Correlation between radiological assessment of acute ankle fractures and syndesmotic injury on MRI

OBJECTIVE

Owing to the shortcomings of clinical examination and radiographs, injury to the syndesmotic ligaments is often misdiagnosed. When there is no indication requiring that the fractured ankle be operated on, the syndesmosis is not tested intra-operatively, and rupture of this ligamentous complex may be missed. Subsequently the patient is not treated properly leading to chronic complaints such as instability, pain, and swelling. We evaluated three fracture classification methods and radiographic measurements with respect to syndesmotic injury.

MATERIALS AND METHODS

Prospectively the radiographs of 51 consecutive ankle fractures were classified according to Weber, AO-Müller, and Lauge-Hansen. Both the fracture type and additional measurements of the tibiofibular clear space (TFCS), tibiofibular overlap (TFO), medial clear space (MCS), and superior clear space (SCS) were used to assess syndesmotic injury. MRI, as standard of reference, was performed to evaluate the integrity of the distal tibiofibular syndesmosis. The sensitivity and specificity for detection of syndesmotic injury with radiography were compared to MRI.

RESULTS

The Weber and AO-Müller fracture classification system, in combination with additional measurements, detected syndesmotic injury with a sensitivity of 47% and a specificity of 100%, and Lauge-Hansen with both a sensitivity and a specificity of 92%. TFCS and TFO did not correlate with syndesmotic injury, and a widened MCS did not correlate with deltoid ligament injury.

CONCLUSION

Syndesmotic injury as predicted by the Lauge-Hansen fracture classification correlated well with MRI findings. With MRI the extent of syndesmotic injury and therefore fracture stage can be assessed more accurately compared to radiographs.

Effect of glucosamine sulphate on joint space narrowing, pain and function in patients with hip osteoarthritis; subgroup analyses of a randomized controlled trial

OBJECTIVE

Recently we reported that glucosamine sulphate (GS) did not have an effect on the symptoms and progression of primary care patients with hip osteoarthritis (OA). The aim of this present study was to investigate whether there are subgroups of patients with hip OA for whom GS might be an effective therapy.

METHOD

We randomized 222 patients with hip OA that met one of the American College of Rheumatology criteria to either 1500 mg of oral GS or placebo once daily for 2 years. Subgroup analyses were predefined for radiographic severity (Kellgren & Lawrence (KL)=1 vs >or=2) and for type of OA (localised vs generalised). Additional exploratory subgroup analyses focused on groups based on pain level, pain medication use, baseline joint space width (JSW), and concomitant knee OA at baseline. Primary outcome measures were Western Ontario MacMaster Universities (WOMAC) pain and function scores over 24 months, and joint space narrowing (JSN) after 24 months.

RESULTS

In the predefined subgroups based on radiographic severity and type of OA, the outcomes WOMAC pain, function and JSN were similar for the GS and placebo group.

CONCLUSION

GS was not significantly better than placebo in reducing symptoms and progression of hip OA in subgroups of patients.

Radiographic evaluation of calcaneal fractures: to measure or not to measure

OBJECTIVE

The aim of this study was to correlate the functional outcome after treatment for displaced intra-articular calcaneal fracture with plain radiography.

DESIGN

The design was a prognostic study of a retrospective cohort with concurrent follow-up.

PATIENTS

A total of 33 patients with a unilateral calcaneal fracture and a minimum follow-up of 13 months participated. Patients filled in three disease-specific questionnaires, graded their satisfaction and the indication for an arthrodesis was noted. Standardised radiographs were made of the previously injured side and the normal (control) side. Different angles and distances were measured on these radiographs and compared with values described in the literature. The differences in values in angles and distances between the injured and uninjured (control) foot were correlated with the outcome of the questionnaires, and the indication for an arthrodesis.

RESULTS

None of the angles correlated with the disease-specific outcome scores. Of the angles only the tibiotalar angle correlated with the VAS (r = 0.35, p = 0.045) and only the absolute foot height correlated with the indication for an arthrodesis (odds = 0.70, CI = 0.50-0.99).

CONCLUSION

In this study the radiographic evaluation correlated poorly with the final outcome. Measurements on plain radiographs seem not to be useful in determining outcome after intra-articular calcaneal fractures.

[A young woman with headaches and skull anomalies: a long road to the diagnosis 'Paget's disease']

A 37-year-old woman complained of headaches, dizziness and squeaking noises in her right ear that had been going on for about 3 months. After experiencing tingling sensations in the left side of her body she consulted a neurologist, who ordered an MRI scan of her head, on which skeletal abnormalities consistent with multiple metastases of the skull were seen. Extensive clinical screening showed no evidence of a primary tumour. Lab examination showed her serum alkaline phosphatase activity to be twice as high as normal. Bone scintigraphy showed increased uptake in the skull. Plain X-rays of the skull showed large osteolytic areas and a thickened and sclerotic vault of the skull, characteristic of osteoporosis circumscripta due to Paget's disease of the skull. Treatment with oral risedronate, 30 mg per day for a period of 2 months resulted in a gradual decrease of symptoms and a rapid normalisation of bone turnover parameters. Five years after treatment the patient was still in remission and repeat X-rays ofthe skull taken after three years showed clear improvement of the osteolytic but not of the sclerotic lesions. Because Paget's disease has a relatively high prevalence in the elderly, it is important to know that it is not always recognised as such on MRI and that a simple X-ray can lead to the correct diagnosis.

Prevalence and pattern of radiographic hand osteoarthritis and association with pain and disability (the Rotterdam study)

OBJECTIVE

To investigate the prevalence and pattern of radiographic osteoarthritis (ROA) of the hand joints and its association with self reported hand pain and disability.

METHODS

Baseline data on a population based study (age >/=55 years) were used (n = 3906). Hand ROA was defined as the presence of Kellgren-Lawrence grade >/=2 radiological changes in two of three groups of hand joints in each hand. The presence of hand pain during the previous month was defined as hand pain. The health assessment questionnaire was used to measure hand disability.

RESULTS

67% of the women and 54.8% of the men had ROA in at least one hand joint. DIP joints were affected in 47.3% of participants, thumb base in 35.8%, PIP joints in 18.2%, and MCP joints in 8.2% (right or left hand). ROA of other joint groups (right hand) co-occurred in 56% of DIP involvement, 88% of PIP involvement, 86% of MCP involvement, and 65% of thumb base involvement. Hand pain showed an odds ratio of 1.9 (1.5 to 2.4) with the ROA of the hand (right). Hand disability showed an odds ratio of 1.5 (1.1 to 2.1) with ROA of the hand (right or left).

CONCLUSIONS

Hand ROA is common in the elderly, especially in women. Co-occurrence of ROA in different joint groups of the hand is more common than single joint disease. There is a modest to weak association between ROA of the hand and hand pain/disability, varying with the site of involvement.

Radiographic measurement of the distal tibiofibular syndesmosis has limited use

Radiographs of 20 plastinated human cadaveric lower legs were obtained in 12 positions of rotation to determine the optimal parameter for reliable assessment of syndesmotic and ankle integrity, and to assess the effect of positioning of the ankle on this parameter. Three observers measured eight parameters twice after four repetitions of ankle positioning. Intraclass correlation coefficients and reproducibility were assessed. Some tibiofibular overlap was present in all radiographs in any position of rotation. The medial clear space was smaller than or equal to the superior clear space in all radiographs. Intraclass correlation coefficients of the other parameters were too weak for reliable quantitative measurements, as was shown with a mixed model analysis of variance. This resulted from the inability to reproduce ankle positioning, even under optimal laboratory circumstances. This study shows that no optimal radiographic parameter exists to assess syndesmotic integrity. Tibiofibular overlap and medial and superior clear space are the most useful, because one-sided traumatic absence of tibiofibular overlap may be an indication of syndesmotic injury, and a medial clear space larger than a superior clear space is indicative of deltoid injury. Additional quantitative measurement of all syndesmotic parameters with repeated radiographs of the ankle cannot be done reliably and therefore are of little value.

Migration of the femoral stem after impaction bone grafting. First results of an ongoing, randomised study of the exeter and elite plus femoral stems using radiostereometric analysis

We report the initial results of an ongoing randomised, prospective study on migration of the Exeter and Elite Plus femoral stems after impaction allografting, as measured by radiostereometry. Clinically, the impaction technique gave good results for both stems. The mean subsidence in the first year was 1.30 mm and 0.20 mm for the Exeter and the Elite Plus stems, respectively. In the second year, the Exeter stem continued to subside further by a mean of 0.42 mm, while the Elite Plus stem did not do so. Subsidence of the Exeter stem correlated with deficiency of bone stock as graded on the Gustilo and Pasternak scale. This correlation was not found for the Elite Plus stem. None of the other parameters which were studied predisposed to subsidence. There was no significant association between the amount of subsidence and the radiological appearance of the graft for either stem. Our findings do not support the theory that radial compression, due to subsidence of the Exeter stem, is the essential stimulus for remodelling in impaction allografting.

Migration of the femoral stem after impaction bone grafting

We report the initial results of an ongoing randomised, prospective study on migration of the Exeter and Elite Plus femoral stems after impaction allografting, as measured by radiostereometry.

Clinically, the impaction technique gave good results for both stems. The mean subsidence in the first year was 1.30 mm and 0.20 mm for the Exeter and the Elite Plus stems, respectively. In the second year, the Exeter stem continued to subside further by a mean of 0.42 mm, while the Elite Plus stem did not do so. Subsidence of the Exeter stem correlated with deficiency of bone stock as graded on the Gustilo and Pasternak scale. This correlation was not found for the Elite Plus stem. None of the other parameters which were studied predisposed to subsidence. There was no significant association between the amount of subsidence and the radiological appearance of the graft for either stem. Our findings do not support the theory that radial compression, due to subsidence of the Exeter stem, is the essential stimulus for remodelling in impaction allografting.

The active straight leg raising test and mobility of the pelvic joints

Objective signs to assess impairment in patients who are disabled by peripartum pelvic girdle pain hardly exist. The purpose of this study was to develop a clinical test to quantify and qualify disability in these patients. The study examined the relationship between impaired active straight leg raising (ASLR) and mobility of pelvic joints in patients with peripartum pelvic girdle pain, focusing on (1) the reduction of impairment of ASLR when the patient was wearing a pelvic belt, and (2) motions between the pubic bones measured by X-ray examination when the patient was standing on one leg, alternating left and right. Twenty-one non-pregnant patients with peripartum pelvic girdle pain in whom pain and impairment of ASLR were mainly located on one side were selected. ASLR was performed in the supine position, first without a pelvic belt and then with a belt. The influence of the belt on the ability to actively raise the leg was assessed by the patient. Mobility of the pelvic joints was radiographically visualized by means of the Chamberlain method. Assessment was blinded. Ability to perform ASLR was improved by a pelvic belt in 20 of the 21 patients (binomial two-tailed P = 0.0000). When the patient was standing on one leg, alternating the symptomatic side and the reference side, a significant difference between the two sides was observed with respect to the size of the radiographically visualized steps between the pubic bones (binomial two-tailed P = 0.01). The step at the symptomatic side was on average larger when the leg at that side was hanging down than when the patient was standing on the leg at that side. Impairment of ASLR correlates strongly with mobility of the pelvic joints in patients with peripartum pelvic girdle pain. The ASLR test could be a suitable instrument to quantify and qualify disability in diseases related to mobility of the pelvic joints. Further studies are needed to assess the relationship with clinical parameters, sensitivity, specificity and responsiveness in various categories of patients. In contrast with the opinion of Chamberlain, that a radiographically visualized step between the pubic bones is caused by cranial shift of the pubic bone at the side of the standing leg, it is concluded that the step is caused by caudal shift of the pubic bone at the side of the leg hanging down. The caudal shift is caused by an anterior rotation of the hip bone about a horizontal axis near the sacroiliac joint.

Treatment of enterocele by obliteration of the pelvic inlet

PURPOSE

Enterocele is defined as a herniation of the peritoneal sac between the vagina and the rectum. This hernial sac contains either sigmoid colon or small bowel. It is well known that enteroceles are associated with symptoms of pelvic discomfort. It is unclear whether enteroceles contribute to evacuation difficulties. Controversies also exist regarding their treatment of choice. The aim of the present prospective study was to evaluate the impact of obliteration of the pelvic inlet on evacuation difficulties and on symptoms of pelvic discomfort.

METHODS

From October 1994 to August 1996 20 females (median age, 53; range, 41-73 years) with symptomatic enterocele diagnosed on evacuation proctography underwent obliteration of the pelvic inlet with a nonabsorbable Mersilene mesh. All patients presented with pelvic discomfort, characterized by feelings of prolapse (n=20), pelvic pressure (n=16), lower abdominal pain (n=13), and false urge to defecate (n=15). Symptoms of obstructed defecation were noted in 15 patients. Six months after repair, evacuation proctography with opacification of the small bowel and the vagina was repeated.

RESULTS

The median duration of follow-up was 25 (range, 10-34) months. A persistent or recurrent enterocele was observed in none of the patients. All symptoms of pelvic discomfort disappeared except feelings of a false urge to defecate, which persisted in 27 percent of cases. Symptoms of obstructed defecation persisted in all patients with evacuation difficulties.

CONCLUSIONS

In patients with pelvic discomfort enterocele should be considered as a possible causative factor. It is unlikely that this abnormality contributes to the problem of obstructed defecation. In patients with a symptomatic enterocele, obliteration of the pelvic inlet with a Mersilene mesh is an adequate treatment.

Giant esophageal polyp: a clinical and radiological entity with variable histology

Giant pedunculated esophageal polyps are very rare. They may stay asymptomatic for a long time, and first come to the attention of the patient and the clinician after regurgitation into the mouth. Regurgitation, however, can be dangerous and has been known to lead to asphyxia and death due to closure of the larynx by the polyp mass. For this reason resection of the giant polyp is essential when it is discovered. We have seen four cases of giant esophageal polyps (GEP) at our institution. All four patients have undergone removal of the giant polyps. The histological diagnoses were fibrovascular polyp, liposarcoma, hamartoma and multiple lipomas. The mode of clinical presentation, radiological appearances, variable histological diagnoses, and therapy options in these four patients are presented along with a review of the literature.

Rectal wall contractility in response to an evoked urge to defecate in patients with obstructed defecation

PURPOSE

The aim of this study was to examine rectal sensory perception and rectal wall contractility in response to an evoked urge to defecate and to identify differences between control subjects and patients with obstructed defecation.

METHODS

Twenty control patients (10 men; median age, 47 (range, 17-78) years) and 29 female patients with disabling obstructed defecation (median age, 48 (range, 18-70) years) entered the study. Under radiologic control, an infinitely compliant barostat balloon was inserted over a guide wire into the proximal part of the rectum. Additionally, a latex balloon was introduced into the distal part of the rectum. This latex balloon was inflated until an urge to defecate was experienced. Simultaneously, rectal wall contractility was assessed by measuring the variations in barostat balloon volume. These variations were expressed as percentage changes from baseline volume.

RESULTS

By comparing controls and patients with obstructed defecation, a significant difference was found regarding mean distending volume required to elicit an urge to defecate (135 +/- 38 vs. 214 +/- 87 ml of air; P < 0.001, Mann-Whitney U-test). In all controls, the evocation of an urge to defecate induced a pronounced increase in rectal tone, proximal to the distal stimulating balloon. By comparing controls and patients, the increase in rectal tone was found to be significantly higher in control subjects (35 +/- 10 vs. 9 +/- 10 percent; P < 0.001). Twenty-five patients (86 percent) showed no or only minimum (<20 percent) increase in rectal tone during the perception of an urge to defecate. In 14 of these patients, the threshold for this perception was increased. Only four patients (14 percent) showed a relatively normal increase (>20 percent) in rectal tone. However, their threshold for perception was greatly increased.

CONCLUSION

The assembly used in this study provides a useful tool for investigation of rectal evacuation. In all of our patients, obstructed defecation was associated with abnormal rectal sensory perception and/or altered rectal wall contractility.

Anismus: fact or fiction?

PURPOSE

Although anismus has been considered to be the principal cause of anorectal outlet obstruction, it is doubtful whether contraction of the puborectalis muscle during straining is paradoxical. The present study was conducted to answer this question.

METHODS

During the first part of the study, we retrospectively reviewed 121 patients with constipation and/or obstructed defecation (male:female, 10/111; median age, 51 years). All of these patients underwent electromyography (EMG) of the pelvic floor and the balloon expulsion test (BET) in the left lateral position. Evacuation proctography was performed in all of these patients in the sitting position. Both the posterior anorectal angle and the central anorectal angle were measured. EMG and BET were also performed in ten controls (male:female, 4/6; median age, 47). In 147 patients with fecal incontinence (male:female, 24/123; median age, 58) only EMG activity was recorded. Criteria for anismus during straining were increase or insufficient (<20 percent) decrease of EMG activity, failure to expel an air-filled balloon on BET, and decrease or insufficient (<5 percent) increase of anorectal angle on evacuation proctography. Between June 1994 and March 1995, we conducted a second prospective study in a consecutive series of 49 patients with constipation and/or obstructed defecation and 28 patients with fecal incontinence. Both groups were compared with 19 control subjects. In this study, all three tests were performed. EMG and BET were performed both in the left lateral position and in the sitting position.

RESULTS

The retrospective study was undertaken by comparing the constipated patients with the incontinent patients and the controls, and the anismus detected by EMG was found in, respectively, 60, 46, and 60 percent. Failure to expel the air-filled balloon was observed in 80 constipated patients (66 percent) and in 9 control subjects (90 percent). Based on posterior anorectal angle and central anorectal angle measurements, anismus was diagnosed in, respectively, 21 and 35 percent of constipated patients. In the prospective study, none of the tests showed significant differences regarding the prevalence of anismus between the two subgroups of patients and the control subjects. The prevalence of anismus only differed between constipated and incontinent patients when the diagnosis was based on BET in the sitting position (67 vs. 32 percent; P < 0.005). Our study shows that contraction of the puborectalis muscle during straining is not exclusively found in patients with constipation and/or obstructed defecation. The three tests most commonly used for the diagnosis of anismus showed an extremely poor agreement.

CONCLUSION

Based on these findings, we doubt the clinical significance of anismus.

Role of defecography in predicting clinical outcome of rectocele repair

PURPOSE

The aim of this study was to evaluate the role of defecography in predicting clinical outcome of rectocele repair.

METHODS

Between January 1988 and July 1994, 74 consecutive patients (median age, 54 (range, 35-81) years) with a rectocele and symptoms of obstructed defecation were studied prospectively. After preoperative evaluation by a standardized questionnaire, physical examination, and defecography, a combined transvaginal/transanal rectocele repair was performed. At follow-up, all patients had defecography. Long-term results were qualified by an independent observer after a median follow-up of 58 (range, 14-89) months as "excellent," "good," or "poor."

RESULTS

Rectocele repair was considered excellent in 37 patients and good in 13 patients. Defecography six months after surgery did not show persistent or recurrent rectocele in any of the patients. Size of the rectocele, barium-trapping in the rectocele, internal intussusception, rectal evacuation, and perineal descent did not appear to influence clinical outcome. Radiologic evidence of anismus did not correlate with long-term results of rectocele repair.

CONCLUSIONS

Combined transanal/transvaginal repair of rectocele is an efficient therapy in patients with obstructed defecation. Various defecographic parameters (size of rectocele, internal intussusception, rectal evacuation, perineal descent, radiologic signs of anismus) do not appear to influence clinical outcome of surgery. The main value of defecography is the objective demonstration of rectocele and any associated abnormalities such as an enterocele preoperatively and again in objective assessment of the postoperative results.

Digital subtraction arthrography in preoperative evaluation of painful total hip arthroplasty

OBJECTIVE

The objective of this clinical study was to define the diagnostic value of plain radiography, digital subtraction arthrography and two-phase bone scintigraphy in patients with clinically loose or infected hip prostheses.

DESIGN

Digital subtraction arthrograms, scintigrams and plain radiographs of 70 consecutive patients who underwent revision hip arthroplasty were scored individually and in masked fashion for the presence or absence of features indicating loosening of femoral and/or acetabular components. The operative findings acted as the gold standard.

RESULTS

Digital subtraction arthrography was best (P < 0.001) for predicting a loose acetabular component, while no significant additional predictive value was found for plain radiographs (P = 0.24) and scintigraphy (P = 0.27). Digital subtraction arthrography was also the most important modality for predicting a loose femoral component (P = 0.001), while the plain radiograph was of significant (P = 0.04) additional value and scintigraphy was of no additional value (P = 0.13) on multivariate analysis.

CONCLUSION

Digital subtraction arthrography gives the best results in the prediction of loosening of acetabular and femoral components. Plain radiographs give additional information on loosening of the femoral component, but scintigraphy offers no additional advantage.

The impact of anismus on the clinical outcome of rectocele repair

There are doubts as to whether rectocele repair (RR) is beneficial for patients with concomitant anismus. The aim of this prospective study was to evaluate the effect of anismus on the clinical outcome of RR. In 71 out of 75 patients who underwent RR evacuation proctography (EP) was performed. Electromyography (EMG) of the pelvic floor and balloon expulsion test (BET) were carried out in 61 and 35 patients respectively. On EP, measuring the central anorectal angle (CARA) and the posterior anorectal angle (PARA), signs of anismus were found in 34 and 28 percent of the patients respectively. EMG and BET revealed anismus in 39 and 71 percent of the patients respectively. These results showed poor agreement. RR was successful in 53 (71%) out of 75 patients (follow up 14-74 months). No differences were found in clinical outcome in patients with and without signs of anismus. In conclusion, RR is beneficial for patients with obstructed defecation, and signs of anismus do not appear to be a contraindication for RR.

Indices from flow-volume curves in relation to cephalometric, ENT- and sleep-O2 saturation variables in snorers with and without obstructive sleep-apnoea

In a group of 37 heavy snorers with obstructive sleep apnoea (OSA, Group 1) and a group of 23 heavy snorers without OSA (Group 2) cephalometric indices, ENT indices related to upper airway collapsibility, and nocturnal O2 desaturation indices were related to variables from maximal expiratory and inspiratory flow-volume (MEFV and MIFV) curves. The cephalometric indices used were the length and diameter of the soft palate (spl and spd), the shortest distance between the mandibular plane and the hyoid bone (mph) and the posterior airway space (pas). Collapsibility of the upper airways was observed at the level of the tongue base and soft palate by fibroscopy during a Muller manoeuvre (mtb and msp) and ranked on a five point scale. Sleep indices measured were the mean number of oxygen desaturations of more than 3% per hour preceded by an apnoea or hypopnoea of more than 10 s (desaturation index), maximal sleep oxygen desaturation, baseline arterial oxygen saturation (Sa,O2) and, in the OSA group, percentage of sleep time with Sa,O2 < 90%. The variables obtained from the flow-volume curves were the forced vital capacity (FVC), forced expiratory and inspiratory volume in 1 s (FEV1 and FIV1), peak expiratory and peak inspiratory flows (PEF and PIF), and maximal flow after expiring 50% of the FVC (MEF50). The mean of the flow-volume variables, influenced by upper airway aperture (PEF, FIV1) was significantly greater than predicted.(ABSTRACT TRUNCATED AT 250 WORDS)

Indices from flow-volume curves in relation to cephalometric, ENT- and sleep-O2 saturation variables in snorers with and without obstructive sleep-apnoea

In a group of 37 heavy snorers with obstructive sleep apnoea (OSA, Group 1) and a group of 23 heavy snorers without OSA (Group 2) cephalometric indices, ENT indices related to upper airway collapsibility, and nocturnal O2 desaturation indices were related to variables from maximal expiratory and inspiratory flow-volume (MEFV and MIFV) curves. The cephalometric indices used were the length and diameter of the soft palate (spl and spd), the shortest distance between the mandibular plane and the hyoid bone (mph) and the posterior airway space (pas). Collapsibility of the upper airways was observed at the level of the tongue base and soft palate by fibroscopy during a Müller manoeuvre (mtb and msp) and ranked on a five point scale. Sleep indices measured were the mean number of oxygen desaturations of more than 3% per hour preceded by an apnoea or hypopnoea of more than 10 s (desaturation index), maximal sleep oxygen desaturation, baseline arterial oxygen saturation (Sa,O2) and, in the OSA group, percentage of sleep time with Sa,O2 < 90%. The variables obtained from the flow-volume curves were the forced vital capacity (FVC), forced expiratory and inspiratory volume in 1 s (FEV1 and FIV1), peak expiratory and peak inspiratory flows (PEF and PIF), and maximal flow after expiring 50% of the FVC (MEF50). The mean of the flow-volume variables, influenced by upper airway aperture (PEF, FIV1) was significantly greater than predicted.(ABSTRACT TRUNCATED AT 250 WORDS)

Stress radiography of the talocrural and subtalar joints

The object of this investigation was to determine a possible subtalar component in a group of 33 patients with chronic ankle instability. A group of 10 subjects without ankle/foot symptoms acted as controls. A standardized radiographic assessment of talar and simultaneous subtalar tilt was made. A hinge device to stress the joints and a specific subtalar stress view (Brodén view) were used under fluoroscopic control. Radiographs were made with the feet: (1) in neutral position, (2) after inversion with moderate force until the point of fair restraint (step 1), and (3) after inverting with more force as far as the conditions would allow (step 2). An increase of talar tilt between step 1 and step 2 was only found in feet that were symptomatic. This suggests that this increase is only possible when lateral ligaments are damaged. Further research is necessary to determine whether this finding can serve as a parameter to discriminate between physiological and abnormal talar tilt. A wide range of subtalar motion was found in both symptomatic and asymptomatic feet. With the present method, practically all subtalar joints showed some loss of congruity and medial shift of the calcaneus in relation to the talus. This could not be correlated with ankle instability at the talocrural joint. The consequence of the use of different subtalar stress methods has so far received little attention and is discussed.

Case report: a hamartoma presenting as a giant oesophageal polyp

Giant oesophageal polyp (GOP) is a very rare intraluminal tumour. It is usually a benign, fibrovascular polyp arising from the proximal third of the oesophagus. We describe a patient with such a polyp but with a histological diagnosis of hamartoma. Regurgitation of the polyp into the mouth, which can lead to asphyxia, is a feared complication. A barium swallow and oesophagoscopy are the common diagnostic procedures. The site of the polyp and its volume often define the method of resection.

Case report: solitary ischaemic small bowel stenosis

A case of a solitary short ischaemic stenosis of the small bowel is presented and the literature reviewed. An ischaemic segmental stenosis of the small bowel is a rare lesion, but can lead to acute or subacute obstructive symptoms. A well conducted small bowel enteroclysis is the diagnostic modality of choice in such a case, which may require surgical resection after the diagnosis is made.

The histological response of the lungs of rats to potentially suitable water soluble bronchographic contrast agents iotrolan (a non-ionic dimer) and iopamidol (a non-ionic monomer)

The recent need for selective bronchography during bronchoscopy in certain patients, together with paediatric indications for tracheo-bronchography, raises the question as to which contrast medium is both safe and efficient. The purpose of the present experimental study was to define the tissue reaction caused by iotrolan and iopamidol in the bronchi and lungs of rats. 60 animals used in this study were divided into five groups receiving iotrolan 300, iopamidol 370, iopamidol 150, physiological saline and anaesthetic only, the last two acting as control groups. Statistically there was no significant difference in the histological reaction between iotrolan 300, iopamidol 370 and iopamidol 150 compared with the control groups, although iotrolan 300 appeared to result in the least tissue reaction. With its adequately high iodine concentration, low osmolality and relatively high viscosity, iotrolan 300 would appear to be a suitable contrast medium for bronchography.

Oesophageal varices: how reliable is a barium swallow?

Although barium swallow is a quick and easy method for diagnosing oesophageal varices, there is considerable variation between observers because objective quantitative radiological criteria have so far not been defined. In order to define these criteria, a blind radiological/endoscopic comparative study using endoscopy as the gold standard was retrospectively carried out in 72 patients. A prospective study was then carried out in 47 patients to define the validity of the radiological criteria found by the first study. The results of both studies showed that the length and the width of the mucosal folds representing varices as measured on barium swallow radiographs have a significant relationship with the grade of the varices as determined by endoscopy. We conclude that barium swallow is a quick and reliable method for quantitative assessment of oesophageal varices.

Pelvic phleboliths: is there an association with diverticulitis?

Pelvic phleboliths are familiar structures to radiologists although their pathogenesis is not fully understood. The literature suggests a relationship between the prevalence of phleboliths and diverticular disease, and with a low-fibre diet. Phleboliths are said to be seen more frequently in women and on the left side in the pelvis. Their number seems to increase with advancing age. We have attempted to establish relations of phleboliths with diverticulitis, diverticulosis, sex, age and pelvic location. In this study the only statistically significant relation was an increase of the number of phleboliths with advancing age.

Accuracy of ultrasound and oral cholecystography in assessing the number and size of gallstones: implications for non-surgical therapy

Prior to non-surgical therapy of gallstones it is important to assess their number and size. In order to evaluate the accuracy of ultrasound (US) and oral cholecystography (OCG) in counting and measuring gallstones, a prospective blind study was conducted to compare the results of US (n = 99) and OCG (n = 36), either alone or in combination (n = 34), with the number and size of gallstones retrieved after cholecystectomy. The number of gallstones was accurately estimated by US and OCG in 74% and 69% of the cases, respectively. In assessing the presence of up to three, five or 10 gallstones both US and OCG proved reliable. In measuring the size of gallstones, there was 19% accuracy with US compared with only 3% with OCG. With an accepted measurement error of 3 mm these values increased to 80% for US and 44% for OCG. US proved more reliable than OCG in discriminating gallstones smaller or larger than 10 mm and smaller or larger than 20 mm, but with US, detection of gallstones larger than 30 mm was problematic. Both US and OCG underestimated gallstone size. The combination of both techniques did not significantly improve the assessment of either number or size of gallstones compared with the results obtained with US or OCG alone. It is concluded that (1) both US and OCG have some limitations in assessing the number and size of gallstones, (2) the combination of both examinations does not improve accuracy, and (3) patient selection for non-surgical treatment of gallstones can be started by US alone.

Case report 724. Yaws

A 15-year-old girl presented with the typical clinical, serological, and pathological lesions of yaws. The patient was a native of Sumatra. The important diagnostic criteria and the relationship to venereal syphilis were discussed.

The value of ultrasound in predicting non-visualization of the gall-bladder on OCG: implications for imaging strategies in patient selection for non-surgical therapy of gallstones

Gall-bladder visualization on oral cholecystography (OCG) is required for most non-surgical therapies of gallstones. In this study we attempted to establish sonographic criteria which will predict non-visualization of the gall-bladder on OCG. For this purpose we compared the results of ultrasound (US) and OCG in 171 patients with gallstones being assessed for non-surgical therapy. Sonographic criteria for non-visualization were a contracted gall-bladder and stone impaction in the gall-bladder neck or cystic duct. In detecting findings which predict non-visualization on OCG, US had a sensitivity of 78.3% and a specificity of 97.6%. The predictive values were: positive findings 92.3% and negative findings 92.4%. The overall accuracy was 92.4%. We conclude that US can be used as a first step in selecting patients for non-surgical therapy and if US indicates a contracted gall-bladder, 11% of the patients can be excluded from further diagnostic imaging.

Evacuation proctography (defecography). A new seat and method of examination

A new evacuation proctography (defecography) seat and method of examination is described. The seat was constructed in association with the department of biotechnology. It is constructed of perspex and radiographic demonstration of the distal rectum and anal canal region is obtained without distracting artefacts.

Radiological and dermatological findings in two patients suffering from early yaws in Indonesia

Two children suffering from early yaws in Indonesia are presented. Apart from skin lesions and a positive treponemal serology in both patients, involvement of tubular bones, particularly of the hands, was revealed by radiological examination. In one patient involvement of a distal phalanx was remarkable. Early diagnosis and treatment of yaws is important since a delay in treatment may result in severe and irreversible bone deformities of the late stage of the disease. This report illustrates that radiological changes, although rare, can still be detected in the early stage of yaws in areas where yaws is resurgent nowadays.

Clinical use of Hexabrix for radiological evaluation of leakage from the upper gastrointestinal tract based on experimental study

The clinical use of Hexabrix (May and Baker) was started about 3.5 years ago for the radiological evaluation of patients in whom the possibility of leakage of contrast medium outside the upper gastrointestinal tract, particularly the oesophagus, was anticipated. The majority (greater than 70%) of the patients were in their early post-operative period. No adverse reactions because of the use of Hexabrix were encountered.

Intraperitoneal toxicity of Hytrast: an experimental study

The toxic effects of Hytrast were studied on the peritoneum of laboratory rats in order to define the lethal dose and possible causes of toxicity. The results show that Hytrast, due to its toxicity, should not be used in any clinical situation where gastrointestinal tract perforation or leakage is a possibility.

Experimental evaluation of various available contrast agents for use in the gastrointestinal tract in case of suspected leakage. Effects on pleura

Intrapleural injections of seven contrast agents were carried out in experimental rats in order to find a safe contrast agent to use in the radiological examination of the upper gastrointestinal tract in cases where leakage outside the upper gastrointestinal tract into the pleural space could be suspected, particularly post-operatively. The contrast agent in such cases could enter the mediastinum, pleura, peritoneum or lungs and bronchi. Hexabrix (May and Baker) and Gastrografin (Schering AG) produced the least tissue reaction in the pleura. Due to the potential risk of aspiration in such cases Gastrografin is not suitable as it is known to produce significant reaction in the lungs and may even prove to be fatal. Hexabrix, therefore, appears to be the safest contrast agent where leakage into the pleural space may be suspected.

Experimental evaluation of various available contrast agents for use in the gastrointestinal tract in case of suspected leakage. Effects on peritoneum

The effects of seven contrast agents were studied on the peritoneum of rats in order to find the most suitable and safe contrast agent in cases where leakage might be expected from the gastrointestinal tract into the peritoneal cavity. Hexabrix appeared to give the least tissue reaction, with Amipaque and Gastrografin in second place (but not significantly different statistically).

Experimental evaluation of various available contrast agents for use in the upper gastrointestinal tract in case of suspected leakage: effects on mediastinum

The tissue reaction of seven contrast agents--pure barium sulphate, Micropaque, Hytrast, Dionosil, Gastrografin, Amipaque and Hexabrix-was evaluated on the mediastinum of rats. This work was undertaken to define the most suitable and safe contrast agent for use in the upper gastrointestinal tract in cases where leakage outside the gut into the mediastinum, pleura or peritoneal cavity may be suspected and aspiration may be an accompanying risk. Keeping in mind the danger of aspiration, Hexabrix and Amipaque appear to be the safest contrast media for the mediastinum.

Experimental evaluation of various available contrast agents for use in the upper gastrointestinal tract in case of suspected leakage. Effects on lungs

The reactions of seven contrast agents--pure barium sulphate, Micropaque, Gastrografin, Dionosil, Hytrast, Amipaque and Hexabrix--on the bronchi and lungs of rats were studied. This work was undertaken to find a safe gastrointestinal contrast agent for use in post-operative patients where aspiration may be an accompanying risk. Amipaque and Hexabrix produced no significant histological reaction in the lungs and would, therefore, appear to be suitable for use in such cases.

Lipoma of the esophagus

A case report is presented of a 64-year-old female with a very large pedunculated lipoma in the esophagus. These lipomas are relatively uncommon and in spite of their large size may cause very few symptoms. Often they are first recognized after regurgitation of the tumor mass in the mouth which may, in some cases, lead to asphyxia and death. Because of the danger of asphyxia, therapy by excision of the tumor soon after diagnosis appears to be essential. A classification of benign esophageal tumors is given and the role of radiology in diagnosis described.