Assessing the scapholunate and lunotriquetral interosseous ligament in MR arthrography: Diagnostic advantages of paraxial reformatting.

PURPOSE: The scapholunate (SLIL) and lunotriquetral interosseous ligament (LTIL) function as the main stabilizers of the proximal carpal row. Even with MR arthrography, component assessability is often limited in orthogonal standard planes due to their horseshoe-like shape and resulting partial volume effects. This study aims to investigate the diagnostic value of reformatting isotropic 3D sequences with respect to the anatomical orientation of the intrinsic carpal ligaments. METHOD: In 110 MR arthrograms of the wrist, we investigated the diagnostic accuracy of two radiologists (R1/R2) for SLIL and LTIL injuries in orthogonal standard planes vs. ancillary angulated reformatting of isotropic 3D dual echo steady state sequence. Component assessability and diagnostic confidence were compared between datasets. RESULTS: The addition of paraxial reformations improved diagnostic accuracy for lesions of the palmar (R1: 0.87 vs. 0.93; R2: 0.86 vs. 0.93; all p < 0.05) and dorsal LTIL (R1: 0.85 vs. 0.93; R2: 0.82 vs. 0.90; all p < 0.05). No significant increase in accuracy could be ascertained for palmar (R1: 0.92 vs. 0.94, p = 0.50; R2: 0.86 vs. 0.92, p = 0.07) and dorsal (R1: 0.95 vs. 0.95, p = 1.00; R2: 0.90 vs. 0.94, p = 0.29) lesions of the SLIL. Interrater reliability was almost perfect with and without angulated planes for SLIL (κ = 0.88 vs. 0.82) and LTIL assessment (κ = 0.88 vs. 0.86). For the LTIL, observer confidence and component assessability were superior with anatomical reformations available (all p < 0.05). CONCLUSIONS: In contrast to SLIL injuries, diagnosis of LTIL lesions benefits from ancillary paraxial reformations of 3D sequences in MR wrist arthrography.

Improved diagnostic accuracy for ulnar-sided TFCC lesions with radial reformation of 3D sequences in wrist MR arthrography.

OBJECTIVES: Triangular fibrocartilage complex (TFCC) injuries frequently cause ulnar-sided wrist pain and can induce distal radioulnar joint instability. With its complex three-dimensional structure, diagnosis of TFCC lesions remains a challenging task even in MR arthrograms. The aim of this study was to assess the added diagnostic value of radial reformatting of isotropic 3D MRI datasets compared to standard planes after direct arthrography of the wrist. METHODS: Ninety-three patients underwent wrist MRI after fluoroscopy-guided multi-compartment arthrography. Two radiologists collectively analyzed two datasets of each MR arthrogram for TFCC injuries, with one set containing standard reconstructions of a 3D thin-slice sequence in axial, coronal and sagittal orientation, while the other set comprised an additional radial plane view with the rotating center positioned at the ulnar styloid. Surgical reports (whenever available) or radiological reports combined with clinical follow-up served as a standard of reference. In addition, diagnostic confidence and assessability of the central disc and ulnar-sided insertions were subjectively evaluated. RESULTS: Injuries of the articular disc, styloid and foveal ulnar attachment were present in 20 (23.7%), 10 (10.8%) and 9 (9.7%) patients. Additional radial planes increased diagnostic accuracy for lesions of the styloid (0.83 vs. 0.90; p = 0.016) and foveal (0.86 vs. 0.94; p = 0.039) insertion, whereas no improvement was identified for alterations of the central cartilage disc. Readers' confidence (p < 0.001) and assessability of the ulnar-sided insertions (p < 0.001) were superior with ancillary radial reformatting. CONCLUSIONS: Access to the radial plane view of isotropic 3D sequences in MR arthrography improves diagnostic accuracy and confidence for ulnar-sided TFCC lesions. KEY POINTS: • In multi-compartment arthrography of the wrist, ancillary radial plane view aids assessability of the foveal and styloid ulnar-sided insertions of the triangular fibrocartilage complex. • Assessment of peripheral TFCC injuries is more accurate with access to radial multiplanar reconstructions. • Additional radial planes provide greater diagnostic confidence.

Experimental Drillable Magnesium Phosphate Cement Is a Promising Alternative to Conventional Bone Cements.

Clinically used mineral bone cements lack high strength values, absorbability and drillability. Therefore, magnesium phosphate cements have recently received increasing attention as they unify a high mechanical performance with presumed degradation in vivo. To obtain a drillable cement formulation, farringtonite (Mg3(PO4)2) and magnesium oxide (MgO) were modified with the setting retardant phytic acid (C6H18O24P6). In a pre-testing series, 13 different compositions of magnesium phosphate cements were analyzed concentrating on the clinical demands for application. Of these 13 composites, two cement formulations with different phytic acid content (22.5 wt% and 25 wt%) were identified to meet clinical demands. Both formulations were evaluated in terms of setting time, injectability, compressive strength, screw pullout tests and biomechanical tests in a clinically relevant fracture model. The cements were used as bone filler of a metaphyseal bone defect alone, and in combination with screws drilled through the cement. Both formulations achieved a setting time of 5 min 30 s and an injectability of 100%. Compressive strength was shown to be ~12-13 MPa and the overall displacement of the reduced fracture was <2 mm with and without screws. Maximum load until reduced fracture failure was ~2600 N for the cements only and ~3800 N for the combination with screws. Two new compositions of magnesium phosphate cements revealed high strength in clinically relevant biomechanical test set-ups and add clinically desired characteristics to its strength such as injectability and drillability.

Muscle Cuff in Distal Pedicled Adipofascial Sural Artery Flaps: A Retrospective Case Control Study.

Amputation after open tibial fracture occurs in 3% of cases. The rate increases when flap reconstruction is required. The standard care involves microsurgical tissue transfer although the pedicled reverse sural artery adipofascial flap (PRSAF) is a local alternative in patients endangered by a prolonged operative time. Incorporation of a gastrocnemius muscle cuff in this flap can be used to fill dead space and increase healing potential. Literature shows superior survival rates for both PRSAF and inclusion of a muscle cuff in comparison with the cutaneous version. The aim of the study was to compare the outcome of the PRSAF and the musculoadipofascial version (PRSMAF). We hypothesize that the PRSMAF provides similar lap viability and flap-related complication rates as does the adipofascial version. The muscle component may reduce the long-term osteomyelitis rate. METHODS: Patients were evaluated retrospectively after reconstruction with either PRSAF or PRSMAF. Preoperative osteomyelitis, flap survival, complications and osteomyelitis clearance were analyzed. RESULTS: The study shows preliminary results supporting the potential use of the PRSMAF. We compare either 23 PRSMAF or 20 PRSAF flaps. We found no statistically significant differences in flap survival or in complication rate. CONCLUSIONS: Although the anatomical situation may sometimes dictate the use of a free flap, a technically less-complicated option may in some cases offer a viable alternative. This study shows that the PRSMAF can serve as an alternative for complex bone defects in the limb, though it does not provide statistical improvement to the PRSAF.

Quality of Life after Flap Reconstruction of the Distal Lower Extremity: Is There a Difference Between a Pedicled Suralis Flap and a Free Anterior Lateral Thigh Flap?

BACKGROUND: Flap reconstruction of the distal lower extremity is challenging. Especially, the concept of perforator surgery has increased available surgical options. Although results are generally judged in terms of objective facts, patients-perceived quality of life has largely remained unexamined. The aim of the study was to compare quality of life after lower extremity reconstruction with pedicled and free flaps. METHODS: Patients were evaluated retrospectively after reconstruction of defects of the distal lower extremity either with distally based adipofascial sural flap (pedicled reverse sural flap) or an anterior lateral thigh (ALT) flap. A specific questionnaire was developed to measure the patient's quality of life, based on short form health survey-12, Dresden Body Image Score-35, Patient Health Questionnaire-4, and X-SMFA questionnaires with additional specific questions. Furthermore, results, secondary surgeries, and complications were analyzed. RESULTS: Thirty-seven patients with reconstruction of lower limb defects treated with a pedicled reverse sural flap and 34 patients treated with an ALT flap were included in the study. There was no statistical significant difference in the overall satisfaction with the procedure in the long-term follow-up between both groups, but patients with ALT showed a higher satisfaction with the treatment in the initial postoperative period. Both groups demonstrated approximately similar results in the long term for self-acceptance and vitality. CONCLUSIONS: Although anatomic situation may dictate flap choice coverage with free flaps, a less-complicated flap is by no means regarded as an inferior treatment option in patient's estimation. Despite the intuitive speculation that patients with more advanced reconstruction methods should have better function and subsequently higher quality of life, this assumption was clearly not supported by data in this study.

A contoured locking plate for distal fibular fractures in osteoporotic bone: a biomechanical cadaver study.

OBJECTIVE: Fixation of ankle fractures in elderly patients is associated with reduced stability conditioned by osteoporotic bone. Therefore, fixation with implants providing improved biomechanical features could allow a more functional treatment, diminish implant failure and avoid consequences of immobilisation. MATERIALS AND METHODS: In the actual study, we evaluated a lateral conventional contoured plate with a locking contoured plate stabilising experimentally induced distal fibular fractures in human cadavers from elderly. Ankle fractures were induced by the supination-external rotation mechanism according to Lauge-Hansen. Stage II fractures (AO 44-B1) were fixed with the 2 contoured plates and a torque to failure test was performed. Bone mineral density (BMD) was measured by quantitative computed tomography to correlate the parameters of the biomechanical experiments with bone quality. RESULTS: The locking plate showed a higher torque to failure, angle at failure, and maximal torque compared to the conventional plate. In contrast to the nonlocking system, fixation with the locking plate was independent of BMD. CONCLUSION: Fixation of distal fibular fractures in osteoporotic bone with the contoured locking plate may be advantageous as compared to the nonlocking contoured plate. The locking plate with improved biomechanical attributes may allow a more functional treatment, reduce complications and consequences of immobilisation.