Anatomical landmarks for locations and boundary of distal tarsal tunnel at medial side of ankle with clinical implication / Puntos de referencia anatómicos para ubicaciones y límites del túnel tarsiano distal en el lado medial del tobillo con implicación clínica

SUMMARY: The tarsal tunnel (TT) is an osteofibrous tunnel that separates into proximal and distal tarsal tunnels. The most common nerve entrapment which involved tarsal tunnel was tarsal tunnel syndrome (TTS) which divided into proximal TTS and distal TTS because they had different compression areas and symptoms. We were interested in distal TT because this structure had limited studies. Therefore, we studied anatomical landmarks of locations and boundary of distal TT. We studied forty legs from fresh frozen cadavers and used two reference lines: Malleolar-calcaneal (MC) and navicular-calcaneal (NC) axes. The locations of the distal tarsal tunnel were defined by 10 located points and were recorded in X-coordinate and Y-coordinate. The lengths of boundary of the tarsal tunnel were measured from one point to the other. These results were reported as mean±SD. We found that the distal TT located deep to abductor hallucis (AbH) muscle. Medial wall of distal TT had two layers such as deep fascia of AbH muscle and deep thin layer. It showed the trapezoidal shape and was divided into two tunnels by the septum. The information of the location and boundary of the distal TT could improve knowledge and understanding of clinicians and anatomists. Additionally, this information could help surgeons improve their treatments, especially tarsal tunnel release.

RESUMEN: El túnel tarsiano (TT) es un túnel osteofibroso que se divide en túneles tarsianos proximal y distal. El atrapamiento nervioso más común del túnel tarsiano es el síndrome del túnel tarsiano (TTS), el cual se divide en TTS proximal y TTS distal debido a diferentes áreas de compresión. En este trabajo se estudiaron los puntos de referencia anatómicos de las ubicaciones y los límites del TT distal. Estudiamos cuarenta piezas de cadáveres frescos congelados y utilizamos dos líneas de referencia: ejes maleolar-calcáneo (MC) y navicular-calcáneo (NC). Las ubicaciones del túnel tarsiano distal se definieron en 10 puntos y se registraron en coordenadas X e Y. Las longitudes de los límites del túnel tarsiano se midieron desde un punto a otro. Estos resultados se informaron como media ±DE. Encontramos que el TT distal se ubicaba profundo al músculo abductor del hállux (AbH). La pared medial del TT distal tenía dos capas, la fascia profunda del músculo AbH y una capa delgada profunda. Se observó la forma trapezoidal del túnel la que se encontraba dividida por el tabique en dos túneles. La información de la ubicación y el límite del TT distal podría mejorar el conocimiento de los médicos y anatomistas. Además, esta información podría ayudar a los cirujanos durante los tratamientos, especialmente la liberación del túnel tarsiano.

The attachment sites and attachment areas of deltoid ligament related to clinical implications: a cadaveric study / Los sitios y las áreas de inserción del ligamento deltoideo relacionadas con las implicaciones clínicas: un estudio cadavérico

Currently, the treatment for patients with deltoid ligament injuries who require surgical treatment are anatomical repair and reconstruction. The clinicians should understand the exact knowledge of attachment areas of individual bands of deltoid ligament for a successful treatment. We studied 46 ankles of fresh frozen cadavers. The individual bands of deltoid ligament were divided to small fibers. Afterwards, each small fiber of each band was cut and marked with acrylic color on the origin and insertion followed by photo taking. Lastly, the photos of individual origin and insertion were used to calculate the attachment areas. We found six bands of deltoid ligament in all ankles except tibionavicular ligament. Moreover, we discovered deep to tibiocalcaneal and posterior to sustentaculum tali ligaments in 3 cases. Regarding the attachment area, the deep posterior tibiotalar ligament had the largest proximal and distal attachment areas which were 87.36±23.15 mm2 and 88.88±24.24 mm2, respectively. The anterior tibiotalar ligament had the least proximal and distal attachment areas which were 23.12±8.25 mm2 and 33.16±14.63 mm2, respectively. Hence, the accuracy and exact areas of attachment of deltoid ligament are important as it can help clinicians to select the suitable treatments including injury prevention.

Actualmente, el tratamiento para pacientes con lesiones del ligamento colateral medial de la articulación talocrural (ligamento deltoideo), que requieren tratamiento quirúrgico es la reparación y reconstrucción anatómica. Los médicos, para un tratamiento exitoso, deben conocer exactactamente las áreas de inserción de las partes de ligamento deltoideo. Estudiamos 46 tobillos de cadáveres congelados frescos. Las bandas individuales del ligamento deltoideo se dividieron en fibras pequeñas. Posteriormente, cada pequeña fibra de cada banda se cortó y marcó con color acrílico en el origen y la inserción, seguido de la toma de fotografías. Por último, las fotos de origen e inserción individuales se utilizaron para calcular las áreas. Encontramos seis bandas de ligamento deltoides en todos los tobillos, excepto el ligamento tibionavicular. Además, descubrimos en profundidad hasta los ligamentos tibiocalcaneaos y posteriores al sustentaculum tali en 3 casos. Con respecto al área de inserciónn, la parte tibiotalar posterior profundamente tenía las áreas de inserción proximal y distal más largas, que eran 87.36 ± 23.15 mm2 y 88.88 ± 24.24 mm2, respectivamente. La parte tibiotalar anterior del ligamento deltoideo tpresentaba áreas de unión menos proximales y distales 23.12 ± 8.25 mm2 y 33.16 ± 14.63 mm2, respectivamente. Por lo tanto, la precisión y las áreas exactas de inserción del ligamento deltoideo de la articulación talocrural son importantes, ya que pueden ayudar a los médicos a seleccionar los tratamientos adecuados, incluida la prevención de lesiones.

Diagnosis and treatment of osteoporosis following hip fracture in Chiang Mai University Hospital.

BACKGROUND: Osteoporosis is defined as a skeletal disorder characterized by compromised bone strength predisposing a person to an increased risk of fracture. Hip fracture is the common and serious consequence of osteoporosis. To improve bone quality and prevent new fracture, osteoporosis should be treated while the patient was admitted with hip fracture problem. Several medications have been proven to be effective. Objectives of the present study were to determine the adequacy of diagnosis and treatment of osteoporosis in hip fracture patients. MATERIAL AND METHOD: A retrospective study of all low energy trauma hip fracture patients, between 1998 and 2003 at the age of 50 years old or more. The National Osteoporosis Foundation guideline was used to identify adequacy of diagnosis and treatment of osteoporosis in this group of patients. Age, sex, admitted diagnosis, mechanism of injury, admission medication, treatment procedures, discharge medication, BMD investigation were analysed. RESULTS: The percentage of calcium supplementation for the discharged patients in 1998 to 2003 was 0%, 10.5%, 33.3%, 32.7%, 39.3% and 43.0% respectively. The percentage of combination of calcium and vitamin D supplementation for the discharged patients was 0%, 8.8%, 21.1%, 12.7%, 24.6% and 37.5% respectively. Bisphosphonate was ordered in 9 and calcitonin in 20 patients. 7% of patients were diagnosied as osteoporosis. The quantity of osteoporosis was confirmed by DXA measurement in only one patient. CONCLUSIONS: In the past 6 years, most of the hip fracture patients were underdiagnosed and undertreated for osteoporosis. There was also a good trend for better treatment.