Literature on the various techniques for imaging injuries to the ankle syndesmosis to determine the most appropriate imaging modality for diagnosing syndesmosis ligament disruption and instability was reviewed using the following data sources: Pubmed, Google scholar, SportsDiscus, E-journals and PLOSone. Search terms used were: syndesmosis paired with injury, imaging, radiology, X-ray, stress X-ray, arthrography, ultrasound, nuclear medicine scan, CT scan, MRI and arthroscopy. Articles were selected by reading abstracts and the full article if indicated. Further articles were derived from the references of the primary articles. Plain x-rays of the ankle will detect approximately half on AP view to two-thirds on mortise view of syndesmosis injuries. Syndesmosis injuries frequently occur in association with tibial or fibular fractures. Intra-operative stress radiography failed to detect approximately half of instabilities confirmed at arthroscopy. The current benchmark imaging techniques to diagnose syndesmosis injury and diastasis are arthroscopy and high-power (3T) MRI. Ultrasound is a promising, developing, cost-effective imaging technique which is yet to reach its full diagnostic potential. CT and nuclear medicine scans have limited roles. MRI (3T) scanning in the plane of the syndesmotic ligaments is the investigation of choice to detect ankle syndesmosis injuries. In the presence of associated injuries requiring surgery, arthroscopic viewing with stress examination is the diagnostic benchmark when available.

A Morel-Lavall ee lesion is a post-traumatic soft tissue degloving injury which presents as a haemolymphatic mass or collection. Morel-Lavall ee lesions are the result of direct trauma or shearing forces abruptly separating skin and subcutaneous tissue from underlying fascia causing disruption of perforating vessels and nerves, creating a potential space that may fill with blood, lymph and debris forming a collection. Morel-Lavall ee lesions usually occur adjacent to osseous protuberances, most commonly along the greater trochanter. Early diagnosis and management is essential to prevent complications. We present this pictorial review to highlight the imaging characteristics of Morel-Lavall ee lesions across imaging modalities to improve recognition, early diagnosis and management.

BackgroundAt present, there are no registered products for the treatment of subchondral Bone Marrow Edema Lesion (BML) and associated knee pain. Patients who do not respond to current anti-inflammatory therapies are left with limited treatment options, and may resort to operative management with Total Knee Arthroplasty (TKA). We report the use of Pentosan Polysulphate Sodium (PPS) for the treatment of BMLs of the knee.Case presentationWe report the case of a 70-year-old female with knee osteoarthritis presenting with a high level of knee pain, scoring 8 on the Numerical Rating Scale (NRS), and functional limitation demonstrating a poor Lysholm Knee Score of 37. MRI scans of the knee revealed subchondral BML in the medial femoral condyle and medial tibial plateau. The patient was administered a course of Pentosan Polysulphate Sodium (PPS) intramuscularly twice weekly, for 3 weeks. MRI scans 2 weeks post-treatment showed complete resolution of the bone marrow edema at the medial femoral condyle and medial tibial plateau with concomitant recovery from pain (NRS pain score of 0), and a 43% improvement of the Lysholm Knee Score. In addition, marked reduction in joint effusion was also demonstrated in the MRI scan post PPS therapy.ConclusionThe MRI interpretations demonstrate improved clinical outcome measures ensuing therapeutic intervention with PPS, and warranting further investigation into the efficacy of PPS in the treatment of BML associated pain and dysfunction in the osteoarthritic population via randomized controlled trial, or equivalent rigorous methodological technique.

Iliopsoas impingement is a commonly recognised source of groin pain following total hip replacement. When conservative measures fail, open or arthroscopic iliopsoas tendon release can reliably alleviate pain and improve function. This article describes an alternative ultrasound-guided percutaneous technique, achieving iliopsoas tenotomy utilising a modified 18G coaxial needle and thus minimising the morbidity and cost associated with an open or arthroscopic procedure. This method proved successful with resultant complete resolution of patient symptoms. To the knowledge of the authors, this is the first case of ultrasound-guided percutaneous iliopsoas tenotomy for iliopsoas impingement post total hip replacement.

Background: An under-recognized complication of gelatin-based haemostatic agents is their potential to cause anaphylactic reactions. This review aims to collate and analyse case in the literature of intraoperative anaphylaxis secondary to locally applied haemostatic agents. Methods: An electronic search was performed on databases Medline, Embase, Pubmed and ProQuest. A total of 7671 articles were reviewed from title and abstract. After exclusion criteria and duplicates removed, 19 articles with 21 cases were included for analysis. Data extracted from each of the articles included patient demographics, haemostatic agent used, surgery type, known allergies and any objective evidence of hypersensitivity post anaphylactic episode, that is tryptase levels, IgE levels, skin prick testing. Results: Fifty-seven percent of cases involved patients <18 years of age; 57% of cases involved spinal surgery; 100% of cases displayed objective evidence of hypersensitivity (tryptase levels, bovine or porcine IgE levels, or skin prick testing). Thirty-three percent of patients had exposure preoperatively to a known agent causing anaphylaxis or allergy which would preclude the use of a gelatin-based haemostat. These products included vaccines, spam meats, red meat, Jell-O and CollaPlug. Gelatin-based haemostat agents included Floseal, Gelfoam, Surgiflo, fibrin glue, Avitene, haemofibrine sponge, topical bovine thrombin and thrombin-soaked gelatin. Conclusion: Increased awareness of allergy to gelatin-based haemostats for surgical and anaesthetic is imperative, with 33% of cases having a known contraindication to gelatinbased haemostat. This review highlights important aspects in the pre-operative patient history and post-event patient investigation that could assist anaesthetists and surgeons in the prevention of future events.

A variety of surgical procedures derive therapeutic benefit from the division of retinacular, ligamentous or tendinous structures. Examples include carpal tunnel release for median nerve impingement, annular pulley release for trigger finger and tendon division for spastic muscular contractures. Here, using an animal cadaveric model, we describe the first steps in determining the feasibility of a novel, percutaneous, ultrasound-guided needle-cutting technique to achieve the same ends. The technique we describe involves the creation of an effective needle tenotomy device via a simple modification to an 18G coaxial, beveled needle. The technique holds promise for the development of a minimally invasive alternative approach that utilises readily available technology and equipment with minimisation of morbidity and cost associated with open procedures.

Requirements for tissue-equivalent mixtures are discussed, and methods are described for formulating mixtures exact in elemental composition and density. Methods are also given for estimating the densities and vapour pressures of mixtures of known compounds, as well as a list of the properties of compounds useful in tissueequivalent formulations. A density value of 1.066 f 0.003 g at 37 ' c is obtained for lean mammalian muscle, from the literature and from experiments. A density of 1.063 g cm-3 at 37'c is obtained from the literature, for Standard Man exclusive of air voids. Tissue-equivalent liquids and their properties are presented for Standard Man and for lean muscle. These are exact in composition for C, H, 0, S, Ca, P, S, K, Sa, Cl and Mg, range from 1.012 to 1.106 g in density at 25 "c, and include mixtures for the standard density range of 1.06-1.07 g cm-3. Two simplified mixtures are also described, correct only for C, H, 0 and N, for use where exact elemental composition is not important.

Study Design:Prospective cohort study.Objectives:To evaluate the role of magnetic resonance imaging (MRI) in evaluation of fusion status following anterior lumbar interbody fusion (ALIF) and compare agreement and confidence in assessing fusion or its absence on MRI to the current standard computed tomography (CT).Methods:A prospective follow up of patients undergoing surgery by 2 spine surgeons between 2012 and 2015 at a single institution. Fusion was assessed at different time points in these patients by 2 independent musculoskeletal radiologists. Fusion was analyzed in coronal and sagittal planes using both imaging modalities, with confidence being attributed on a scale of 0 to 3. Assessors were blinded to patient data.Results:Fourteen patients (25 levels) with mean follow-up of 10.2 months (range 2.4-20.3 years) and age of 41 years (range 20.7-61.5 years) were assessed. MRI within the interbody cage in coronal (κ = .58) and sagittal (κ = .50) planes had the highest interobserver agreement. CT anterior to the cage in coronal (κ = .48) and sagittal (κ = .44) planes, as well as within the cage in coronal (κ = .50) and sagittal planes (κ = .44) showed moderate agreement. Confidence anterior to the interbody cage using MRI scan was reduced when compared with remaining angles and imaging modalities.Conclusions:The study demonstrates that MRI may be a useful tool in the assessment of fusion following ALIF with results comparable to CT, and that it may have a useful role in select patients especially considering marked radiation exposure reduction.