Standardization of the Radiographic Study of the Foot Using the Niza Box / Padronização do estudo radiográfico do pé pela caixa Niza

Abstract Objective This study proposes the Niza box, a device created to reduce interpretive errors among professionals and facilitate the correct positioning of structures by standardizing orthopedic radiography of the foot in anteroposterior, loaded, and Saltzman views. Methods Descriptive study based on material collected at an Orthopedics Ambulatory from a tertiary service in a large Brazilian city. The X-ray device was a Lotus X, model HF 500 M, 500 milliamperes and 125 kilovolts capacity, 100 cm focus-film distance, and 24 × 30 cm radiographic chassis. Device controls were set at 100 mA, 5 mA/sec, and 60 kilovolts, depending on the variable size of the foot. The same team of previously trained radiography technicians performed the tests under the authors' supervision. The chassis were positioned in three specific Niza box spaces per the proposed incidence. Data from 50 images from people between 18 and 70 years old were analyzed. Results Radiographs taken using the proposed device usually had a satisfactory quality, allowing correct identification of the anatomical elements of the foot and ankle and angular reconstruction. Small image variations due to foot size were acceptable and expected, allowing radiograph standardization. Conclusion The Niza box is a good method for minimizing interference and avoiding radiographic interpretation errors, providing quality and agility to the examination, and reducing cost and unnecessary repetitions. It is an innovative, low-cost device made of recyclable and biodegradable material.

Resumo Objetivo Este estudo propõe a utilização da Caixa Niza, dispositivo criado com a finalidade de diminuir os erros interpretativos entre profissionais e facilitar o correto posicionamento das estruturas radiografadas ao padronizar as incidências radiográficas ortopédicas do pé anteroposterior, perfil com carga e Saltzman. Métodos Pesquisa descritiva, material coletado em Ambulatório de Ortopedia em serviço terciário de cidade brasileira de grande porte. Utilizado aparelho de radiografia marca Lotus X, modelo HF 500M, capacidade de 500 miliamperes e 125 quilovolts, distância foco-filme de 100cm, chassi radiográfico 24×30 cm e os comandos do aparelho ajustados para 100 mA, 5mA/seg e 60 quilovolts dependendo do tamanho variável dos pés. Exames realizados pela mesma equipe de técnicos em radiografia previamente treinados com supervisão dos autores. O chassi é posicionado em três espaços específicos da Caixa conforme a incidência proposta. Foram analisados dados de 50 imagens de pessoas entre 18 e 70 anos. Resultados A avaliação das radiografias após utilização do dispositivo proposto ocorreu de modo geral com qualidade satisfatória, permitindo correta identificação dos elementos anatômicos do pé e tornozelo e reconstrução angular. Pequenas variações nas imagens devido ao tamanho dos pés são aceitáveis e esperadas, sendo possível perceber padronização das radiografias. Conclusão A Caixa proposta se mostra um bom método de minimizar as interferências e evitar erros de interpretação radiográfica, proporcionando qualidade e agilidade ao exame, diminuindo custo e repetições desnecessárias. É inovador, um dispositivo de baixo custo, de material reciclável e biodegradável.

Evaluación radiológica pre y posoperatoria de la osteotomía de Austin y uso de AutoCAD® / Preoperative and Postoperative Radiological Evaluation of Austin Osteotomy and Use of Autocad®

Introducción: Se han descrito más de 300 técnicas quirúrgicas para la corrección del hallux valgus. Una de ellas es la técnica de Austin, la cual constituye una osteotomía capital en V con una angulación de 60º utilizada en el tratamiento quirúrgico del hallux valgus leve-moderado. Objetivos: Analizar el grado de corrección que tiene la osteotomía de Austin sobre diferentes parámetros radiológicos y describir la frecuencia con la que se utilizan técnicas complementarias sobre la falange proximal. Métodos: Se realizó un estudio descriptivo, transversal, observacional y retrospectivo. Se seleccionó una muestra de 29 pies intervenidos mediante la técnica de Austin, a los que se les realizaron varias mediciones sobre sus radiografías pre y posoperatorias con AutoCAD®. Resultados: Se obtuvieron diferencias estadísticamente significativas en todos los parámetros evaluados. Conclusiones: Esta técnica corrige significativamente todos los parámetros analizados. Se demuestra que el uso de técnicas quirúrgicas complementarias sobre la falange proximal es bastante frecuente al realizar esta osteotomía(AU)

Introduction: More than 300 surgical techniques have been described for the correction of hallux valgus. One of them is the Austin technique, which constitutes a capital V osteotomy with an angulation of 60º used in the surgical treatment of mild-moderate hallux valgus. Objectives: To analyze the degree of correction that Austin osteotomy has on different radiological parameters and to describe the frequency with which complementary techniques are used on the proximal phalanx. Methods: A descriptive, cross-sectional, observational and retrospective study was carried out in a sample of 29 feet operated on using the Austin technique. Several measurements were made on their pre- and postoperative radiographs with AutoCAD®. Results: Statistically significant differences were obtained in all the parameters evaluated. Conclusions: This technique significantly corrects all the parameters analyzed. It is shown that the use of complementary surgical techniques on the proximal phalanx is quite frequent when performing this osteotomy(AU)

Demostración original de la interferencia de los efectos modeladores corticales expansivos de un entrenamiento sobre los de otro ulterior: (la modelación 'marca el terreno' para la remodelación) / Original demonstration of the interference of the expansive cortical modeling effects of one training on those of another further training: (modeling "sets limits" for remodeling)

La expansión modeladora de la geometría cortical de un hueso inducida por su entorno mecánico podría ser difícil de modificar por estímulos ulteriores con diferente direccionalidad. Este estudio, que por primera vez combina datos tomográficos del peroné (pQCT) y dinamométricos de la musculatura peronea lateral, intenta demostrar que, en individuos jóvenes no entrenados, el entrenamiento en fútbol produce cambios geométricos peroneos expansivos, similares a los del rugby, que podrían interferir en los efectos de un entrenamiento ulterior direccionalmente diferente (carrera larga). Confirmando la hipótesis, los resultados indican, con evidencias originales, 1) la relevancia creciente del uso del pie (rotación externa y eversión provocadas por los peroneos laterales) para la determinación de la geometría peronea (incremento del desarrollo de los indicadores de masa y de diseño óseos), evidenciada por la secuencia creciente de efectos: carrera < fútbol < rugby; 2) la predominancia de esos efectos sobre el desarrollo centro-proximal del peroné para resistir a la flexión lateral, y en la región distal para resistir el buckling (principal sitio y causa de fractura del hueso) y 3.) la relevancia de la anticipación de esos efectos para interferir en la manifestación de los cambios producidos por un entrenamiento ulterior (carrera), cuando los del primero (fútbol) afectan la modelación cortical de modo expansivo. Esta última deducción demuestra, en forma inédita, que un cambio modelatorio expansivo tempranamente inducido sobre la estructura cortical ósea 'delimitaría el terreno'para la manifestación de cualquier otro efecto ulterior por estímulos de distinta direccionalidad. (AU)

The modeling-dependent, geometrical expansion of cortical bone induced by the mechanical environment could be hard to modify by subsequent stimulations with a different directionality. The current study aimed to demonstrate that in young, untrained individuals, training in soccer or rugby enhances the geometric properties of the fibula cortical shell in such a way that the geometrical changes could interfere on the effects of a second training in which the loads are induced in a different direction, e.g. long-distance running. The original findings reported herein confirm our hypothesis and support 1) The relevance of the use of the foot (external rotation and eversion produced by peroneus muscles) to determine fibula geometry (improved development of indicators of bone mass and design) as evidenced by the increasing nature of the effects induced by running < soccer < rugby trainings; 2) The predominance of those effects on the ability of the fibula to resist lateral bending in the centralproximal region (insertion of peroneus muscles), and to resist buckling in the distal region (the main cause and site of the most frequent bone fractures), and 3) The interaction of the effects of a previous training with those of a subsequent training with a different orientation of the loads when the former induced a modeling-dependent expansion of the cortex. Our results support the proposed hypothesis with original arguments by showing that a first, expansive effect induced on cortical bone modeling would set the stage the manifestation of any subsequent effect derived from mechanical stimuli. (AU)

Presencia y biometría del os peroneum en individuos chilenos: estudio radiológico / Presence and biometry of os peroneum in Chilean individuals: radiological study

RESUMEN: El esqueleto está formado por 206 huesos constantes (200 huesos axiales y apendiculares más los 6 osículos del oído). Sin embargo, aparte de éstos existen otros huesos que pueden ser inconstantes, los que se denominan accesorios y sesamoideos. Basado en lo anterior, el objetivo fue identificar el os peroneum, que es uno de los huesos sesamoideos que podría estar presente en el pie humano, relacionando su presencia con el sexo, grupos etarios y dominancia, registrando también mediciones de cada hueso encontrado. Se realizó un estudio de tipo descriptivo, en donde se utilizaron radiografías de 200 pacientes, de ambos sexos, chilenos, de la IX región de La Araucanía, 50 de sexo masculino y 150 de sexo femenino, con edades entre 15 y 90 años. De los 200 pacientes estudiados, se encontraron 28 (14 %) con presencia de Os peroneum, 23 del sexo femenino y 5 de sexo masculino. En 16 (57,1 %) individuos se determinó que los huesos eran bilaterales. Los registros biométricos del hueso en estudio se muestran en tablas. Los datos obtenidos complementarán el conocimiento morfológico y médico acerca de este hueso en la población chilena, ya que el dolor en la zona lateral del pie puede ser causado por un espectro de etiologías, y con los datos obtenidos, caracterizar a nuestra población, aportando otra posible causa al dolor lateral de pie.

SUMMARY: The skeleton is made up of 206 constant bones (200 bones and the 6 ossicles of the ear). However, apart from these there are other bones that can be inconstant, which are called accessories and sesamoids. Based on the above, the objective was to identify to the Os peroneum, which is one of the sesamoid bones that could be present in the human foot, relating its presence with sex, age groups and dominance, also recording measurements of each bone found. A descriptive study was carried out, in which radiographs of 200 patients of both sexes were used, Chilean, from the IX region of La Araucanía, 50 male and 150 female, aged between 15 and 90 years. Of the 200 patients studied, 28 (14 %) were found with the presence of peroneal bone, 23 of the female sex and 5 of the male sex. In 16 (57.1 %) individuals it was determined that the bones were bilateral. The biometric records of the bone under study are shown in tables. The data obtained will complement the morphological and medical knowledge about this bone in the Chilean population, since the pain in the lateral zone of the foot can be caused by a spectrum of etiologies, and with the data obtained, characterize our population, providing another possible cause to lateral standing pain.

Acrometástasis óseas, serie de casos y revisión de la literatura / Bone acrometástasis, case series and literature review

Resumen: Las acrometástasis se definen como metástasis óseas localizadas distales al codo y la rodilla. Su prevalencia es muy baja, aproximadamente el 0,1% de todas las metástasis óseas y se presentan en pacientes con enfermedad avanzada y son indicador de mal pronóstico. Hasta en el 10% de los casos se presentan como el primer signo de neoplasia oculta. Su forma de presentación clínica y radiológica es inespecífica, lo que genera retraso en su diagnóstico y tratamiento. La resonancia magnética es la imagen de elección para el diagnóstico. El tratamiento en la mayoría de los casos es paliativo. Presentamos cuatro pacientes con acrometástasis y una revisión de la literatura.

Abtract: Acrometastasis are defined as localized bone metastases distal to the elbow and knee. Its prevalence is very low, approximately 0.1% of all bone metastases and they present in patients with advanced disease and are considered indicators of poor prognosis. In up to 10% of cases are the first sign of undiagnosed neoplasia. Its clinical and radiological presentation is non-specific which generates delays in its diagnosis and treatment. Magnetic resonance is the image of choice for diagnosis. The treatment in most cases is palliative. We present four patients with acrometastasis and a review of the literature.

Comparative evaluation of anatomic structures in regio manus and regio pedis on computed tomography images and plastinated cross-sections of horse / Evaluación comparativa de estructuras anatómicas en regio manus y 1 en imágenes de tomografía computarizada y cortes transversales plastinados de caballos

SUMMARY: Movement analysis of horses is closely related to the bone, joint and muscle composition. Equine foot is quiet important not only for veterinarians, but also for farmers and horseshoer. In this study, it is aimed to evaluate and compare the anatomical structures of equine foot obtained from computed tomography images and S10B silicone plastinated sections of horse and 3 dimensional images of related structures as well. Four adult horses were used in this study. Computed tomography images were acquired in a proper position for equine feet. Then S10B silicone plastination was performed for the same specimens. Plastinates were sliced into 1 cm sections, corresponding to the computed tomography images. The sections obtained from silicone plastination were found to be compatible with computed tomography images. It was seen that osseous structures and tendons were clearly identified on computed tomography images. It was observed that the shrinkage on the osseous tissues was very limited. It was thought that the proportional differences between the plastinated specimens and computed tomography images were related with the fixation process. The specimens plastinated with S10B silicone polymer was determined to be closer to natural colour when compared to the standard polymers. Therefore it was found to be more useful. It is considered that plastinates can be effectively used in veterinary orthopaedics and radiology trainings as well as in veterinary anatomy education.

RESUMEN: El análisis del movimiento de los caballos está estrechamente relacionado con la composición ósea, articular y muscular. El pie equino es muy importante no solo para los veterinarios, sino también para los agricultores y herradores. El objetivo de este trabajo consistió en evaluar y comparar las estructuras anatómicas del pie equino obtenidas a partir de imágenes de tomografía computarizada y secciones plastinadas con silicona S10B y también con imágenes tridimensionales de estructuras relacionadas. Cuatro caballos adultos fueron utilizados en este estudio. Las imágenes de tomografía computarizada se adquirieron en una posición adecuada para los pies equinos. Luego se realizó plastinación con silicona S10B para las mismas muestras. Los plastinados se cortaron en secciones de 1 cm, correspondientes a las imágenes de tomografía computada. Las secciones obtenidas de plastinación con silicona fueron compatibles con las imágenes de tomografía computarizada. Se observó que las estructuras óseas y los tendones estaban claramente identificados en las imágenes de tomografía computarizada. Se observó que la contracción de los tejidos óseos era muy limitada. Se pensó que las diferencias proporcionales entre las muestras plastinadas y las imágenes de tomografía computada estaban relacionadas con el proceso de fijación. Se determinó que las muestras plastinadas con polímero de silicona S10B se presentaron con un color más cercano al natural en comparación con los polímeros estándar. Por lo tanto, se encontró que fue más útil. Se considera que los plastinados se pueden utilizar eficazmente en ortopedia veterinaria y capacitación en radiología, así como en educación en anatomía veterinaria.

Evidencia original directa (dinamométrico-tomográfica) de la influencia sitio-específica de la musculatura sobre la estructura ósea: hacia una concepción más amplia del mecanostato / Original dynamometric and tomographic evidence of site-specific muscle effects on bone structure: towards a wider scope on the bone mechanostat concept

Para analizar el impacto directo de la musculatura sobre la estructura ósea se determinaron el área (CtA), la densidad mineral ósea volumétrica (vDMOc) y los momentos de inercia corticales para flexión anteroposterior y lateral (MIap, MIlat) ajustados a CtA, y las relaciones entre MI y vDMOc (de Ê»distribución/calidadʼ, d/c, que describen la eficiencia de la optimización biomecánica del diseño cortical por el mecanostato) en 18 cortes seriados a lo largo de todo el peroné del lado hábil (pQCT), y la fuerza de salto y de rotación externa del pie (dinamometría computarizada) de 22 hombres sanos de 18 a 33 años entrenados en fútbol competitivo por más de 4 años, y de 9 controles etarios no entrenados. Los entrenados tuvieron valores más altos de MI en función de la fuerza de rotación del pie (no de salto), con un ajuste homogéneo para MIap pero variable (más pobre distalmente y más alto proximalmente, en la región de inserción de los peroneos) para MIlat, coincidiendo este último con pobres ajustes de las relaciones d/c (efecto arquitectónico independiente de la rigidez del tejido). Esto evidencia la influencia directa de la tracción de la musculatura peronea sobre la estructura cortical proximal subyacente del hueso y también sugiere que el mecanostato procedería, en este caso, fuera de su conocida concepción como mecanismo regulatorio de la resistencia ósea. (AU)

To analyze the direct impact of muscle contractions on the structure of bones, we determined the cortical cross-sectional area (CtA), volumetric mineral density (vBMDc) and the CtA-adjusted moments of inertia for anterior-posterior and lateral bending (MIap, MIlat), and the ʻdistribution/qualityʼ (d/c) relationships between MIs and vBMDc (which describe the efficiency of the biomechanical optimization of cortical design by bone mechanostat) in 18 serial scans taken throughout the fibula of the dominant side (pQCT), and the jump and the foot-lateral-rotation forces (computed dynamometry) of 22 healthy men aged 18-33 years, who had been trained in competitive soccer for more than 4 years, and of 9 untrained, agematched controls. Trained individuals showed higher MI values as a function of the rotative force of the foot (not the jumping force). The adjustment of these relationships was homogeneous for MIap throughout the bone, but variable (poorer distally and higher proximally, at the insertion area of peroneus muscles) for MIlat, this latter being paralleled by poor adjustments of the corresponding, d/c relationships (architectural effect independent of tissue stiffness). These findings,1. Show the direct influence of the traction force of peroneal muscles on proximal fibula structure close to the insertion area, and 2. Suggest that, in the studied conditions, the bone mechanostat would proceed beyond its known conception as a regulatory mechanism of structural bone strength. (AU)

Síndrome de miembros inferiores post trasplante / Post-transplant distal limb syndrome

El síndrome de miembros inferiores post trasplante (SMIPT) es una entidad poco conocida con una prevalencia del 5% en pacientes con trasplante renal. Su diagnóstico se basa en la clínica, afectando predominantemente miembros inferiores de forma simétrica y bilateral, centellograma óseo y resonancia magnética nuclear (RMN). Tiene una evolución benigna y se cura sin secuelas. Presentamos el caso de un hombre de 37 años con antecedentes de enfermedad de Berger en 1999 que requirió diálisis trisemanal por 4 años (2009-2013) y posterior trasplante renal en julio del 2013. Consultó en enero del 2014 refiriendo dolor intenso en ambos pies, de inicio súbito, recordando la fecha exacta del inicio del dolor, sin relación con traumatismo, que impedía su deambulación. En el centellograma óseo se observó fijación patológica del radiotrazador en pies sin diferencia de captación entre ambos. Si bien aún no hay tratamiento específico, la evolución de esta enfermedad es benigna.

The post-transplant distal limb syndrome is a not well known entity, with a prevalence of 5% in patients with renal transplant. Its diagnosis is based on clinical symptoms, bone scintigraphy and MRI, it has a benign course and the patient recovers without sequel. We present the case of a 37-year-old male, with medical history of hypertension, Berger's disease in 1999 that required dialysis three times a week for four years (2009-2013) and renal transplant in 2013. The patient consults on January 2014 referring severe pain in both feet, with sudden onset; he remembers the exact date of the beginning of the pain and denies trauma, pain prevents ambulation. The bone scintigraphy shows pathological uptake in both feet with no difference between the two. Although there is no treatment for this disease, it has a benign course.

Extraarticular Subtalar Arthrodesis for Pes Planovalgus: An Interim Result of 50 Feet in Patients with Spastic Diplegia

BACKGROUND: There are no reports of the pressure changes across the foot after extraarticular subtalar arthrodesis for a planovalgus foot deformity in cerebral palsy. This paper reviews our results of extraarticular subtalar arthrodesis using a cannulated screw and cancellous bone graft. METHODS: Fifty planovalgus feet in 30 patients with spastic diplegia were included. The mean age at the time of surgery was 9 years, and the mean follow-up period was 3 years. The radiographic, gait, and dynamic foot pressure changes after surgery were investigated. RESULTS: All patients showed union and no recurrence of the deformity. Correction of the abduction of the forefoot, subluxation of the talonavicular joint, and the hindfoot valgus was confirmed radiographically. However, the calcaneal pitch was not improved significantly after surgery. Peak dorsiflexion of the ankle during the stance phase was increased after surgery, and the peak plantarflexion at push off was decreased. The peak ankle plantar flexion moment and power were also decreased. Postoperative elevation of the medial longitudinal arch was expressed as a decreased relative vertical impulse of the medial midfoot and an increased relative vertical impulse (RVI) of the lateral midfoot. However, the lower than normal RVI of the 1st and 2nd metatarsal head after surgery suggested uncorrected forefoot supination. The anteroposterior and lateral paths of the center of pressure were improved postoperatively. CONCLUSIONS: Our experience suggests that the index operation reliably corrects the hindfoot valgus in patients with spastic diplegia. Although the operation corrects the plantar flexion of the talus, it does not necessarily correct the plantarflexed calcaneus and forefoot supination. However, these findings are short-term and longer term observations will be needed.

Bone marrow edema: an MRI diagnostic clue in patients with chronic foot and ankle pain

To describe the patterns of bone marrow edema observed on MRI and its relevance in distinction between the different causes of chronic pain at ankle and foot. The study included 47 patients complaining of chronic pain at ankle and foot with positive bone marrow edema findings on MRI examination. bone marrow edema intrinsic to osseous lesions were noted in 22 patients. Bone marrow edema with associated soft tissue lesions were noted in 25 patients findings included tenosynovitis in 15, impingement syndromes in seven diabetic foot infection in two and diabetic osteoneuroarthropathy in one patient

Anatomic and radiographic study of Egyptian calcaneal angles in comparison to other populations

This study was performed to determine the mean Egyptian calcaneal angles: Bohler's angle [BA] and Gissane's angle [GA] in comparison to other populations. Lateral plain radiographs of 267 normal Egyptians' feet and ankles, of 184 females and 83 males, with an age range of 17-69 years, were studied retrospectively at Erfan hospital Jeddah KSA, between August 2005 to July 2006. Six reformatted CT scans and Eight MRI of the ankle were studied measuring the BA and GA to determine the fallacies in radiographic readings. In addition, 30 adult dry calcaneal bones [17 right and 13 left], 7 of which were of known sex [5 males and 2 females] were collected from the Anatomy Department, Faculty of Medicine, Ain Shams University. The values of BA and GA were estimated on the dry bones and their lateral plain radiographs. The range, mean and standard deviation of each angle were calculated. Using the student t-test and One-Way Analysis of Variance, the presence of statistical differences between age, gender and side of the body were determined for both angles. Moreover, the results of the present study were compared with those of other populations to determine any racial differences. The mean of BA in the Egyptian population was 31.5° with a range of 15-48° in males and 30.5° with a range of 19-42° in females. The mean of GA was 117° with a range of 100-134° in males and 125° with a range of 101-149° in females. Bohler's angle and GA were not significantly related to gender or side of the body. However, there were statistical significant differences between different age groups. Moreover, the range of both angles was greater than that reported in other population-samples. No significant different values were obtained between dry bones and those of plain radiographs. This study showed the statistical dissimilarity between the different populations as regards to BA and GA and reinforced the need to establish the normal ranges of BA and GA in a given population. These angles were shown to be an accepted method for quantifying fracture displacement and predicting the prognosis of calcaneal fractures. By using simple radiographic measurements, the data of the present study might lead to better diagnosis and treatment

Independent associations of anti-cyclic citrullinated peptide antibodies and rheumatoid factor with radiographic severity of rheumatoid arthritis

Recent studies have established a strong association between anti-cyclic citrullinated peptide antibody [anti-CCP] positive rheumatoid arthritis [RA] and carriage of shared epitope [SE] alleles. Although anti-CCP have also been associated with more severe RA, the issue of whether this is independent of rheumatoid factor [RF] has not been addressed. To indentify associations between RF, anti-CCP, SE status and radiological damage, we studied a large cross-sectional cohort with longstanding RA. Individuals [n=100] enrolled in the study all fulfilled the American College of Rheumatology criteria for RA had a minimum disease duration of 4 years, and at least one definite radiographic erosion was present in hands or feet. Radiographs were scored blind at study entry by a single musculoskeletal radiologist using a modified Larsen's score, Anti-CCP and RF levels were determined using enzyme-linked immunosorbent assay, and DRBI typing was performed using polymerase chain reaction based methodology. Both anti-CCP and RF status, evidence of independent associated with radiographic severity [P<0.0001]. In subgroups stratified for both anti-CCP and RF status, evidence of independent associations of both antibodies with radiographic outcome was found [P<0.0001]. An association of SE alleles playing at most a secondary role. Our study support the view that previously described associations between SE and radiological severity, especially in RF-negative patients, may be indirect and due to an association with anti-CCP

Combined chevron osteotomy and lateral capsuloligamentous release in treatment of hallux valgus

Twenty two patients with 34 bunions were treated surgically by exostectomy, lateral translation of the metatar-sal head after V- shaped osteotomy, a lateral release of the capsuloligamentous structures and reconstruction of the medial metatarsosesamoid ligament. The versatility of the osteotomy allows correction of the hallux valgus [HV] deformity by tilting the metatarsal head medially, dorsally and plantarwardly. Fixation by 2 k-wires added stability to the osteotomy site and allowed early rehabilitation. Tlie mean age of the patients was 41 years at time of operation. Most of our patients were females [91.9%]. The feet were evaluated clinically and radiologicaliy with a mean follow up period of 21 months [range from 10-36 months]. The mean correction of the hallux valgus angle was [13 WHITE BULLET] and of the intermetatarsal angle [6 WHITE BULLET]. Patient satisfaction was 95% as-regard bunion pain, and shoe. fitting. The American orthopedic foot and ankle society [AOFAS] scale [0-100] was used. The average value was 81.2 [ +/- SD 14.7] points according to the AOFAS rating system at the end of the study

Humerus Varus in a Patient with Pseudohypoparathyroidism

A 7-yr-old girl presented with progressive shortening of the right upper arm and limitation of shoulder motion. Pseudohypoparathyroidism associated with Albright's hereditary osteodystrophy was diagnosed by biochemical, hormonal and radiographic studies. Her condition was complicated by severe humerus varus on the right side. Proximal humeral valgization osteotomy and concomitant humeral lengthening resulted in an improvement of the shoulder joint motion and activity in daily life.

A case of acromegaly.

A fifty years old woman hailing from Purbadhala of Netrokona district complaining of gradual enlargement of hands, feet, nose and other acral parts of the body for about last eight years. She noticed coarsening of the skin and gradual protrusion of her lower jaw. She complained of headache, vertigo, frequent passage of urine, increased thirst, weight loss and fatiguability. She was found hypertensive having blood pressure 200/110 mm of Hg. Her appearance was coarse with rough skin. There were enlargement of hands, feet, nose, lower jaw with prognathism and enlargement of other acral parts. Investigations revealed high plasma glucose level, both fasting and 2 hrs. after glucose, high level of growth hormone, failure of suppression of growth hormone during OGTT. Thyroid function tests of the patient were found normal with increased heel pad size and enlarged sella turcica in all diameters. She was diagnosed as a case of acromegaly due to growth hormone hypersecretion.