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Distinguishing Categories of Medial Column Ligamentous Fracture

Weight bearing CT scans offer new, three-dimensional perspectives that reveal a better understanding of the biomechanics of flat foot. That was a finding on an academic poster on display at The American Orthotic and Prosthetic Association’s National Assembly in Las Vegas (Sept. 4 – 9).

“IRD, PTTD, Posterior Tib, Flat Foot, Pronation…these are all terms that various professions use to describe some sort of medial column ligamentous breakdown,” according to the poster. “The purpose of this study is to better distinguish some types of pathomechanics of the foot. By categorizing and redefining them, it makes the description of pathology more useful for Orthotic Treatment. This was possible through the use of 3D rendering of the pedCAT machine and CurveBeam software.”

The study was conducted by Ian Engelman, M.S. CPO, and Harold Chamberlin, DPM. They looked at 3D renderings of the bony structures in flat feet, and came up with some new descriptions, as well as their possible ligamentous causes.

For example:

Lisfranc Breakdown
Lisfranc Breakdown – Tarsometatarsal Ligamentous Failure
Lateral Foot Dislocation - Deltoid Ligament Fracture
Lateral Foot Dislocation – Deltoid Ligament Fracture

 

 

 

 

 

 

 

 

 

 

The study concluded that while the exterior contours of the foot suggest certain bony pathologies, the 3D renderings provided by the pedCAT would allow for orthotists to better distinguish the pathomechanics of the foot and ankle.

An unexpected result showed a moderately strong correlation (-0.68) between the vertical position of the navicular and medial displacement in a patient population with ranging degrees of medial column breakdown.

Moderately strong correlation of -0.68
Moderately strong correlation of -0.68

 

 

 

 

 

pedCAT: Weight Bearing CT Views of Lisfranc conditions

Lisfranc injuries can easily be missed on traditional radiographs.

One research study tried to determine the level of accuracy when using plain radiographs to assess midfoot conditions. Their results confirmed a high incidence of missed diagnosis even by experienced observers.¹

“Radiographic evaluation is crucial in the diagnosis…Weight bearing views are more sensitive since tarso-metatarsal instability may be revealed…The threshold for cross sectional imaging such as multi-detector CT should be low,” according to the study.

With the pedCAT, it is possible to get a weight bearing, three dimensional scan at the point of care. The tarso-metatarsal joint can be viewed without any superimposition from surrounding anatomy.

Delaying a 3D scan can be detrimental to recovery.

“The identification of Lisfranc joint injury can be difficult and is often not detected on initial presentation to the accident department. This is important because of the correlation between delay in treatment, particularly more than six months, and poor functional outcome,” the study reported.

Midfoot dislocation, fracture, pedCAT

In this pedCAT scan, the 3D rendering shows the 2nd metatarsal is pushing on the 3rd metatarsal. The multi-planar slices reveal the fracture that is causing the dislocation. The sagittal and axial slices show a bone fragment as well. It would be impossible to see this information on a plain radiograph.

lisfranc AP

This pedCAT scan clearly depicts the gap between the first and second metatarsals.

¹ Sherief, Tamer. “Lisfranc injury: How frequently does it get missed? And how can we improve?” International Journal of the Care of the Injured. Elsevier Ltd. 10.106/j.injury.2006.10.002

Webinar: Dr. Erik Nilssen – A New Paradigm in Foot & Ankle Diagnosis

FAI webinar

“Patients come to my practice with an expectation of a higher level of care, that they’re getting the best. With the pedCAT, I am able to give them information immediately, and they leave feeling this was well worth the trip.” – Dr. Erik Nilssen

Learn how the pedCAT has changed Dr. Nilssen’s clinical practice in a webinar hosted by Foot & Ankle International and Foot & Ankle Specialist.

We hope you can join us! Sign up here.

CurveBeam Reception at AOFAS: You’re Invited!

If you’re attending the AOFAS/IFFAS Annual Meeting 2014 in Chicago from September 19 – 23, be sure to plan to attend the CurveBeam reception on September 21 at 7:30 p.m.

Sip cocktails and dine on hors d’oeuvres while mingling with colleagues who have integrated the pedCAT into their practices. Meet like-minded forward thinking peers who are considering a pedCAT acquisition at their facilities.

This informal event will feature brief talks by Prof. Dr. med. Martinus Richter, who has published studies on the pedCAT’s efficacy, as well as Dr. Erik Nilssen, MD and Dr. Martin O’Malley, MD.

When: Sept. 21, 7: 30 p.m.

Where: Hyatt Regency Wrigley’s Room (Bronze Level, West Tower)

If you can’t attend the seminar, you can visit us at booth #307 all conference long.

pedCAT: Fracture & Fusion Assessments

X-rays of the foot and ankle may not always provide conclusive assessments for post-operative fusions such as of the tarso-metatarsal joint or hind foot joints. Similarly, the physician is often left guessing if a fracture has properly healed.

“The pedCAT takes all the variability out, all the guesswork out of it,” Dr. Martin O’Malley, MD, an Associate Attending Orthopedic Surgeon at the Hospital for Special Surgery in New York, New York, said.

Dr. O’Malley said pedCAT scans allow him to clearly determine if a fusion has healed more than 50 percent, and he decides when to ambulate his patient accordingly.

“I let people walk on it earlier than before, and I keep them off longer than before,” Dr. O’Malley said.

The pedCAT provides a three-dimensional view of fractures that changes the way O’Malley sees this common diagnosis.

“These posterior pieces are often bigger than we thought were based on plain X-ray and they often travel all the way around the medial side as well, which we never thought they did,” Dr. O’Malley said. “You know, we thought it was an infrequent fracture, but now we see it routinely. Now most of my ankle fracture work, I’d say more than half the time, is through a posterior approach. For the first 15 to 18 years of my practice I would do medial/ lateral incisions. Now I’m going to the back of the ankle. And a lot of it is driven by the pedCAT.”

 

pedCAT Stress Fracture Cross Section

 

Above is an example of a navicular stress fracture in a collegiate runner that had not healed at all after six weeks of casting. Were it not for the conclusive pedCAT scan, this patient would have been allowed to ambulate.

Watch Dr. O’Malley talk more about the pedCAT here .

To offer your patients state-of-the-art fracture & fusion assessment, consider a pedCAT for your practice.

 

pedCAT: Will it Fit?

The pedCAT has been deployed to a range of medical facilities – from large hospitals to single physician practices. Each site has its own unique requirements, and CurveBeam works with each customer to ensure the first weight bearing CT scanner dedicated to the foot & ankle meets all safety requirements. Because the pedCAT is an ultra low dose device, the shielding infrastructure required is similar to that of a plain X-Ray device. The pedCAT does not need to be in a lead lined room.

Because of its compact size and relatively minimal required shielding, the pedCAT can easily fit into a practice with limited space. Take a look at these examples:

This pedCAT was placed next to a treadmill used for gait analysis.
This pedCAT was placed next to a treadmill used for gait analysis.
This pedCAT was placed in a patient examination room in this New York City podiatrist’s office.
This pedCAT was placed in a patient examination room in this New York City podiatrist’s office.
This pedCAT fit into a tight corner next to an X-Ray machine in this California podiatrist’s office.
This pedCAT fit into a tight corner next to an X-Ray machine in this California podiatrist’s office.

 

 

 

World Cup Special Edition: Soccer Player with a Sesamoid Injury

The 2014 FIFA World Cup officially begins Thursday, June 12. The world’s top soccer players will all be in Rio, Brazil for one of the biggest sporting events of the decade. The next two weeks will be filled with cheering fans, tears of joy,  and national pride. But inevitably, there will also be injuries. In fact, before the games even begin, a number of players already know they will have to sit them out.

For professional athletes and weekend warriors alike, an accurate diagnosis from the onset can make a huge impact on the speed of recovery.  When it comes to bony injuries of the foot and ankle, the pedCAT is the only tool in the world that can provide a weight bearing, three dimensional image of the entire foot or both feet.

Here’s a case of a 30-year-old soccer player, who was treated by a  California podiatrist. The athlete injured his right great toe and sesamoids while playing soccer. The doctor observed that the patient’s first metatarsophalangeal joint was swollen and ecchymotic, and that he was tender upon palpation of the great toe joint and sesamoid bones.

The doctor took standard non-weight bearing X-Ray images of the patient. The AP and lateral X-Rays showed an obvious fracture with displacement in the medial sesamoid. The lateral appeared to have a fracture, but the doctor could not confirm his suspicion with the X-Ray. The doctor also took an axial X-Ray, but it had no diagnostic benefit since the patient could not extend his great toe.

double sesamoid fracture x-ray

The doctor then took a pedCAT scan of the same patient. The CT images clearly showed a severely displaced right medial sesamoid oblique fracture and a minimally displaced lateral sesamoid fracture. The oblique lateral sesamoid fracture demonstrated 2 mm of plantar displacement with excellent bony contact/ apposition in the dorsal 4 mm of the sesamoid.

pedCAT double sesamoid fracturepedCAT lateral sesamoid fracture displacement

Although the diagnostic information provided by the pedCAT did not alter the treatment plan for the medial sesamoid, it did confirm the injury to the lateral sesamoid. More importantly, the pedCAT was able to provide diagnostic information regarding the geometric nature of the lateral sesamoid fracture.

 

“I could determine that there was enough bony contact to allow for bone healing with appropriate conservative care management,” the doctor said.

 

 

New Study: pedCAT Allows for More Accurate Bone Angle Measurements than Radiographs or CT

A study published in Foot and Ankle Surgery compared three common angle measurements of the foot taken from non-weight bearing CT, weight bearing digital radiographs, and weight bearing pedCAT scans. The study concludes, “The angles differed between radiographs, CT and pedCAT, indicating that only pedCAT is able to detect the correct angles… pedCAT prevents inaccuracies of projection and foot orientation in contrast to radiographs due to the 3D dataset which is principally independent from projection and foot orientation.”

The study also found the average image acquisition time for the pedCAT (average 270 seconds) was 70 percent faster than with radiographs and 35 percent faster than with CT.

The study was authored by Martinus Richter, Bernd Seidl, Zech Stefan, and Sarah Hahn.

High Resolution Imaging

Cone Beam CT voxel dimensions vs. Medical CT voxel dimensions
Cone Beam CT voxel dimensions vs. Medical CT voxel dimensions

pedCAT scans give you one of the highest resolution views of the foot and ankle available.

And those high resolution views are infinite – physicians can view the foot and ankle from the axial, coronal and sagittal planes by scrolling through .5 mm slices. The average medical CT slice, in comparison, is about 1 mm – 5 mm thick.

Plus, a pedCAT scan is high resolution from every dimension. To understand what that means, here’s a crash course in 3D imaging: Just like a photo is made up of two-dimensional pixels, a foot scan is made up of three-dimensional voxels. Think of a Rubik’s Cube that’s made up of millions of microscopic mini cubes.  Because the voxels are uniform, or isotropic, a pedCAT scan is the same high resolution in all planes.

A medical CT , meanwhile, is often anisotropic. Imagine that same Rubik’s Cube, but this time made up of microscopic rectangular bricks. A typical medical CT image may only be high resolution in one dimension. The other two dimensions will be relatively blurry. The degree of blurriness will depend on the voxel thickness.

If your practice or medical facility prefers not to settle for anything less than the best, it’s time to consider a pedCAT.

pedCAT: Improved Outcomes

pedCAT: Improved Outcomes

The message at RSNA Annual Meeting this past November was clear: new US healthcare laws mean the practice of radiology is no longer about volume, but value.

“We are focusing on quality metrics. It’s becoming important for us to become champions of quality in our institutions,” said Dr. Vijay Rao, MD, in a course at the meeting.

How could a pedCAT add value to your practice?

We might get an idea by looking at a comparable new technology. Breast tomosynthesis mammography provides 3D imaging for breast cancer screening, similar to the way the pedCAT provides 3D imaging for the foot and ankle. Breast tomosynthesis technology can detect breast cancers earlier than traditional 2D mammography, and can more accurately pinpoint the size, shape and location of abnormalities, according to the Massachusetts General Hospital Imaging Department.

Dr. Liane Philpotts, professor of diagnostic radiology at the Yale School of Medicine, called tomosynthesis a “game changer” and a “win-win.”

In the same way, the pedCAT eliminates variability, helps lead to better diagnoses, and makes both you and your patients more confident that treatment will result in better outcomes.

Dr. Erik Nilssen, MD, said the pedCAT helps him determine exactly when to allow patients to ambulate, “based on our ability to monitor fracture healing and fusion rates.”

Also, pedCAT scans can take the guesswork out of hindfoot alignment, said Dr. Martin O’Malley, MD, because they allow for reproducible measurements.

“We’ve never had a reproducible measurement,” until now, he said.

To see an example of a pedCAT scan that led to a more accurate diagnosis, click on the blog post title.

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