Surgical management of non-ischemic diabetic heel ulcers and the role of magnetic resonance imaging [MRI] in these cases

Amputations distal to the heel are minor foot amputations while proximal amputations to the heel are major. Heel ulcers may be superficial but may send infection deep to bone [calcaneus] and/or-Achilles tendon .In the start of the treatment the anticipated outcome is not well known. The Aim of the work is to report our results of management of chronic non-ischemic diabetic heel ulcers including: surgical management in the form of debridement, partial calcnectomy and partial excision of Achilles tendon plus off-loading, edema management and wound management. Role of medical management of diabetes mellitus [DM] and comorbid conditions and to report the role of MRI in diagnosis and management these cases. This retrospective study involved Sixty patients [33 female, and 27 male], mean age 55.87 [range 26-78 years, mode 60 years] with 66 heel ulcers in the 4 year period from January 2002 to January 2006. Diagnosis of neuropathy and vascular state were done. Photographic documentation of the ulcers, Plain-x-ray and MRI were used to diagnose osteomyelitis. In twelve cases partial calcanectomy and in 5 Achilles tendon was partially excised. Regular debridement, wound care and control, management of infection, hyperglycemia, comorbid conditions was performed in all patients plus post-operative off-loading, patient and relatives education. Follow up of the patients. End points of the study were ambulation and independency of the patient, healing of the ulcers, proximal amputation, or death of the patient. All of the Ulcers were >2 cm[2] surface area with duration > 8 weeks. Most of them were in the right side in the planter aspect. MRI showed osteomyelitis in 12 cases of the calcaneus and they were managed by partial calcanectomy. Foot stability and patient independence was achieved after partial excision of Achilles tendon. Complete healing of the ulcers after one year of management was in 68% of the ulcers. Blow knee amputations were done in 5 cases and above knee in two. Seven patients died within 4 year period due to metabolic, cardiac and cerebral causes. Multidisciplinary approach including vascular surgery, radiological imaging and internal medicine is crucial to successful treatment through integration of knowledge and experience. Debridement of chronic or infected tissues even if Achilles tendon or calcanei are involved is essential for ulcer healing. MRI has a role in accurate detection of precise area of osteomyelitis allowing proper debridement and partial calcanectomy with little morbidity and major impact on patient and limb outcome

Knee trauma: MR imaging

To assess the role of MRI in evaluation of patients suffering from trauma. The study was conducted on 30 patients who had history of knee trauma and subjected to MRI examination. MRI showed bone contusion or fracture in 27 patients, the commonest site was found in lateral femoral condyle followed by medial femoral condyle and intercondylar eminence of tibia. All patients showed soft tissue injuries, the commonest injury was knee effusion followed by tear of anterior cruciate ligament and medial meniscus. MRI is the imaging modality of choice to assess knee trauma. It showed bony, cartilaginous, ligamentous and soft tissue injuries. It could characterize the nature of post traumatic knee collections

Management of adult tethered cord syndrome

This study was done to evaluate the surgical outcome of untethering of the cord in a consecutivec 10 adult patients suffering from tethered cord syndrome. This prospective study was carried out on consecutive 10 adult patients suffering from manifestations due to tethering of the cord. The patients were admitted to the Alexandria main university hospital over a period of 3 years starting from March 2002 to March 2005. The male to female ratio was 7 to 3 and their ages ranged from 25 till 57 years with mean age of 38.5. Most patients [9 patients] suffered from low back pain, while 7 patients showed signs of root affection and radiculopathy, sphincteric disturbances were present in all patients. Interestingly one patient had bilateral neuropathic ulcers at the site of the heel. All our patients developed signs and symptoms of tethered cord syndrome in adulthood. All patients were subjected to preoperative MRI of the lumbosacral spine, urodynamic study, and preoperative electrophysiological study of the lumbo-sacral plexuses. Intraoperative electrophysiological monitoring maneuvers using a bipolar stimulating electrode were used to identify functional neural tissue from the filum terminale and the response of lower limb muscles, and external anal sphincter were recorded either manually or by electromyography. Untethering of the cord using surgical microscope was done under general anesthesia without muscle relaxation. Dural graft was used in one case with secondary adhesions. Mean postoperative follow-up period was 15 months, including both clinical and MRI examination. The lower level of the conus was at lumbar vertebra L2 in one case, at L4 in 6 cases and at level from L5 to sacrum in 3 cases. The tethering lesions were tight filum terminale in 7 patients, lipoma in 2 patients, and secondary adhesions in one patient. Thickness of the filum was ranged from 1 to 7mm with a mean of 3.7mm. There was no operative mortality, and surgery did not provoke any permanent neurological aggravation of our cases. After surgery 2 patients [20%] were asymptomatic, 5 patients [50%] improved, and 3 patients [30%] stabilized, also all the patients were independent. The surgical outcome after tethered cord release in the adults is favorable, as most patients report improvement or stabilization of their symptoms. Safe surgical treatment with minimal complications and side effects can be achieved with the aid of intraoperative neurophysiological monitoring techniques. The success of surgery depends on early diagnosis and complete untethering of the spinal cord. It seems reasonable to recommend early surgical treatment in both symptomatic and asymptomatic adults

Value of MRI in grading of supratentorial diffuse astrocytomas

The present study included 15 patients [8 males and 7 females] with their age ranged from 25 years to 68 years. The MR images in the studied patients with biopsy-proven diffuse ostrocytomas were analyzed in order to demonstrate which MRI features of gliomas that correlate with the histopathologically determined tumor grade. According to the histopathological diagnosis, 3 patients had grade II astrocytomas, 5 patients had grade III astrocytomas and 7 patients had glioblastoma multiformes [GBMs]. The MRI features studied included tumor heterogeneity, edema, mass effect, border sharpness, contrast enhancement, hemorrhage and the presence of flow voids. Contrast enhancement was found to be the best predictor of histological grade followed by necrosis, signal heterogeneity and border sharpness. Hemorrhage, flow void and necrosis were common in the GBM group and were absent in grade II astrocytoma group. In particular, flow void was found only in GBM [n=3 patients], hemorrhage was present in GBM [n= 3 patients] and in grade III astrocytoma [one patient]. Necrosis was found in all 7 GBM cases and in 5 patients with histological diagnosis of anaplastic astrocytoma [grade III astrocytoma]. No areas of necrosis detected in grade II astrocytoma [3 patients]. All GBM cases [n = 7] showed grade 3 edema [larger than the tumor volume], marked and heterogeneous enhancement, midline shift and heterogeneous signal intensity on both Tl-W and T2-W images. In grade III astrocytomas [n = 5 patients], there is edema of grade 2 [less than the tumor volume], moderate contrast enhancement, midline shift and heterogeneous signal intensity on T2-W images. In grade II astrocytomas [n = 3 patients], there is edema of grade 1 [none-to mild], subarachnoid space effacement, none- to mild contrast enhancement and homogeneous signal intensity. The frontal lobe was the most commonly affected lobe, frontal gliomas were present in 9 patients, fronto-parietal gliomas in 4 patients and fronto-temporal gliomas in 2 patients. In conclusion, all MRI features can help to distinguish the pathological grade of diffuse astrocytic tumours and help in planning treatment strategies