3D-radiographic analysis does not improve the Neer and AO classifications of proximal humeral fractures.

The Neer and AO fracture classifications for fractures of the proximal humerus have shown poor reproducibility based on plain radiography. We wanted to investigate whether the addition of 3-dimensional (3D) reconstructions would increase the reproducibility of classification. 7 observers independently classified 24 fractures of the proximal humerus using both plain radiographs, CT and 3D and the classification was repeated 2 months later. There was a moderate interobserver agreement when using the Neer classification, but only a fair agreement with the AO classification. The Neer system had a mean kappa value of 0.44 and the AO had a value of 0.32 for the first assessment. In the second assessment, the mean kappa values were 0.49 and 0.34, respectively. Intraobserver reproducibility was fair to substantial agreement for Neer (kappa range 0.27-0.73) and for AO (kappa range 0.29-0.74). In conclusion, the addition of CT and 3D to plain radiographs did not improve the reproducibility of the classifications of Neer and AO of the proximal humerus.

Diagnosis and prognosis in lumbar disc herniation.

In a prospective 2-year followup study of 160 consecutive patients undergoing primary surgery for suspected lumbar disc herniation, the authors studied the diagnostic and prognostic factors by using stepwise logistic regression analysis. When the different factors were entered in the same order as presented clinically, history and pain analysis contained most of the predictive information available. When all factors were entered simultaneously in the computations, the following factors (in order of relative importance) predicted relief of sciatica after 2 years: rupture of the anulus (as opposed to bulging disc or negative exploration), no preoperative comorbidity, and male gender. The following factors predicted return to work at 2 years: no preoperative comorbidity, duration of sciatica less than 7 months, education or vocational training in addition to compulsory school, age younger than 41 years, male gender, and no previous nonspinal surgery. Return to work does not seem to be a valid result parameter in lumbar disc surgery. The most important physical signs were root tension tests and lumbar range of motion, whereas neurologic signs were of secondary importance. Many people have asymptomatic herniations, and today supersensitive diagnostic imaging is widely available. Thus, the importance of clinical evaluation has increased, and most of the relevant information can be obtained by listening to the patient. A simple anamnesis apparently is a good alternative to psychologic tests in surgical triage.

A method for morphometric study of the intercostal muscles by high-resolution ultrasound.

Besides their main function of assisting in breathing, the intercostal muscles also play an important role in maintaining the balance of forces acting on the thoracic cage including the thoracic spine. Since it is virtually impossible to conduct a morphometric evaluation of these muscles, a study was undertaken to standardize an ultrasound method for accurate determination of the area of the intercostal muscles and hence, indirectly, their function. In a pilot study, the area of the intercostal muscles was determined on the torso of a fresh specimen of a grown-up lamb, using high-resolution ultrasound and CT, and by direct measurements of the intercostal space at two points equidistant from the midline on the left and the right sides of the back of the specimen. The size of the intercostal muscles was determined either by tracing or from the perpendiculars of the area of the muscles both on sonographs and on CT scans. The results showed that measurements derived from the perpendiculars of the muscle area on the sonographs give better estimates than those derived from CT scans, and were in good accordance with the direct measurements of the corresponding intercostal space on the specimen. To evaluate the applicability of the method in vivo the area of the intercostal muscles at maximal inhalation and exhalation was determined in one adult person. It was found that measurements at maximal inhalation were more accurate than those taken at maximal exhalation. It is concluded that ultrasonography is a reliable, safe, easy to apply and high-resolution method for measurements of the area and, indirectly, of the activity of the intercostal muscles in humans, and that the measurements are more accurate at maximal inhalation.

Tarsal tunnel syndrome. Outcome of surgery in longstanding cases.

Cases of longstanding (median, 60 months) tarsal tunnel syndrome were decompressed surgically in 14 female and four male patients. Patients reported intermittent dysesthesia, paresthesia, or anesthesia at the medial plantar aspect of the foot. Symptoms were aggravated by physical activities. Previous trauma was noted in four patients. Tinel's sign was positive in 16 patients. Magnetic resonance imaging was performed in 10 patients but was conclusive in only two. At surgery, the posterior tibial nerve or one of its branches was found to be entrapped in 15 patients. Entrapments were observed isolated or in combination within the fascial septa (n = 5), varicose veins (n = 6), scar tissues (n = 4), tenosynovitis and edema (n = 1), or within the abductor hallucis muscle (n = 1). Two neuromas were excised. In three patients no obvious entrapments were found. Clinical followup was performed a median 18 months after surgery. Relief of symptoms was reported as long as 1 year after surgery. All symptoms were relieved in 11 (61%) patients. Three (17%) patients with previous trauma had relatively severe pain after surgery and were considered to have failed results. Surgical decompression was beneficial in most patients with longstanding tarsal tunnel syndrome.

Ultrasonography-guided percutaneous core biopsy in Achilles tendon disorder.

Ultrasound-guided percutaneous core biopsy technique was studied in 15 consecutive patients with chronic Achilles tendon disorder defined as persisting local pain during daily activities, localized pain and swelling on palpation 2-5 cm proximal to the calcaneal insertion. Ultrasound verified widening of the tendon and low echogenous areas at the site of pain. Percutaneous biopsies were taken from both the low echogenous areas and the normoechogenic tendon tissue. Of 104 core biopsies 99 were representative. Open biopsies were taken from the macroscopically injured and normal tendon for comparison. Core and open biopsies of the low echogenous and macroscopically injured tendon showed similar histopathology. In 10 patients the core biopsy was performed under local anesthesia with limited subjective symptoms. Five of these patients were operated 18-41 days later. No adverse effect was found referring to the biopsy taken a few weeks prior to surgery. No complications occurred. We conclude that the percutaneous core biopsy, guided by ultrasound and performed under local anesthesia, can be used under clinical and experimental in vivo studies for improving knowledge on pathoanatomy and healing processes of the Achilles tendon.

Poor reproducibility of classification of proximal humeral fractures. Additional CT of minor value.

Fractures of the proximal humerus can be described using the Neer and AO fracture classifications. To assess the reproducibility and reliability of these classifications, we investigated 26 proximal humeral fractures with both plain radiographs and CT. 5 specialists in orthopedic surgery and 5 specialists in radiology independently classified all radiographs on 2 occasions. There was a moderate agreement between the observers when using the Neer classification, but only a fair agreement with the AO classification. The Neer system had a kappa value of 0.42 and the AO had a value of 0.31 in the first assessment. In the second assessment the kappa values were 0.45 and 0.30, respectively. Intraobserver reproducibility was slight to almost perfect agreement with Neer (kappa range 0.20-0.85) and slight to moderate agreement with AO (kappa range 0.16-0.60). The observers most familiar with shoulder fracture radiographs and shoulder fracture treatment were more consistent in their classifications. We conclude that even with CT, the fracture classifications of Neer and AO have a low consistency. Neither classification system is reproducible enough to allow comparisons of different studies.

Pathology of the Achilles tendon in association with ciprofloxacin treatment.

Achilles tendon pain or rupture after fluoroquionolone treatment has been described as an uncommon adverse effect. We report two patients with ciprofloxacin-associated Achilles tendon disease, one with histopathological examination. Microscopic evaluation showed irregular collagen fiber arrangement, hypercellularity, and increased interfibrillar glycosaminoglycans. These pathological features are also seen in tendon overuse injuries in athletes.

Plantar fascia rupture: diagnosis and treatment.

Two patients with spontaneous medial plantar fascia rupture due to a definite injury with no prior symptoms, were referred to our institution. Clinically, there was a tender lump in the sole, and magnetic resonance imaging confirmed the diagnosis. Nonoperative treatment was sufficient in curing the acute total rupture. Endoscopic release was used on the partially ruptured plantar fascia, but it is probably more optimal in the acute phase. The literature provides no comparative data on operative or nonoperative treatment efficacy for this rare condition.

Dislocation of the tibialis posterior tendon: diagnosis and treatment.

Traumatic dislocation of the tibialis tendon occurred from minor ankle sprains in a 37-year-old male and a 53-year-old female. Both complained of local pain at the medial malleolus, and both walked with a limp. The diagnosis was suspected by clinical examination, in one case with 2 months' delay, and verified by ultrasound, computed tomography, and magnetic resonance imaging. The male patient was initially treated for an "uncomplicated ankle sprain." For various reasons surgery was delayed 4 months. During this interval the male patient complained of pain and severe dysfunction, requiring analgesic treatment. A medial Achilles tendon flap was used to support the repositioned tendon. The female patient was operated on within 1 week from injury, by resuturing of the retinaculum over the tendon. Postoperatively, both patients were immobilized with below-knee casts for 6 weeks, allowing full weightbearing, followed by strength and stretching exercises. They were free of symptoms 2 and 3 months, respectively, after surgery. At follow-up 1 year postoperatively, both were asymptomatic and participated in activities like those before their injuries.

Effects of accidental intramuscular injection on insulin absorption in IDDM.

Recent studies have shown that with the injection technique presently recommended to diabetic patients, accidental intramuscular injection of insulin is liable to occur quite frequently. In this study, the simultaneous absorption of 125I-labeled soluble human insulin (5 U) from subcutaneous and intramuscular injection sites in the thigh and abdomen was measured for 3 h in 10 insulin-dependent diabetic subjects to evaluate the importance of accidental intramuscular injection for insulin absorption in the resting state. Injection sites were located with computed tomography of the thigh and abdomen. From a superficial part of the thigh musculature, the absorption rate was at least 50% higher than from the adjacent subcutaneous tissue, the time until 50% of the initial activity remained (t1/2) being 123 +/- 14 and greater than 180 min, respectively (P less than .001). No difference in absorption rates was found between the two tissues in the abdomen (t1/2 84 +/- 6 vs. 93 +/- 7 min, NS). The results suggest that in the thigh, accidental intramuscular injections will considerably increase the variability of insulin absorption and may impair glycemic control in insulin-dependent diabetic patients. Furthermore, the influence of accidental intramuscular injection on insulin absorption seems to vary among injection regions.