procedures which should be used in toxicological laboratories willing to detect diabetic metabolism disorders after death.     

Ct method for visualization of the appendix using a fixed oral dosage of diatrizoate—clinical experience in 525 cases

Purpose: The purpose of this study is to determine if focused CT examinations of the pelvis, utilizing fixed oral dosage of diatrizoate contrast media, improve overall reader confidence in visualization of the appendix. Materials and methods: Five hundred and twenty-five patients referred for, rule out appendicitis, evaluations underwent focused CT examinations of the pelvis following fixed oral dosage of diatrizoate contrast media. A five-point scale was used to assess the effect of contrast enhancement of the distal small bowel, cecum, and appendix on overall reader confidence, and subsequent visualization of the appendix. Results: Bowel preparation was ideal in 504 of 525 (96%) patients. Enhanced supine CT images following oral administration of fixed dosage of diatrizoate had consistently good scores for reader confidence for bowel opacification (4.8±0.1, P<0.005) and visualization of the appendix (3.7±0.1, P<0.005), at 50 min following oral contrast administration. This method improved visualization of the normal appendix in 446 of 504 (88%) patients, with a specificity of 99%. In a patients meeting CT criteria for appendicitis, 21 of 21 (100%) patients were proven at surgery. Conclusion: The use of fixed oral dosage of diatrizoate contrast media resulted in good overall reader confidence to visualize the appendix and peri-appendiceal area, in addition to high specificity and rapid transit time.     

“Black bone” MRI: a potential alternative to CT when imaging the head and neck: report of eight clinical cases and review of the Oxford experience

Objective

The potential risks associated with ionising radiation are well documented. We have previously reported the “black bone” MRI sequence, useful when imaging cortical bone. The objective of this paper is to report our initial experience of this technique in patients undergoing imaging of the head and neck region.

Methods

Using the departmental database those patients having had “black bone” sequences of the head and neck performed as part of their MRI examination in the preceding 5 years were identified. The radiological reports were reviewed to identify those cases where “black bone” or conventional MRI sequences had been performed in place of the requested CT, and the patient medical records for these cases were reviewed. Medical record review was also conducted for those cases where it was considered that the pathological condition requiring imaging would ordinarily be investigated with CT.

Results

The “black bone” sequence had been performed in 69 patients as part of routine MRI of the head and neck. Of these, 67% (n=46) were performed in combination with CT imaging, the majority of cases being primary tumours. In four cases, an MRI was performed in place of the requested CT scan. We present eight clinical cases illustrating the potential benefits of the “black bone” sequence.

Conclusions

“Black bone” MRI offers a radiation-free method of imaging the head and neck, and has been successfully utilised in a range of benign and malignant conditions affecting this region.

Advances in knowledge

Adoption of this approach, where feasible, would be a significant advance in radiation protection.Hounsfield, in his 1973 paper on CT, stated that “the exposure of the patient to x-rays must be restricted” [1]. The potential risks of ionising radiation are well documented; however, we continue to fall short of Hounsfield’s advice because of increased imaging demands through a combination of defensive medicine, a decrease in exploratory surgery and the ability to meet the increased requests for CT. The largest increases in CT use have been in paediatric diagnosis and adult screening [2]. Further concern relates to the use of cone-beam CT, with scanners being installed and used in a rapidly increasing number of dental practices within the UK [3]. During the year 2002–3 the National Health Service in England [4] reported 1.7 million CT examinations, representing 8% of all X-ray examinations, and 6% of all imaging investigations. By 2009–10 this had risen to over 3.7 million: 13% and 10%, respectively. The United Nations Scientific Committee estimated that CT constitutes 5% of all X-ray examinations worldwide while accounting for about 34% of the resultant collective dose [5].The consensus among radiology professionals is that steps should be taken to reverse, or at least arrest, radiation exposure from CT [6]; yet for maxillo-cranio-facial imaging this has largely consisted of radiation reduction techniques and the introduction of cone-beam CT. The superior quality of bony imaging on CT and the ability to create three-dimensional (3D) rendered images of the craniofacial skeleton has maintained CT as the gold standard for this region.However, we have been increasingly utilising MRI when imaging the head and neck, following close collaboration between the MRI and oral and maxillofacial departments. In particular, we have previously reported the “black bone” MRI sequence for imaging cortical bone as a potential replacement for CT [7]. The technique utilises a low flip angle, with short repetition and echo times, to produce uniform contrast of the soft tissues, with densely black cortical bone. The imaging parameters are shown in

ALA—Photodynamic treatment in Lichen sclerosus—clinical and immunological outcome focusing on the assesment of antinuclear antibodies

BackgroundLichen sclerosus (LS) is a difficult to treat, often relapsing disease with unknown background. Autoimmune diseases also coexist with LS. Over recent years photodynamic therapy (PDT) has been shown to be a noninvasive and successful therapeutic approach for the effective treatment of many conditions. However, the change of immune status of the patients based on ANA antibodies has not been yet reported. Our aim was to observe the clinical response followed by possible changes in autoimmune antibodies levels before and after PDT for LS.Material and MethodsWe enrolled 100 women with Lichen sclerosus with or without a concomitant autoimmune disease. All patients received 10 cycles of PDT (65 treated with DIOMED Light, 35 with PhotoDYN Light). We assessed autoimmune antibodies before and after PDT in addition to the clinical response evaluation.Two-year prospective controlled before-and-after study.ResultsFollowing PDT, patients showed a significant attenuation in symptoms’ intensity (itching, pruritus, vulvar discomfort). After therapy 41% of patients had partial response, 51% of patients had no symptoms and 8% had persistent or worsened symptoms. The most frequent autoimmune disease were thyroid disorders, followed by vitiligo and arthritis. 57% patients with an additional autoimmune disease before PDT had ANA antibodies. The mean level of ANA in this group diminished significantly after PDT treatment (261.74 IU/ml before vs. 123.20 IU/ml after treatment).ConclusionBased on our results, we assume that PDT may influence the immune status of patients with Lichen sclerosus.     

Quantifying the potential of morphological parameters for human dental identification: part 3—selecting the strongest skeletal identifiers in the mandible

International Journal of Legal Medicine - The current study aimed to select the best mandibular morphological identifiers. One-hundred eighty-five panoramic radiographs were retrospectively...     

Gorham–Stout disease: the experience of the Rizzoli Institute and review of the literature

Gorham–Stout disease (also known as “disappearing bone disease”) was first described by Jackson in 1838, but was properly defined by Gorham and Stout in a series of 24 patients in 1954–1955. It is a rare disease of unknown etiology (about 200 cases reported in the literature) characterized by spontaneous progressive resorption of bone without malignant proliferation of vascular structures. The diagnosis is one of exclusion and it is based on combined histological, radiological, and clinical features. Benign vascular proliferation with fatty bone marrow and thinning of bony trabeculae is a typical histological feature. Standard radiographs of disappearing bone disease show progressive bony resorption with adjacent soft tissue involvement. Most cases of Gorham–Stout disease resolve spontaneously, but prognosis remains unpredictable. This study reports 13 cases of Gorham–Stout disease treated in our institution from 1968 to 2008. The aim of the work was to review our series and the literature on this rare disease, as well as to evaluate whether or not an optimal treatment can be identified and recommended.     

Accessory salivary tissue in the mylohyoid boutonnière: a clinical and radiologic pseudolesion of the oral cavity

BACKGROUND AND PURPOSE: Though classically depicted as a continuous muscular barrier between the sublingual and submandibular spaces, the mylohyoid muscle is often discontinuous. These areas of discontinuity may contain fat, blood vessels, salivary tissue, or combinations thereof that may be mistaken both clinically and radiologically for pathologic abnormalities. We sought to demonstrate the prevalence and radiologic appearance of dehiscence of the mylohyoid muscle. METHODS: One hundred axial, contrast-enhanced CT studies of the neck, obtained over a 10-month period, were retrospectively reviewed. Inclusion criteria included 3-mm-thick slices and absence of pathologic abnormalities or surgical changes in the oral cavity. Scans were assessed for the presence and contents of mylohyoid defects such as accessory salivary tissue, defined as nonlymphoid tissue within defects in the mylohyoid, having attenuation and enhancement characteristics similar to those of orthotopic sublingual and submandibular salivary tissue. RESULTS: Mylohyoid defects were identified in 77 of 100 individuals. The deficiencies were bilateral in 67% and unilateral in 33%. Accessory salivary tissue was identified in 37 of 100. Fat and blood vessels were commonly identified within the mylohyoid defects. Sixty-one percent of the defects contained only fat. Thirty-five percent of the defects contained blood vessels. CONCLUSION: Deficiencies in the mylohyoid muscle were visible in 77% of individuals who underwent scanning. The defects may contain fat, blood vessels, salivary tissue, or all three characteristics. Accessory salivary tissue was identified in 37% of individuals who underwent scanning. Recognition of mylohyoid deficiencies and the typical appearance of accessory salivary tissue will allow accurate diagnosis of this benign, anatomic variant.