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Need Bunion Surgery? A Weight Bearing CT Scan Could Help You Decide

When a patient appears to have a bunion, a physician typically orders traditional foot X-Rays as part of the clinical evaluation. The X-Rays capture three views of the foot- dorsoplantar, medial oblique, and lateral. But is this enough information to understand complex, three-dimensional object such as the foot? 

A growing number of foot & ankle specialists are advocating that there may be better way to evaluate this common deformity.

“Weight bearing computed tomography scans are beginning to take our understanding to the next level,” Dr. Paul Dayton, DPM, of Des Moines, IA, said in a roundtable discussion on bunions published in the Foot & Ankle Specialist academic journal. “Once you see the connection between coronal rotation and what we have traditionally evaluated on AP radiographs, it opens up a whole new understanding.”

On X-Rays, physicians have to “mentally interpolate” the valgus component of the bunion because they do not adequately capture the frontal plane, said Dr. Robert Weinstein, DPM, FACFAS, of Atlanta, explained in a CurveBeam case study.  

“Since the condition is a tri-plane deformity, we need to understand all of the components and their angular values contributing to the deformity,” Weinstein said. “Better deformity analysis leads to better pre-operative planning, surgical execution, and post-operative results.”

The new data on the coronal position is “exciting” because it explains so many of foot and ankle specialists’ previous questions, Dayton said.  

Weight bearing CT imaging also allows for evaluating deformities that involve external rotation. Rotation of one or more metatarsals, including displacement of the sesamoids, cannot be clearly seen in standard foot X-ray imaging. The lack of the weight-bearing aspect in traditional medical CT imaging means the physician cannot evaluate displacement and rotation under load.

Hallux Valgus Blog Post Image 1
One component of the deformity that is seldom quantified is external rotation, or frontal plane deviation. The presence of rotation of the hallux implies a more complex deformity. A very careful assessment of the first metatarsophalangeal joint architecture, including sesamoid position, their condition, and erosion or flattening of the crista on the inferior first metatarsal head is essential.

It has long been known that in hallux valgus or bunions the relationship between the metatarsal head and the sesamoids is altered,” Andy Goldberg, MD, MBBS, FRCS (TR and Orth), of Stanmore, United Kingdom, told Lower Extremity Review magazine. he said. “The sesamoid bones should sit underneath the metatarsal head, while in hallux valgus the big toe drifts off the sesamoids and the tip of the big toe points outwards. But our research has shown that in many cases the cartilage is worn, which in essence is localized arthritis, and we believe that this could affect the outcome of surgery.”

rotated first met and sesamoids

CubeVue, the pedCAT weight bearing CT imaging system’s custom visualization software, allows physicians to create oblique and frontal-plane images of varying angles and thicknesses from the weight bearing CT data.
CubeVue, the pedCAT weight bearing CT imaging system’s custom visualization software, allows physicians to create oblique and frontal-plane images of varying angles and thicknesses from the weight bearing CT data.

Weight bearing CT images could have an impact on the technique a physician selects to repair a bunion, Dr. Dayton said.

“The knowledge that the sesamoids can be in normal position medial and lateral to the crista yet look dislocated on the AP X-ray because of pronation completely changes our mindset about the need for capsular balancing,” Dayton said. “We can see that in those cases supination corrects the deformity.”

Standing CT vs. MRI for Advanced Visualization of Knee Cartilage and Meniscus

At the 2016 OARSI World Congress in Amsterdam, Netherlands, Dr. Neil Segal, MD, MS, and Dr. Ali Guermazi, MD, PhD , presented a poster describing “Advances In Visualization Of Knee Cartilage And Meniscus With Standing Computed Tomography Arthrography”.

Standing CT arthrography (SCTa) has also been shown to have some distinct advantages over MRI, according to the poster presentation. “Potential advantages of SCTa over non-weight-bearing MRI/MRA include: 3D measures of meniscal position and morphology; detection of pathology not detected in unloaded positions; and ability to bear weight bilaterally in a functional position, better recreating the magnitude of muscle and external forces acting about the knee during usual standing….  SCTa can be obtained in multiple knee flexion angles, while an MRI knee coil may permit imaging only with the knee in extension, and SCTa is less expensive than MRI.”

Figure 1: SCTa and corresponding MR arthrography demonstrating outstanding delineation of tibiofemoral and patellofemoral articular cartilage, with better differentiation between the cartilage and subchondral bone on SCTa. Visualization of the boundaries of the menisci was achieved to a similar degree on SCTa and MRA.
Figure 1: SCTa and corresponding MR arthrography demonstrating outstanding delineation of tibiofemoral and patellofemoral articular cartilage, with better differentiation between the cartilage and subchondral bone on SCTa. Visualization of the boundaries of the menisci was achieved to a similar degree on SCTa and MRA.

As part of the background for their presentation, Drs. Segal and Guermazi stated that “MRI is the standard for non-invasive visualization of cartilage and menisci, and … Absence of weight bearing limits evaluation of the functional position and configuration of these structures…Advances in standing CT (SCT) have allowed 3D imaging of the knees while under physiological loads, similar to fixed-flexed or semi-flexed radiograph protocols.”

Their objective was to evaluate a protocol for SCTa for imaging weight bearing cartilage and menisci and to assess potential advantages over non-weight bearing MRI.

figure 2
Figure 2: Sagittal reformatted SCTa and its corresponding MRA demonstrated outstanding delineation of articular cartilage with better differentiation between the cartilage and subchondral bone on SCTa, while also visualizing the ACL and PCL in the femoral notch.

Although the sample size was small, the results were noteworthy. As shown in the images, SCTa permits evaluation of cartilage and menisci in three dimensions, while the patient is standing and under physiological load. Furthermore, SCTa, “may be useful for assessment of menisci as well as tibiofemoral and patellofemoral cartilage in functional stance,” according to the presentation.

The two participants in the study were a 42-year-old man without osteoarthritis (Figures 1 and 2), and a 67-year-old woman with KL2 knee osteoarthritis (figures 3-5). The participants had a similar contrast agent applied.

Figure 3a: Sagittal SCTa demonstrating minimal cartilage thinning on the left medial tibial plateau Figure 3b: Axial image depicting location of the sagittal slice in Figure 3a
Figure 3a: Sagittal SCTa demonstrating minimal cartilage thinning on the left medial tibial plateau
Figure 3b: Axial image depicting location of the sagittal slice in Figure 3a

The actual imaging techniques used were fixed-flexed (approximately 20°) SCTa (INVESTIGATIONAL ONLY cone beam CT knee imaging system*, CurveBeam, Warrington, PA, USA) and non-weight bearing MRI (Siemens TrioTim, Washington DC, USA).

“Following 2-3 minutes of unloaded knee flexion and extension, a low-dose SCT scan was acquired utilizing cone beam reconstruction. Participants were positioned with the tips of the great toes, patellae, and the anterior superior iliac spines coplanar to each other and the feet 10°externally rotated. Scans were acquired with a 0.3mm isotropic voxel size (20x 35x35cm) with an effective radiation dose of approximately 0.1 mSv. 10 minutes following SCTa, MR arthrography was acquired (NEX=1, ETL=3, Slice thickness=2 mm, Slice spacing 2 mm, Matrix= 240 x 320, FOV=140 mm with axial T1 fat-sat (TR=712 msec, TE=12 msec); coronal T1 fat sat (TR=730 msec, TE=10 msec); and sagittal T1 fat sat (TR=796 msec, TE=10 msec).

Figure 4a: Coronal SCTa demonstrating minimal cartilage thinning on the left medial tibial plateau Figure 4b: Axial image depicting location of coronal slice in Figure 4a
Figure 4a: Coronal SCTa demonstrating minimal cartilage thinning on the left medial tibial plateau
Figure 4b: Axial image depicting location of coronal slice in Figure 4a
Figure 5a: Sagittal SCTa image demonstrating a small tear of the tibial surface of the post. horn of the medial meniscus Figure 5b: Axial image depicting location of sagittal slice in Figure 5a
Figure 5a: Sagittal SCTa image demonstrating a small tear of the tibial surface of the post. horn of the medial meniscus
Figure 5b: Axial image depicting location of sagittal slice in Figure 5a

*The CurveBeam knee imaging system is investigational only and is not available for sale in the US.

pedCAT: Early Diagnosis of Osteomyelitis in the Diabetic Patient

The pedCAT weight bearing CT imaging system could identify bone infection at an early stage, and possibly prevent amputations, researchers at the California School of Podiatric Medicine at Samuel Merritt University determined in a report.

The researchers outlined two cases where “the use of CBCT device enabled us to diagnose and treat osteomyelitis in a timely manner, preventing its spread to adjacent bone and soft tissue, and minimizing the amount of required surgical resection.”

Plain radiograph is the primary imaging modality for the osteomyelitis diagnosis, the report states, but X-Rays may not reveal osteolytic changes for up to 20 days from the onset of infection or until the bone density is reduced by 30 – 50 percent.

Osteomyelitis is one of the most feared complications of diabetic foot ulceration, which often leads to lower extremity amputation and disability. Early diagnosis of osteomyelitis increases the likelihood of successful treatment and preserving ambulatory function. Unfortunately, most of the currently available imaging modalities are of limited use in assessing early stages of bone infection due to their low specificity and sensitivity for early osteolytic changes.

Magnetic resonance imaging (MRI) is more sensitive and specific than X-Ray, and yields greater accuracy in detecting soft tissue abscesses or early osteomyelitis in patients with high clinical suspicion and negative radiographs. In controversial or uncertain cases where MRI is not available, other imaging techniques such as indium-labeled leukocyte imaging combined with radionucleotide bone scan can be used as an alternative. (“Preventive and Therapeutic Strategies for Diabetic Foot Ulcers” – Foot & Ankle International® 2016, Vol. 37(3) 334– 343 – Chris C. Cychosz, BS, Phinit Phisitkul, MD, Daniel A. Belatti, BS, and Dane K. Wukich, MD).

Nuclear Imaging and MRI perform well in detecting early onset of osteomyelitis; but they are expensive to own and operate, are time-consuming in their acquisition of images.

What is desirable for early detection is a method that is accurate, inexpensive, and readily available. Cone beam CT, and the pedCAT in particular, fills this gap nicely.  The device is small enough to fit into most practices, offers high-resolution 3D imaging capabilities, and has a reduced radiation dose compared to traditional CT, according to the report.

Lead author Alexander M. Reyzelman, DPM,  and his associates reported on two diabetic patients who presented with infected neuropathic foot ulcers and were evaluated for potential osteomyelitis using plain film radiographs and the pedCAT CBCT scanner. In both cases, the “pedCAT was instrumental in identifying bone infection. The diagnosis of osteomyelitis was later confirmed by positive findings on bone biopsy. The use of CBCT device enabled us to diagnose and treat osteomyelitis in a timely manner, preventing its spread to adjacent bone and soft tissue, and minimizing the amount of required surgical resection.”

Case 1

A 49 year old diabetic female presented with an infected neuropathic ulcer at the lateral aspect of her fourth digit. The ulcer demonstrated malodor, cellulitis that extended to fourth metatarsophalangeal joint and positive probe-to-bone test. The plain film radiographs and CBCT were utilized in order to rule out osteomyelitis and assess the extent of soft tissue infection. The weight-bearing X-rays of the affected foot revealed subtle lucency at the lateral aspect of the proximal phalanx of the fourth digit, which was contiguous with the ulcer location. However, this finding alone was not sufficient to yield a conclusive diagnosis.  The images obtained using PedCAT clearly demonstrated the break in the cortex and the area of osteolysis involving the proximal phalanx of the fourth digit. The head of the fourth metatarsal and adjacent digits appeared intact. These findings, in conjunction with the clinical appearance of the affected digit, led to a preliminary diagnosis of osteomyelitis. The patient was treated with an arthroplasty of the fourth proximal interphalangeal joint, and has fully recovered. The bone specimens obtained intraoperatively were sent for biopsy, which confirmed our preliminary diagnosis of osteomyelitis.

Case 2

A 53 year old diabetic male presented with an infected neuropathic ulcer at his fifth metatarsal head, which exhibited malodor, edema and erythema extending through tthe plantar lateral aspect of  fifth metatarsal shaft and probed to joint capsule. The X-rays demonstrated no signs of bone involvement, while CBCT revealed distinct areas of cortical lysis and bony fragmentation of the fifth metatarsal head. The proximal two thirds of the shaft of the fifth metatarsal appeared unaffected, with intact cortex, uniform bony density and lack of osseous fragmentation. The patient was treated with partial resection of the fifth metatarsal. The bone biopsy has confirmed our preliminary diagnosis of osteomyelitis.

In the concluding discussion, Dr Reyzelman noted: “Though in our case studies we have not taken advantage of the option allowing to scan the patient in both, a weight-bearing and a non-weight bearing positions, this option could be highly useful for evaluation of complex fractures and dislocations of the foot and ankle.”

Orientation of the Subtalar Joint: Measurement and Reliability Using Weight Bearing CT Scans

Is there a reliable method to predict the type and perhaps the extent of osteoarthritis one might find in the ankle? Based on a recent article, which the examined the varus and valgus orientation of the talus and the configuration of the subtalar joint under weight bearing conditions, the possibility is there.

“A majority of the patients with ankle osteoarthritis present with an asymmetric wear pattern (eg, varus or valgus type),” according to a study published in 2009 by Valderrabano V, Horisberger M, Russell I, Dougall H, Hintermann B. titled, “Etiology of ankle osteoarthritis.”

Evaluation of these wear patterns, however, remained a challenge until recently, when Nicola Krähenbühl, MD, Michael Tschuck, Lilianna Bolliger, MSc, Beat Hintermann, MD, and Markus Knupp, MD published “Orientation of the Subtalar Joint: Measurement and Reliability Using Weightbearing CT Scans.” (Foot & Ankle International® 2016, Vol. 37(1) 109–114.)

Osteoarthritis of the ankle joint is relatively common and found in 1 percent of the world’s population, and a majority of those patients present with an asymmetric wear pattern (eg, varus or valgus type), according to the authors. Furthermore, up to 60 percent of the patients suffering from an osteoarthritic ankle joint develop talar tilt with progression of the osteoarthritic process.

Current research suggests this condition is caused by deformities of the lower leg and knee joint, ligamentous laxity, tendon dysfunction and neurologic disorders. Recently, it has been proposed that the adjacent joints and, particularly, the subtalar joint may have a major influence on this process.  “However, it is rather difficult to evaluate the orientation

of the subtalar joint using conventional radiographs; CT scans would be more appropriate,” the authors posit.

To distinguish between varus/valgus configuration of the subtalar joint, Van Bergeyk et al introduced the subtalar vertical angle (SVA) in 2002 using non weight bearing CT scans. “Today, weight bearing CT scans can be performed, leading to a better understanding of the functional anatomy of the hindfoot,” the article states.

Weight bearing CT technology became available in 2012. Weight bearing imaging only had been available in 2-dimensional X-Ray imaging prior to this, but weight bearing combined with computed tomography was needed to properly measure the SVA without superimposition of non-relevant anatomy that might throw off the measurement, including analyzing the shape of the subtalar joint. The subtalar joint is especially difficult to clinically and radiographically assess in 2D, due to the superimpositions, and attempts to artificially stress the joint and then scan using a conventional (non weight bearing) CT produced inconsistent results.

“Using weight bearing CT scans, we assessed the reproducibility of the SVA and analyzed the orientation of the subtalar joint in patients with asymmetric ankle osteoarthritis. We hypothesized that the SVA would provide reliable and reproducible measurements in varus ankles presenting with a varus subtalar joint and valgus ankles with a valgus orientation of the subtalar joint, respectively,” the authors said.

Using the new technology to view the joints, including utilization of the SVA measurement, the authors concluded the SVA measurements were reliable and consistent. “In our cohort, varus osteoarthritis of the ankle joint occurred with varus orientation of the subtalar joint whereas in patients with valgus osteoarthritis, valgus orientation of the subtalar joint was found,” the study said.

The authors found the results for the healthy cohort were significantly different, suggesting the orientation of the subtalar joint may play an important role in the development of ankle joint osteoarthritis.

Weight bearing CT not only allowed the authors to clinically and radiographically assess the ankle joints under the patient’s normal weight bearing conditions, but it also enabled them to make consistent and reproducible measurements.

Panel Recap: Dr. Michael Chin, DPM, Speaks about pedCAT at FABI

Dr. Michael Chin, DPM, and Arun Singh, President & CEO of CurveBeam
Dr. Michael Chin, DPM, and Arun Singh, President & CEO of CurveBeam

His decade old X-Ray system was failing, and feeling like a warrior without his weapon, Dr. Michael Chin, DPM, knew it needed to be replaced fast.

“We could have gotten a DR system, but at the end of the day, I wanted something that was unique, and something that would change the way I practice,” Dr. Chin said.

Dr. Chin participated in a panel discussion about new technology at the Foot and Ankle Business Innovations meeting in Chicago on Jan. 30. Dr. Chin practices at The Running Institute in downtown Chicago.

Dr. Michael Chin, DPM, at FABI

Dr. Chin uses the pedCAT for all of his X-Ray and CT imaging. His X-Ray revenues cover the device’s monthly capital lease payment, and the approximately 20 CTs he and his associate order every month provide his practice with an additional revenue stream.

Dr. Chin said he is able to order a CT scan and his staff can get payer authorization in the same day. This saves his patients from having to come in for a follow-up visit.

“We can fill that slot that we would have used for a follow up with another patient,” Dr. Chin said.

Webinar Recap: “Using Weight Bearing CT to Guide Clinical Decisions”

Dr. Steven K Neufeld, MD, presented “Using Weight Bearing CT to Guide Clinical Decisions” on FOOTInnovate™  in late 2015. In one of his opening statements, Dr. Neufeld described why he decided to give the webcast: “This talk was put together really out of my enthusiasm and excitement and interest in this technology.”

The pedCAT saves time

“… (It’s) quicker for me to get a cat scan in my office, and show the results to my patient,” Dr. Neufeld said.  By the time the patient leaves the X-Ray room and gets back to the exam room, the images are ready.

Also, it helps streamline his pre-op planning. “I don’t have to send the patient to the hospital for a CT. I don’t have to schedule another appointment to review the results,” he said. “All the information is right there. It also saves the patient money. The cost of a CT scan in my office is much less than a big hospital or institution.”

Immediate feedback to the patient also helps put the patient at ease. “The patient feels comfortable with me, that I have a plan and that I know what we were going to do, and I go in there and I execute it,” Dr. Neufeld said.

The in-office workflow has improved accuracy and consistency in imaging for him as well, “Instead of getting a standard Saltzman or heel view … the weight bearing CT scan is much easier for the technician,” he said. “You don’t have to position the foot in any particular way, you don’t have to angle your beam in a particular way. You just have them stand on the machine and you then push the button, and you can determine alignment very easily.”

The pedCAT aids in definitive diagnosis and evaluation

In his webcast, Dr Neufeld proposed the following: “Based on our knowledge, it’s pretty much understood that the standard of care for any Orthopaedic foot and ankle or Podiatric evaluation of a foot and ankle problem is a weight-bearing radiograph – at least currently. The big question again is: does this X-Ray give enough?”

When it comes to alignment, weight-bearing is deemed necessary to properly evaluate the ankle under load. This is especially true when superimposition of structures does not allow you to properly determine position, rotation, translation, and joint space. In the case shown below, only weight-bearing CT allows you to see the impingement in the subtalar region; a 2D x-ray would not allow you to properly evaluate the joint spaces.

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A Total Ankle Replacement (TAR) is another surgical procedure where weight-bearing CT is a must, according to Dr Neufeld. “A non weight-bearing CT scan would really not give me information about the implant position… (The PedCAT is) a great modality for post-op,” he said. The convenience of having 3D imaging on hand for follow-up exams, even if they are non-weight-bearing, makes it easier to follow the progress of healing post-op. Failed hardware and non-unions are more readily diagnosed this way.

Dr Neufeld also regularly prescribes weight-bearing CT scans for unknown pain. “The other way that I use weight-bearing CT scan is … sometimes a patient comes in the office, and they just hurt! And you just can’t figure it out!” he said. “You know – X-Rays are normal, the exam is very vague … we’re all faced with this patient. You just can’t figure out what is going on sometimes.”

Other uses for his weight-bearing CT include Lisfanc, navicular & other hard to evaluate fractures, sesamoid problems (especially when coupled with Metatarsalgia), and arthritis. The fact that you can scan a foot in a shoe with an Orthotic also makes it easier to determine if the Orthotic is accomplishing what it is supposed to do, as shown in the image below.

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An investment worth the regulatory hurdles

Dr Neufeld, Director of the Orthopedic Foot and Ankle Center in Falls Church, Virginia, began using his pedCAT in August of 2015. The state of Virginia requires medical facilities to obtain a Certificate of Need to purchase CT systems. The approval process can be challenging. However, Dr Neufeld was both persistent and patient in his determination to bring the new weight-bearing technology into his office.

“It is brand new,” he said. “There is nothing like it out there in the state. If you can prove and show that this technology is different than what they have out there- you’re not competing with the hospitals, you are not competing with the radiology centers – and that it is unique and essential for your practice, then you can put up a fight. And if you have perseverance and some patience, you can get it, and that’s what we did.”

So why persist? Dr Neufeld’s answerer is simple.“The PedCAT has been a game-changer for my practice and one of the best investments,” he said. “It has really become a crucial part of my practice, and I would say it’s probably one of the most profitable, influential investments in modalities that I’ve added.”

Weight Bearing CT Imaging for Cuboid Subluxations

Dr. Michael Chin, DPM, presented how weight bearing CT imaging has changed how he evaluates cuboid subluxations at the American Academy of Podiatric Sports Medicine meeting held near the West Point Military Academy campus in early September, 2015.

Dr. Chin began using the pedCAT in his office in February of this year.

Not much research is out there on how to use plain radiographs to measure cuboid subluxations, Dr. Chin said in his lecture, titled, “Cuboid Syndrome…The Other Side of Heel Pain.”

Dr. Chin has tested using a bilateral oblique projection to understand the cuboid/ metatarsal relationship, and has been able to observe a slide between the head of the fourth metatarsal and the head of the cuboid.

An MRI could be ordered to see the condition of the peroneal tendon, but the study would be limited because the scan would not be weight bearing, he said.. A traditional CT scan would provide great  visualization of the bone, but would provide no information on anatomic alignment.

The pedCAT weight bearing CT imaging system is excellent for evaluating stress fractures, sesamoids, periosteal changes, or anything medullar, Dr. Chin said. Another benefit is he can measure the exact degree of subluxation between the cuboid and the fourth metatarsal head.

Dr. Chin displayed pedCAT images depicting  pre and post-reduction views of a cuboid subluxation.

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pedCAT scan of a pre-surgical patient with cuboid subluxation. Dr. Chin was able to reduce the subluxation to 2.18 mm.

Dr. Chin practices at The Running Institute in Chicago.

AOFAS Annual Meeting – CurveBeam Symposium Recap

Weight bearing CT is a vital tool for determining the cause of inexplicable pain, and also for avoiding painful surgical complications.

That was the takeaway message from a talk by Dr. Phinit Phisitkul, a clinical associate professor of orthopaedics at the University of Iowa. He shared some of his most interesting cases at a CurveBeam sponsored symposium held during the AOFAS Annual Meeting in Long Beach during the evening session.

We’ve selected three of his cases to share on this blog:

18-year-old male with Noonan Syndrome & severe flat foot: The patient presented with an unusual amount of pain that was difficult to diagnose on plain X-Ray. A weight bearing CT scan revealed he had a severe deformity – a congenital vertical talus. He also had severe impingement.

Vertical Talus - Weight Bearing CT
Vertical Talus – Weight Bearing CT
Impingement - weight bearing CT
Impingement – weight bearing CT

58 year-old male with ankle arthritis: The patient presented with a lot of pain in the ankle joint. A weight bearing CT scan showed a subluxation of the ankle joint and dramatic impingement of the calcaneal fibula. Interestingly, the subtalar joint was in pristine condition. Dr. Phisitkul determined the patient was a good candidate for ankle replacement and hindfoot realignment, and that his subtalar joint could be spared.

Calcaneal-fibular impingement and arthritis - Weight Bearing CT
Calcaneal-fibular impingement and arthritis – Weight Bearing CT

41-year-old female with Hallux Valgus: A weight bearing CT scan revealed a bone spur on the patient’s first metatarsal head. If the doctor had done a normal release, the spur may have ended up pinching the sesamoid. Instead, he performed a lateral release and excised the bone spur.

1st MT Bone Spur - Weight Bearing CT
1st MT Bone Spur – Weight Bearing CT

 

 

 

 

pedCAT: A Positive User Experience

 

Baravarian Western

“After using the pedCAT for a year, I am very impressed with how much I need it, and how many different things I use it for,” Dr. Bob Baravarian said at the 2015 Western Foot and Ankle Conference held in Anaheim, Cali. The California Podiatric Medical Association hosted the meeting at the end of June.

Dr. Baravarian cited Hallux Rigidus as one example where pedCAT imaging has been helpful because he is able to properly assess the sesamoids.

Dr. Baravarian confirmed his practice is realizing positive revenue streams as a result of the device.

Diagnostic Options for Freiberg’s Avascular Necrosis

The underlying causes of avascular necrosis of the second metatarsal head are not totally understood, but early diagnosis is essential. Delayed treatment can result in a collapse of the articular surface, making treatment more difficult.

Dr. Bob Baravarian, DPM, explained his preferred methods for diagnosing the condition in the May 2015 issue of Podiatry Today.

An X-Ray will show the overall contour and alignment of the metatarsal head.

MRI is one option for a secondary study, but edema and swelling can limit visualization of the surrounding bone region, Dr. Baravarian explained.

Weight bearing CT scans, meanwhile, clearly show the bones and joints and how they are aligned. Weight bearing CT is “our go-to imaging study,” Dr. Baravarian said in the article.

Source: Podiatry Today
Source: Podiatry Today
Source: Podiatry Today
Source: Podiatry Today

“With adequate diagnostic testing and proper patient and procedure selection, one can treat avascular necrosis of the metatarsal head with good to excellent outcomes,” Dr. Baravarian said.

Dr. Baravarian is the director of University Foot and Ankle Institute in Los Angeles. His practice offers weight bearing CT imaging services.