The bifurcation and topography of the posterior tibial artery within the tarsal tunnel

PURPOSE

The tarsal tunnel (TT) is a fibro-osseous anatomical space coursing from the medial ankle to the medial midfoot. This tunnel acts as a passage for both tendinous and neurovascular structures, including the neurovascular bundle containing the posterior tibial artery (PTA), posterior tibial veins (PTVs) and tibial nerve (TN). Tarsal tunnel syndrome (TTS) is the entrapment neuropathy that describes the compression and irritation of the TN within this space. Iatrogenic injury to the PTA plays a significant role in both the onset and exacerbation of TTS symptoms. The current study aims to produce a method to allow clinicians and surgeons to easily and accurately predict the bifurcation of the PTA, to avoid iatrogenic injury during treatment of TTS.

METHODS

Fifteen embalmed cadaveric lower limbs were dissected at the medial ankle region to expose the TT. Various measurements regarding the location of the PTA within the TT were recorded and multiple linear regression analysis performed using RStudio.

RESULTS

Analysis provided a clear correlation (p < 0.05) between the length of the foot (MH), length of hind-foot (MC) and location of bifurcation of the PTA (MB). Using these measurements, this study developed an equation (MB = 0.3*MH + 0.37*MC - 28.24 mm) to predict the location of bifurcation of the PTA within a 23° arc inferior to the medial malleolus.

CONCLUSIONS

This study successfully developed a method whereby clinicians and surgeons can easily and accurately predict the bifurcation of the PTA, to avoid iatrogenic injury that would previously lead to an exacerbation of TTS symptoms.

327 The Impact of Implementation of Recommendations from the IFHD 2017 Annual Report in an Irish Model 3 Hospital

Background

Hip fractures in the older person are associated with high mortality rates (NICE, 2011). Up to 40% of patients never regain their pre-fracture mobility, 10-20% never return to live at home. The Irish Hip Fracture Database (IHFD) National Report 2017 recommends appointment of an orthogeriatric consultant in this hospital to achieve IHFD standards 4 to 6.

Methods

We analysed a subset of HIPE data collected for the IHFD in patients over 60 years over a three month period from September – November 2017 and compare it to September – November 2018 after introduction of an orthogeriatric service. We looked at geriatrician review, bone health assessment, falls assessment, discharge destination, 30-day re-admission rate and mortality during admission.

Results

There were 45 hip fracture patients in each group. In the 2017 group, mean age was 79, female 64%; compared to mean age of 80, female 62.2% in 2018. In 2018, after the appointment of an orthogeriatrician, 95.6% of patients were seen by a geriatrician compared to 4.4% in 2017. In 2018, 97.7% received bone health assessment compared to 26.8% in 2017. In 2018 95.3% received specialist falls assessment, compared to 2.4% in 2017. Mean length of stay was 18 days in 2018 versus 13 days in 2017. 2.2% of patients were discharged to convalescence in 2018, 26.7% in 2017. 57.8% of patients were discharged to off-site rehabilitation in 2018 compared to 40% in 2017. 2.2% patients died during admission in 2018, 8.9% in 2017. In 2018, 6.7% of patients were readmitted within 30 days, 8.8% in 2017.

Conclusion

Provision of rapid Comprehensive Geriatric Assessment to all hip fracture patients, reduces falls and fracture risk. There is evidence of improvement in IHFD standards 4-6, mortality rate and 30-day readmission rate. Moreover, the orthogeriatric service has led to increased referral to rehabilitation services ensuring optimal functional recovery.

284 Improving Adherence to Irish Hip Fracture Database Standards 1 and 2

Background

The Irish Hip Fracture Database (IHFD) National Report 2017 demonstrated poor performance across all six IHFD standards in our hospital. For the purpose of this study we focused on standards 1 and 2. IHFD standard 1: All patients with hip fracture should be admitted to an acute orthopaedic ward within 4 hours of ED presentation/ brought directly to theatre from ED within 4 hours, and IHFD standard 2: All patients with hip fracture who are medically fit should have surgery within 48 hours of admission and during normal working hours.

Methods

We examined IHFD standards 1 and 2 from August 2017-January 2018 and August 2018-January 2019 after the appointment of an orthogeriatrician and use of the first Hip Fracture Pathway in August 2018. We also analysed data collected from February-April 2019 after amendment of the hip fracture pathway for patients presenting to the ED.

Results

IHFD Standard 1: From August to January 2017, 2.5% of patients were admitted to an orthopaedic ward within 4 hours versus 18.1% in 2018. IHFD Standard 2: in 2017, 64.8% underwent surgery within 48 hours during working hours, versus 65.3% in 2018. From February to April 2019, 32.1% of patients were admitted to an orthopaedic ward within 4 hours (IFHD 1) and 56.6% of patients underwent surgery within 48 hours and during working hours (IFHD 2).

Conclusion

Close collaboration between Emergency Medicine, Orthopaedic Surgery, Radiology, Nursing colleagues, Allied Health Professionals and Orthogeriatrics and amendment of the Hip Fracture Pathway have led to improvements in Standards 1 and 2. The addition of an orthogeriatric service in the hospital has resulted in an improvement in adherence to all IFHD standards. However, there are ongoing challenges to achieving Standard 2 including limited theatre access and increasing numbers of older patients on novel oral anticoagulants.

Emergency Department Overcrowding And The Full Capacity Protocol Cross Over Study: What Patients Who Have Experienced Both Think About Being An Extra Patient In The Emergency Department Or On A Ward

Hospital overcrowding is evidenced by Emergency Department (ED) overcrowding. The Full Capacity Protocol (FCP) is activated to move patients to temporary extra beds placed in the inpatient wards. This research aims to establish patient preferences when waiting for a ward bed in an Irish Hospital. The FCP in Beaumont Hospital was updated in the context of national guidelines. Patients’ attitudes towards boarding in the ED as opposed to being in extra beds on the wards were assessed using a questionnaire based structured interview. Ninety nine patients took part in the study. Eighty three patients (83.83%) preferred being an additional patient on the ward, 12 (12.12%) had no preference and four (4.04%) preferred being boarded in the ED. Moving patients from the ED into extra beds on the wards creates space, facilitating safer care delivery. The vast majority of patients who have experienced both, prefer being boarded in the ward rather than in the ED.

Unusual orange-colored choroidal metastases

PURPOSE

To report the clinical and paraclinical features of two patients with orange- colored choroidal metastases in whom the primary cancers have not previously been associated with such lesions.

CASE REPORT

Orange-colored choroidal lesions were detected on the fundus examination of one patient with metastatic small cell neuroendocrine tumor of the larynx and oropharynx, and in another subject with metastatic alveolar soft part sarcoma of the leg. Although ultrasonographic characteristics of the choroidal masses were comparable to those of choroidal hemangiomas, fluorescein angiography revealed delayed initial fluorescence along with minimal fluorescence in subsequent phases of the angiogram which were in clear distinction from the earlier appearing and progressively intense fluorescence observed with circumscribed choroidal hemangiomas.

CONCLUSION

Small cell neuroendocrine tumors and alveolar soft part sarcomas should be considered among the differential diagnoses for orange-colored choroidal metastases. Identifying these choroidal lesions could facilitate localizing the occult primary tumor. Fluorescein angiography may differentiate a unifocal orange choroidal metastasis from a circumscribed choroidal hemangioma.

Clinical and pathologic characteristics of biopsy-proven iris melanoma: a multicenter international study

OBJECTIVE

To collaborate with multiple centers to identify representative epidemiological, clinical, and pathologic characteristics of melanoma of the iris. This international, multicenter, Internet-assisted study in ophthalmic oncology demonstrates the collaboration among eye cancer specialists to stage and describe the clinical and pathologic characteristics of biopsy-proven melanoma of the iris.

METHODS

A computer program was created to allow for Internet-assisted multicenter, privacy-protected, online data entry. Eight eye cancer centers in 6 countries performed retrospective chart reviews. Statistical analysis included patient and tumor characteristics, ocular and angle abnormalities, management, histopathology, and outcomes.

RESULTS

A total of 131 patients with iris melanoma (mean age, 64 years [range, 20-100 years]) were found to have blue-gray (62.2%), green-hazel (29.1%), or brown (8.7%) irides. Iris melanoma color was brown (65.6%), amelanotic (9.9%), and multicolored (6.9%). A mean of 2.5 clock hours of iris was visibly involved with melanoma, typically centered at the 6-o'clock meridian. Presentations included iritis, glaucoma, hyphema, and sector cataract. High-frequency ultrasonography revealed a largest mean tumor diameter of 4.9 mm, a mean maximum tumor thickness of 1.9 mm, angle blunting (52%), iris root disinsertion (9%), and posterior iris pigment epithelium displacement (9%). Using the American Joint Commission on Cancer-International Union Against Cancer classification, we identified 56% of tumors as T1, 34% of tumors as T2, 2% of tumors as T3, and 1% of tumors as T4. Histopathologic grades were G1-spindle (54%), G2-mixed (28%), G3-epithelioid (5%), and undetermined (13%) cell types. Primary treatment involved radiation (26%) and surgery (64%). Kaplan-Meier analysis found a 10.7% risk of metastatic melanoma at 5 years.

CONCLUSIONS

Iris melanomas were most likely to be brown and found in the inferior quadrants of patients with light irides. Typically small and unifocal, melanomas are commonly associated with angle blunting and spindle cell histopathology. This multicenter, Internet-based, international study successfully pooled data and extracted information on biopsy-proven melanoma of the iris.

Ring melanoma of the ciliary body: clinical and ultrasound biomicroscopic characteristics

BACKGROUND

Diagnosis of ring melanoma is clinically difficult since the mass can remain hidden with standard slit-lamp biomicroscopy. The aim of this study was to evaluate the utility of ultrasound biomicroscopy (UBM) as a diagnostic tool for ring melanoma of the ciliary body.

METHODS

This was a retrospective study of 6 eyes of 6 patients at Princess Margaret Hospital, Toronto, Ont., with a diagnosis of ring melanoma of the ciliary body. The tumor extension was measured clinically, gonioscopically, ultrasonographically (by UBM), and pathologically.

RESULTS

Since 2000, 6 cases of ring melanoma have been diagnosed at Princess Margaret Hospital: 2 women and 4 men, median age 57 years. Five patients presented as uncontrolled hyperchromic glaucoma (83%). Ciliary body involvement on slit-lamp examination ranged from 60 to 180 degrees. Ciliary body involvement as assessed by UBM ranged from 180 to 300 degrees. Tumor extension according to pathological examination ranged from 210 to 360 degrees. With these measures, the ring melanoma clinical criteria were not filled by 5 patients.

INTERPRETATION

UBM is an important tool in determining the extent of ciliary body involvement and classifying these lesions.

Primary intraosseous hemangioma of the orbit: an unusual presentation of an uncommon tumor

CASE REPORT

An asymptomatic patient was referred for assessment of an intraocular amelanotic mass in her left eye. Examination showed a mass effect in the inferior location at the 5 o'clock position. This abnormality was defined with ultrasound biomicroscopy and standard ultrasound, but because the appearance was not typical of a melanoma or other choroidal infiltrate, magnetic resonance images and computed tomograms of the orbits were obtained, identifying an extraocular mass arising from the zygomatic rim. Results of a biopsy reported an intraosseous hemangioma.

COMMENTS

The diagnosis of intraosseous hemangioma, because of its low incidence and unusual manner of presentation, can be challenging. Computed tomography and biopsy are helpful in making a definitive diagnosis.

Extrascleral extension in association with ciliochoroidal melanoma: ultrasound biomicroscopy with histopathological correlation

CASE REPORT

We present the case of a 71-year-old man with a melanoma arising from the ciliary body and extending into the choroid. Ultrasound biomicroscopy (UBM) revealed connection via an emissary canal to a subconjunctival nodule. Although evaluation for metastasis was negative at the time of diagnosis, multiple hepatic metastatic deposits were found 2 years post-enucleation.

COMMENTS

It is crucial to identify the presence of scleral invasion and extrascleral extension for proper management planning in patients with choroidal melanomas. This case demonstrates that UBM is an accurate and useful tool for characterizing the morphologic pattern of scleral invasion of intraocular tumours.

Stereotactic radiotherapy in the treatment of juxtapapillary choroidal melanoma: preliminary results

PURPOSE

To evaluate the preliminary results of stereotactic radiotherapy in the management of patients with juxtapapillary choroidal melanoma.

METHODS & MATERIALS

A retrospective, consecutive case series of 28 patients with choroidal melanoma located within 2 mm of the optic nerve who were treated with stereotactic radiotherapy at Princess Margaret Hospital, Toronto, between October 1998 and May 2001.

RESULTS

Median age was 62 years. Median tumor height was 4.6 mm and median maximum tumor diameter was 9.4 mm. The prescribed radiation dose was 70 Gy in five fractions over 10 days and median follow-up was 18.5 months. Posttreatment, 2 patients developed local tumor regrowth and 3 patients developed liver metastases. Actuarial rates of local tumor control, metastases, and survival at 18 months were 96%, 10%, and 94%, respectively. Actuarial rates of radiation-induced neovascular glaucoma, cataract, retinopathy, and optic neuropathy at 18 months were 20%, 29%, 30%, and 37%, respectively. A higher radiation dose to the lens was associated with an increased risk of cataract (p = 0.02).

CONCLUSIONS

Stereotactic radiotherapy offers a noninvasive alternative to enucleation and brachytherapy in the management of juxtapapillary choroidal melanoma. However, further efforts are needed to optimize local tumor control and minimize radiation-induced complications.

'The trouble with sex - it always gets in the way': an evaluation of a peer-produced teenage pregnancy video

This paper describes the development and pilot evaluation of a peer-produced video, produced for use as part of North Staffordshire's Personal and Social Education school programme. A number of studies carried out in the area, including a recent audit into post-coital contraception in the under 20s, have shown that young people need to know how to access contraceptive services. Background surveys also suggest that young people need to be aware of the wider issues implicit in contraception. The impetus for the video came from the Advice Centres for the under Twenties (ACT) Working Party, who produced the video together with Staffordshire University's Media Studies Department and a local high school drama group. The video was intended for use in schools, and was designed to be complimentary to an updated and standardised teaching pack, which was already in preparation. The pilot study showed the video to be beneficial as a stand-alone intervention, principally to promote active discussion on topics that might otherwise be difficult to approach. A comparison of responses before and after the educational session demonstrated an improvement in knowledge in most areas. Further objective evaluation of the combined video and teaching pack is now necessary.

Renal prostanoids after unclipping the denervated one-kidney, one-clip hypertensive rat

The contribution of the renal nerves in maintaining blood pressure and modulating renal prostanoid synthesis was examined in established (less than 8 wk in duration) one-kidney, one-clip (1K,1C) hypertension in the rat. Systolic blood pressure was measured for 7 days after renal denervation, at which time the renal artery clip was removed. Twenty-four-hour urinary excretion of PGE2 and 6-keto-PGF1 alpha (stable degradation product of PGI2) was determined before and after denervation and unclipping. Compared with sham-denervated rats, denervation (n = 15) resulted in a small but significant fall in blood pressure (from 216 +/- 4 to 182 +/- 4 mmHg after 48 h) and an increase in urinary 6-keto-PGF1 alpha (from 31 +/- 4 to 43 +/- 5 ng/24 h after 24 h). There was no change in PGE2 excretion. Seven days after surgery, blood pressures were similar in denervated (202 +/- 4 mmHg) and sham-denervated (211 +/- 5 mmHg) rats and fell to a similar extent 24 h after unclipping (142 +/- 3 and 147 +/- 4 mmHg, respectively). Urinary 6-keto-PGF1 alpha increased from 25 +/- 5 to 74 +/- 11 in denervated and 21 +/- 2 to 72 +/- 9 ng/24 h in sham-denervated rats in the 24 h after unclipping. PGE2 excretion increased approximately twofold over this period. These findings indicate that the renal nerves have only a minor role in established hypertension in the 1K,1C rat and that the reversal of hypertension and stimulation of renal prostanoid synthesis following unclipping is not dependent on neural mechanisms.

Increased renal prostanoid synthesis after unclipping the one-kidney, one-clip hypertensive rat: effect of renal denervation

Renal denervation of hypertensive one-kidney, one-clip (1K, 1C) rats resulted in a minor fall in blood pressure (216, s.e.m. = 4, to 182, s.e.m. = 4, mmHg) 24 h later, which returned to predenervation levels with 1 week. Subsequent unclipping led to a similar fall in blood pressure in denervated (202, s.e.m. = 4 to 142, s.e.m. = 3) and sham-denervated (211, s.e.m. = 5 to 147, s.e.m. = 4) rats. Unclipping also resulted in a marked rise in urinary PGE2 and 6-keto PFG1 alpha in both denervated and sham-denervated animals. It appears that 1K, 1C hypertension, 8 weeks after clipping, is only slightly dependent on renal nerves. Unclipping results in increased renal synthesis of PGE2 and PGI2 which is not dependent on intact renal innervation.

Corneal and conjunctival deposits in monoclonal gammopathy

An IgG kappa monoclonal gammaglobulinopathy was discovered during investigation of long-standing corneal deposits. The deposits were located between the basal epithelial cells, in the anterior layer of Bowman's membrane and in keratocytes. This is the third reported case of corneal deposits associated with Bence Jones proteinuria and the fifth case of corneal deposits associated with crystalline inclusions within plasma cells of the bone marrow. A biopsy of the buccal mucosa showed intraepithelial inclusions. Immunoelectrophoresis of the tears revealed a small amount of secretory IgA and a moderate amount of IgG, practically all kappa light chains.