ACR Appropriateness Criteria® Orbital Imaging and Vision Loss-Child.

Orbital disorders in children consist of varied pathologies affecting the orbits, orbital contents, visual pathway, and innervation of the extraocular or intraocular muscles. The underlying etiology of these disorders may be traumatic or nontraumatic. Presumed location of the lesion along with the additional findings, such as eye pain, swelling, exophthalmos/enophthalmos, erythema, conjunctival vascular dilatation, intraocular pressure, etc, help in determining if imaging is needed, modality of choice, and extent of coverage (orbits and/or head). Occasionally, clinical signs and symptoms may be nonspecific, and, in these cases, diagnostic imaging studies play a key role in depicting the nature and extent of the injury or disease. In this document, various clinical scenarios are discussed by which a child may present with an orbital or vision abnormality. Imaging studies that might be most appropriate (based on the best available evidence or expert consensus) in these clinical scenarios are also discussed. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.

CR Appropriateness Criteria® Orbital imaging and vision loss-child

Orbital disorders in children consist of varied pathologies affecting the orbits, orbital contents, visual pathway, and innervation of the extraocular or intraocular muscles. The underlying etiology of these disorders may be traumatic or nontraumatic. Presumed location of the lesion along with the additional findings, such as eye pain, swelling, exophthalmos/enophthalmos, erythema, conjunctival vascular dilatation, intraocular pressure, etc, help in determining if imaging is needed, modality of choice, and extent of coverage (orbits and/or head). Occasionally, clinical signs and symptoms may be nonspecific, and, in these cases, diagnostic imaging studies play a key role in depicting the nature and extent of the injury or disease. In this document, various clinical scenarios are discussed by which a child may present with an orbital or vision abnormality. Imaging studies that might be most appropriate (based on the best available evidence or expert consensus) in these clinical scenarios are also discussed. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.

Outcomes in Pediatric Thyroidectomy: Results From a Multinational, Multi-institutional Database.

OBJECTIVE: Traditionally, data regarding thyroidectomy were extracted from billing databases, but information may be missed. In this study, a multi-institutional pediatric thyroidectomy database was used to evaluate recurrent laryngeal nerve (RLN) injury and hypoparathyroidism. STUDY DESIGN: Retrospective multi-institutional cohort study. SETTING: Tertiary care pediatric hospital systems throughout North America. METHODS: Data were individually collected for thyroidectomies, then entered into a centralized database and analyzed using univariate and multivariable regression models. RESULTS: In total, 1025 thyroidectomies from 10 institutions were included. Average age was 13.9 years, and 77.8% were female. Average hospital stay was 1.9 nights and 13.5% of patients spent at least 1 night in the pediatric intensive care unit. The most frequent pathology was papillary thyroid carcinoma (42%), followed by Graves' disease (20.1%) and follicular adenoma (18.2%). Overall, 1.1% of patients experienced RLN injury (0.8% permanent), and 7.2% experienced hypoparathyroidism (3.3% permanent). Lower institutional volume (odds ratio [OR], 3.57; 95% CI, 1.72-7.14) and concurrent hypoparathyroidism (OR, 3.51; 95% CI, 1.64-7.53) correlated with RLN injury on multivariable analysis. Graves' disease (OR, 2.27; 95% CI, 1.35-3.80), Hashimoto's thyroiditis (OR, 4.67; 95% CI, 2.39-9.09), central neck dissection (OR, 3.60; 95% CI, 2.36-5.49), and total vs partial thyroidectomy (OR, 7.14; 95% CI, 4.55-11.11) correlated with hypoparathyroidism. CONCLUSION: These data present thyroidectomy information and complications pertinent to surgeons, along with preoperative risk factor assessment. Multivariable analysis showed institutional volume and hypoparathyroidism associated with RLN injury, while hypoparathyroidism associated with surgical indication, central neck dissection, and extent of surgery. Low complication rates support the safety of thyroidectomy in pediatric tertiary care centers.

Canine squamous cell carcinoma cell lines with high expression of survivin are sensitive to survivin inhibitor YM155.

Treatment of unresectable canine squamous cell carcinoma (SCC) remains challenging and new therapeutic strategies are needed. Survivin is a member of the inhibitor of apoptosis protein family and its inhibitor, YM155, is a potential anti-tumour agent. In the present study, 10 canine tumour cell lines (representing eight different tumour types) were screened for sensitivity to YM155; the drug potently inhibited the growth of the HAPPY SCC cell line. The growth inhibitory properties of YM155 were then examined in more detail using a panel of seven SCC cell lines. YM155 inhibited the growth of the cell lines HAPPY and SQ4; in contrast to the other lines in the panel, these two cell lines had high levels of expression of survivin. In HAPPY cells, YM155 inhibited expression of the survivin gene at the transcriptional level. In contrast, YM155 down-regulated survivin at the post-transcriptional level in SQ4 cells. YM155 suppressed cell growth in HAPPY cells, mostly via induction of apoptosis, but this was not the case in SQ4 cells. Two canine SCC cell lines with high cellular expression of survivin were sensitive to YM155. The possible underlying mechanisms of the cytotoxic effect of YM155 in these cell lines were different. One cell line had down-regulation of survivin mRNA and protein expression, associated with induction of apoptotic cell death. The other cell line had post-transcriptional down-regulation of survivin expression and subsequent induction of non-apoptotic cell death. Targeting survivin with YM155 is a potential approach for the treatment of canine SCCs with high expression of survivin.

Increased time between diagnosis and surgery in slipped capital femoral epiphysis results in increased radiographic deformity.

PURPOSE: Previous work has examined the impact of delay of diagnosis in slipped capital femoral epiphysis (SCFE) but not the impact of delay in treatment after radiographic diagnosis. Due to requirements for long distance transportation from less developed regions for many of our patients, our hospital was able to study variation in time between diagnosis and surgery for SCFE, as related to slip severity. METHODS: This is a retrospective review of patients treated for SCFE between 2005 and 2014 at a tertiary care paediatric hospital. Demographics, time between diagnosis and surgery, radiographic deformity (Southwick angle), postoperative complications and need for further surgery were variables of interest. Statistical analysis included Pearson and Spearman rank correlations and chi-squared tests. RESULTS: The study sample included 147 hips (119 patients). Mean time between radiographic diagnosis and surgery was 20.9 days (sd 46, 0 to 321). The mean Southwick angle (SA) at the time of surgery was 31.9˚ (sd 19.6˚, 1° to 83˚). There was a significant relationship between increased delay and increased SA (0.34, p < 0.001). Increased SA was correlated with need for future significant surgery (0.27, p < 0.01).Patients from less-developed regions, with barriers to timely care, had moderate and severe deformity (SA) (p < 0.01), and required significant further surgery more often than SCFE patients from the local population (p < 0.01). CONCLUSION: The unique referral environment of our hospital provided an opportunity to examine traditional recommendations for treating SCFE promptly after radiographic diagnosis. Delay in treatment is correlated with increased radiographic deformity. LEVEL OF EVIDENCE: III.

Effect of dasatinib in a xenograft mouse model of canine histiocytic sarcoma and in vitro expression status of its potential target EPHA2.

Canine histiocytic sarcoma (HS) is an aggressive and highly metastatic tumor. Previously, the kinase inhibitor dasatinib was shown to have potent growth inhibitory activity against HS cells in vitro, possibly via targeting the EPHA2 receptor. Here, the in vivo effect of dasatinib in HS cells was investigated using a xenograft mouse model. Moreover, the expression status of EPHA2 was examined in six HS cell lines, ranging from insensitive to highly sensitive to dasatinib. In the HS xenograft mouse model, dasatinib significantly suppressed tumor growth, as illustrated by a decrease in mitotic and Ki67 indices and an increase in apoptotic index in tumor tissues. On Western blot analysis, EPHA2 was only weakly detected in all HS cell lines, regardless of sensitivity to dasatinib. Dasatinib likely results in the inhibition of xenograft tumor growth via a mechanism other than targeting EPHA2. The findings of this study suggest that dasatinib is a targeted therapy drug worthy of further exploration for the treatment of canine HS.

Selective growth inhibition by suppression of F1Fo ATPase in canine malignant melanoma cell lines.

Canine malignant melanoma (CMM) is a highly aggressive and fatal neoplasm. To identify potential therapeutic compounds and/or targets, 320 compounds were screened for their growth inhibitory activity in a CMM line (CMM-1) using a chemical library known to target specific signaling pathways/cell growth-related molecules. Among the compounds screened, the F1Fo ATPase inhibitor oligomycin showed potent growth inhibitory effects in CMM-1 cells, while exhibiting less toxic effects in a non-neoplastic control cell line (MDCK cells). The growth inhibitory effect of oligomycin A was then examined using six CMM lines and MDCK cells. Three CMM lines were highly sensitive to oligomycin A, with around 3000-20 000 times lower IC50 compared with oligomycin A-resistant CMM lines and MDCK cells. Oligomycin A-sensitive CMM-1 cells exhibited much greater oligomycin A-induced decreases in cellular ATP compared to oligomycin A-resistant cell lines. Although the oligomycins are clinically unsuitable because of its in vivo toxicity, these findings implicate the potential of F1Fo ATPase as a therapeutic target in a subset of CMM.

Anticancer effects of gemcitabine are enhanced by co-administered iRGD peptide in murine pancreatic cancer models that overexpressed neuropilin-1.

BACKGROUND: Impaired drug transport is an important factor that reduces the efficacy of anticancer agents against pancreatic cancer. Here, we report a novel combination chemotherapy using gemcitabine (GEM) and internalised-RGD (iRGD) peptide, which enhances tumour-specific drug penetration by binding neuropilin-1 (NRP1) receptor. METHODS: A total of five pancreatic cancer murine models (two cell line-based xenografts (CXs) and three tumour grafts (TGs)) were treated with either GEM (100 mg kg(-1), q3d × 4) alone or GEM plus iRGD peptide (8 µmol kg(-1)). Evaluation of NRP1 expression in xenografts and 48 clinical cancer specimens was performed by immunohistochemistry (IHC). RESULTS: We identified a subset of pancreatic cancer models that showed NRP1 overexpression sensitive to iRGD co-administration. Treatment with GEM plus iRGD peptide resulted in a significant tumour reduction compared with GEM monotherapy in CXs, but not remarkable in TGs. Potential targets of iRGD were characterised as cases showing NRP1 overexpression (IHC-2+/3+), and these accounted for 45.8% of the clinical specimens. CONCLUSIONS: Internalised RGD peptide enhances the effects of co-administered drugs in pancreatic cancer models, its efficacy is however only appreciable in those employing cell lines. Therefore, the clinical application needs to be given careful consideration.

Decrease of blood dendritic cells and increase of tissue-infiltrating dendritic cells are involved in the induction of Sjögren's syndrome but not in the maintenance.

We have demonstrated previously that, in primary Sjögren's syndrome (SS), immature myeloid dendritic cells (DCs) are decreased in blood and mature myeloid DCs are accumulated in salivary glands, suggesting recruitment of the myeloid DCs from blood to salivary glands. To verify whether this finding is universal in patients of not only primary SS but also secondary SS, in this study we analysed the blood DCs of secondary SS patients. We examined 24 secondary SS and 29 primary SS patients. A direct correlation between the decreased number of myeloid DCs and the duration of Sicca syndrome in primary and secondary SS was observed; namely, the reduction of myeloid DCs in blood was restored spontaneously with duration time of Sicca syndrome. We also examined the immunohistochemical staining of salivary glands of SS patients with monoclonal antibodies against fascin, CD11c and human leucocyte antigen DR (HLA-DR). Fascin(+) or CD11c(+)/HLA-DR(+) mononuclear cells were present in the salivary glands of secondary SS patients, as in primary SS. However, fascin(+) mononuclear cells were barely detected in the salivary glands of a chronic phase of SS patients. We also found a negative correlation between the frequency of blood myeloid DCs and salivary gland-infiltrating DCs in secondary SS patients, as well as primary SS. Our results suggest that the reduction of blood myeloid DCs and preferential trafficking of myeloid DCs into salivary glands is a common event in the early stage of SS. Myeloid DCs may play essential roles in the pathogenesis of Sicca syndrome of SS by initiating T helper cell immune responses.

Surgical management of obstructive sleep apnea in infants and young toddlers.

OBJECTIVE: Review surgical management of obstructive sleep apnea (OSA) in infants and young toddlers compared with a medically treated group. STUDY DESIGN: Case series with chart review of children younger than 24 months treated at a tertiary pediatric hospital between 2000 and 2005. SUBJECTS AND METHODS: Surgical treatment included adenotonsillectomy, adenoidectomy, and tonsillectomy. Polysomnography results, comorbidities, and major complications were recorded. The change in apnea-hypopnea index (AHI) before and after treatment was analyzed. Logistic regression analysis reviewed effects of comorbidities and OSA severity on complications. RESULTS: A total of 73 children met inclusion criteria. The surgical treatment group (AHI) improved posttreatment: mean AHI change was 9.6 (95% CI, 5.8-13.4). The medical treatment group did not improve posttreatment: mean AHI change was -3.0 (95% CI, -15.1 to 9.1). The difference in AHI change between surgical and medical groups was 12.56 (95% CI, 2.7-22.4). An independent t test found this difference to be statistically significant (P = 0.01). Eleven (18%) patients suffered significant postoperative surgical complications; 55 surgical patients and 8 medical patients had comorbidities. There were no long-term morbidities or mortalities. CONCLUSIONS: AHI in the surgically treated group significantly improved. The complication rate for a tertiary pediatric hospital population that included patients with multiple comorbidities was acceptable.

Roles of induced expression of MAPK phosphatase-2 in tumor development in RET-MEN2A transgenic mice.

Germline mutations in the RET tyrosine kinase gene are responsible for the development of multiple endocrine neoplasia 2A and 2B (MEN2A and MEN2B). However, knowledge of the fundamental principles that determine the mutant RET-mediated signaling remains elusive. Here, we report increased expression of mitogen-activated protein kinase phosphatase-2 (MKP-2) in carcinomas developed in transgenic mice carrying RET with the MEN2A mutation (RET-MEN2A). The expression of MKP-2 was not only induced by RET-MEN2A or RET-MEN2B mutant proteins but also by the activation of endogenous RET by its ligand, glial cell line-derived neurotrophic factor (GDNF). MKP-2 expression was also evident in the MKK-f cell line, which was established from a mammary tumor developed in a RET-MEN2A transgenic mouse. Inhibition of MKP-2 attenuated the in vitro and in vivo proliferation of MKK-f cells, which was mediated by the suppression of cyclin B1 expression. Furthermore, we found that MKP-2 is highly expressed in medullary thyroid carcinomas derived from MEN2A patients. These findings suggest that the increased expression of MKP-2 may play a crucial role in oncogenic signaling downstream of mutant RET, leading to deregulation of cell cycle.

Bilateral congenital vocal cord paralysis: a 16-year institutional review.

OBJECTIVE: To review the management and outcome of bilateral congenital true vocal cord paralysis in 22 patients treated over a 16-year period and to review the role of tracheostomy in these patients. DESIGN: Retrospective chart review. SETTING: Pediatric tertiary hospital. PATIENTS: Twenty-two pediatric patients diagnosed with bilateral congenital true vocal cord paralysis. INTERVENTIONS: Flexible or rigid diagnostic evaluation, tracheostomy, and vocal cord lateralization procedures. MAIN OUTCOMES MEASURES: Vocal cord recovery and decannulation. RESULTS: With a mean follow up of 50 months, 15 of 22 patients (68%) with bilateral vocal cord paralysis required tracheostomy for airway securement. Of the 15 tracheotomized patients, 10 were successfully decannulated (8 had spontaneous recovery, whereas 2 required lateralization procedures). Eleven of these patients with tracheostomy had comorbid factors, including neurologic abnormalities (midbrain/brainstem dysgenesis, Arnold-Chiari malformation, global hypotonia, and developmental delay). Of the 7 patients not requiring tracheostomy, 6 recovered vocal cord function (86%). CONCLUSION: In our series of 22 patients with bilateral vocal cord paralysis, 14 had spontaneous recovery of function. Patients managed with tracheostomy were noted to have a high incidence of comorbid factors. In this series, recovery rates were found to be higher in nontracheostomized patients than in tracheostomized patients. Patients can be carefully selected for observation versus tracheostomy at the time of diagnosis based on underlying medical conditions.

Development of visual attention skills in prelingually deaf children who use cochlear implants.

OBJECTIVE: To determine the effects of length of cochlear implant use and other demographic factors on the development of sustained visual attention in prelingually deaf children and to examine the relations between performance on a test of sustained visual attention and audiological outcome measures in this population. DESIGN: A retrospective analysis of data collected before cochlear implantation and over several years after implantation. Two groups of prelingually deaf children, one >6 years old (N = 41) and one <6 years old (N = 47) at testing, were given an age-appropriate Continuous Performance Task (CPT). In both groups, children monitored visually presented numbers for several minutes and responded whenever a designated number appeared. Hit rate, false alarm rate, and signal detection parameters were dependent measures of sustained visual attention. We tested for effects of a number of patient variables on CPT performance. Multiple regression analyses were conducted to determine if CPT scores were related to performance on several audiological outcome measures. RESULTS: In both groups of children, mean CPT performance was low compared with published norms for normal-hearing children, and performance improved as a function of length of cochlear implant use and chronological age. The improvement in performance was manifested as an increase in hit rate and perceptual sensitivity over time. In the younger age group, a greater number of active electrodes predicted better CPT performance. Results from regression analyses indicated a relationship between CPT response criterion and receptive language in the younger age group. However, we failed to uncover any other relations between CPT performance and speech and language outcome measures. CONCLUSIONS: Our findings suggest that cochlear implantation in prelingually deaf children leads to improved performance on a test of sustained visual processing of numbers over 2 or more years of cochlear implant use. In preschool-age children who use cochlear implants, individuals who are more conservative responders on the CPT show higher receptive language scores than do individuals with more impulsive response patterns. Theoretical accounts of these findings are discussed, including cross-modal reorganization of visual attention and enhanced phonological encoding of visually presented numbers.

Behavioral inhibition and clinical outcomes in children with cochlear implants.

OBJECTIVES/HYPOTHESIS: Individual speech and language outcomes of deaf children with cochlear implants (CIs) are quite varied. Individual differences in underlying cognitive functions may explain some of this variance. The current study investigated whether behavioral inhibition skills of deaf children were related to performance on a range of audiologic outcome measures. DESIGN: Retrospective analysis of longitudinal data collected from prelingually and profoundly deaf children who used CIs. METHODS: Behavioral inhibition skills were measured using a visual response delay task that did not require hearing. Speech and language measures were obtained from behavioral tests administered at 1-year intervals of CI use. RESULTS: Female subjects showed higher response delay scores than males. Performance increased with length of CI use. Younger children showed greater improvement in performance as a function of device use than older children. No other subject variable had a significant effect on response delay score. A series of multiple regression analyses revealed several significant relations between delay task performance and open set word recognition, vocabulary, receptive language, and expressive language scores. CONCLUSIONS: The present results suggest that CI experience affects visual information processing skills of prelingually deaf children. Furthermore, the observed pattern of relations suggests that speech and language processing skills are closely related to the development of response delay skills in prelingually deaf children with CIs. These relations may reflect underlying verbal encoding skills, subvocal rehearsal skills, and verbally mediated self-regulatory skills. Clinically, visual response delay tasks may be useful in assessing behavioral and cognitive development in deaf children after implantation.

Association of anterior glottic webs with velocardiofacial syndrome (chromosome 22q11.2 deletion).

OBJECTIVE: An association between anterior glottic webs and velocardiofacial syndrome (chromosome 22q11.2 deletion) has previously been noted in a number of case reports. Our objective was to determine if the presence of such webs warrants a high index of suspicion for this chromosome deletion. Study design and setting This study was carried out in the Division of Pediatric Otolaryngology-Head and Neck Surgery at Cincinnati Children's Hospital Medical Center. Chromosome 22q11.2 deletion status was determined for all patients endoscopically diagnosed with anterior glottic webs between July 1998 and December 2000. Families of patients who tested positive for the deletion were referred to the Cincinnati Children's Division of Human Genetics for additional evaluation and counseling. RESULTS: Eleven of 17 patients (65%) with anterior glottic webs were positive for chromosome 22q11.2 deletion. Of these 11 patients, 5 showed subtle clinical manifestations of velocardiofacial syndrome and underwent genetic testing due only to the presence of a web. All 11 patients were diagnosed with velocardiofacial syndrome. CONCLUSION: We strongly recommend that all patients diagnosed with anterior glottic webs undergo fluorescence in situ hybridization evaluation for this chromosome deletion.

Pediatric neurotology.

Pediatric neurotology is a subspecialty encompassing the medical and surgical treatment of conditions involving the middle ear, inner ear and lateral skull base. Multiple otologic and neurotologic diseases exist. In the pediatric patient the most common neurotologic conditions are vertigo, complications of otitis media, cholesteatoma, hearing loss and facial paralysis. Vertigo is differentiated into peripheral and central vestibular abnormalities. Peripheral vestibular causes include Meniere's disease, benign paroxysmal positional vertigo, vestibular neuronitis, otitis media and labyrinthitis. The predominant lesions in our field causing central vestibular disorders are brainstem and posterior fossa tumors. Mastoiditis, meningitis, petrositis, sigmoid sinus thrombosis, extradural abscess, brain abscess, otitic hydrocephalus, cholesteatoma and cholesterol granuloma are complications of otitis media and middle ear disease. Sensorineural hearing loss is now readily treated with cochlear implantation. Facial nerve paralysis may result from infectious and other etiologies.

Positron emission tomography in cochlear implant and auditory brainstem implant recipients.

UNLABELLED: Positron emission tomography (PET) imaging was used to evaluate the brain's response to auditory stimulation, including speech. Five cases of adults illustrate the utility of PET to illuminate auditory processing with cochlear or brainstem implants. Subjects showed varying degrees of success in processing speech, which was reflected in the resulting PET images. Functional speech processing was associated with activation in areas classically associated with speech processing. In one patient who did not achieve functional speech processing, activation in frontal regions suggests that the subject used other cognitive strategies to assist auditory processing. LEARNING OUTCOMES: As a result of this activity, the participant will be introduced to the principles of PET and the application of this technology to deaf patients who have received an implanted auditory prosthesis.

[A clinical investigation of oro-maxillary sinus-perforation due to tooth extraction].

Oro-maxillary sinus perforation occurs occasionally at the extraction of a maxillary tooth, and it may be a cause of maxillary sinusitis or antro-oral fistula. Our purpose was to investigate the most frequent site of perforation, and to understand the clinical course of patients after perforation. We examined 2,038 maxillary teeth extracted from 1,337 patients (473 males and 864 females) at the First Department of Oral and Maxillofacial Surgery, Tokyo Medical and Dental University, from January 1991 to December 1993. Perforation occurred in 77 of all 2,038 teeth (3.8%). Of these, 38 teeth were from males (38/733; 5.2%), and 39 were from females (39/1,305; 3.0%). The perforation rate was significantly higher in males. Perforation occurred most often with extraction of an upper first molar, and in the third decade of life. The perforation rate gradually decreased with higher age. We classified 38 cases into 3 categories according to panorama X-P: 1) The tip of the root crossed over the bottom line of the maxillary sinus (29 cases), 2) Not crossed over distinctly (4 cases), 3) Just lie on, or whether the tip of the root crossed over the bottom line of the maxillary sinus was not distinct (5 cases). As to treatment, 30 perforations (39.0%) closed spontaneously in the course of observation, irrigation with physiological saline was used in 43 cases (55.8%), radical sinusotomy accompanied by closure of the perforation was performed in 4 cases, and only flap closure was used in 7 cases. There were no cases of relapse.

Ligamentous restraints of the second tarsometatarsal joint: a biomechanical evaluation.

Ligamentous injury of the tarsometatarsal joint complex is an uncommon, but disabling condition that frequently occurs in elite athletes. There are few options for managing these injuries, in part because the relative mechanical contribution of the ligaments of the tarsometatarsal joint is unknown, complicating decisions regarding which ligaments need reconstruction. In the current study, strength and stiffness of the dorsal, plantar, and Lisfranc ligaments of 20 paired cadaver feet were measured and compared. The plantar and Lisfranc ligaments were significantly stiffer and stronger than the dorsal ligament, and the Lisfranc ligament was significantly stronger and stiffer than the plantar ligament.