背景:在儿童足外侧疼痛或反复踝关节扭伤的情况下,医学成像通常被用来调查潜在的原因,如跟骨联合或跟骨前突过长(TLAP)。跟骨关节的诊断和分类(滑膜,综合征,或联合纤维化)通常是通过成像促进的,与TLAP相比,缺乏明确的符号学特征,除了一个小于5毫米的跟骨空间测量。然而,由于脚部和重叠骨骼的位置变化,最初在斜视射线照片上进行的这种测量可能会缺乏精度。此外,TLAP作为解剖变异体和TLAP综合征(以症状表现为特征)之间的区别,仍然是一个不确定性的主题。
目的:我们的回顾性研究目的是探讨TLAP综合征的影像学诊断。
方法:进行了一项不匹配的回顾性病例对照研究,涵盖2014年2月至2021年1月的数据。所有患者,包括回顾性和连续的,最初在我们医院接受X线摄影术和/或计算机断层扫描(CT)和/或磁共振成像(MRI).两名放射科医生独立审查了拍摄的图像(X射线照片,CT扫描,和MRI)在小儿骨科接受TLAP综合征治疗的患者和对照受试者,利用标准化问卷。对照组由没有提示TLAP综合征特征的受试者组成。问卷包括跟骨关节间隙的测量和与跟骨关节相关的间接体征的识别,如相关文献所述。
结果:共128例符合纳入标准的患者被纳入分析,包括38名患者和90名对照。研究人群中TLAP的患病率为71.5%,对照组为62.6%。在3.2mm处测量跟骨间隙的阈值有利于TLAP综合征(敏感性=97%,特异性=70%,曲线下面积[95%置信区间]=0.881[0.812-0.949]),使用CT具有更好的精度。三个间接迹象很重要:“食蚁兽鼻子”迹象,距骨喙,和锥形的跟骨前突。当与跟骨关节间隙减少一起观察时,这些体征显示出与TLAP综合征的更强关联。尤其是CT扫描。
结论:TLAP在对照组中是常见的。因此,一个变体似乎是最合理的解释,它可以被认为是跟骨联盟的一种温和形式。然而,结合提示TLAP综合征的症状,影像学进一步支持诊断,特别是跟骨关节间隙测量小于3.2毫米。使用在所有三个平面中具有二维重建的CT最准确地获得该测量。同时存在“食蚁兽鼻子”标志,距骨喙,或锥形前跟骨突提供了额外的诊断证据。在跟骨联盟的诊断方法中,斜足X线照相术在最初检测异常联盟(骨与否)方面似乎很有用,互补地,CT成为表征TLAP综合征的最佳方式。
In the presence of pain over the lateral aspect of the foot or recurrent ankle sprain in children, medical imaging is often employed to investigate potential causes, such as a calcaneonavicular coalition or a too-long anterior process (TLAP) of the calcaneus. Diagnosis and categorization of calcaneonavicular coalitions (synostosis, synchondrosis, or synfibrosis) is generally facilitated through imaging, in contrast to TLAP, which lacks well-defined semiological characteristics, apart from a calcaneonavicular space measurement of less than 5 mm. However, this measurement initially performed on an oblique view radiograph can be subject to a lack of precision due to positional variations of the foot and overlapping bones. Furthermore, the differentiation between TLAP as an anatomical variant and TLAP syndrome (characterized by symptomatic presentation), remains a subject of uncertainty.
The objective of our retrospective study was to investigate the imaging diagnosis of TLAP syndrome.
A retrospective unmatched case-control study was conducted, covering data from February 2014 to January 2021. All patients, included retrospectively and consecutively, were initially managed in our hospital with radiography and/or computed tomography (CT) and/or magnetic resonance imaging (MRI). Two radiologists independently reviewed the images taken (radiographs, CT scans, and MRIs) of patients undergoing treatment in pediatric orthopedics for TLAP syndrome and control subjects, utilizing a standardized questionnaire. The control group consisted of subjects with no features suggestive of TLAP syndrome. The questionnaire included measurements of the calcaneonavicular space and identification of indirect signs associated with calcaneonavicular coalitions, as described in the related literature.
A total of 128 patients who met the inclusion criteria were included in the analysis, including 38 patients and 90 controls. The prevalence of TLAP was 71.5% in the study population and 62.6% among controls. A threshold measurement of the calcaneonavicular space at 3.2 mm favored TLAP syndrome (sensitivity=97%, specificity=70%, area under the curve [95% confidence interval] =0.881[0.812-0.949]), with better precision using CT. Three indirect signs were significant: the \"anteater nose\" sign, the talar beak, and the tapered anterior calcaneal process. These signs demonstrated an even stronger association with TLAP syndrome when observed in conjunction with a reduction in the calcaneonavicular space, particularly in CT scans.
TLAP is common among control subjects. Therefore, a variant appears to be the most plausible explanation and it can be considered a mild form of calcaneonavicular coalition. However, in conjunction with symptoms suggestive of TLAP syndrome, the diagnosis is further supported by imaging, specifically with a calcaneonavicular space measurement of less than 3.2 mm. This measurement is most accurately obtained using CT with 2-dimensional reconstructions in all three planes. The simultaneous presence of the \"anteater nose\" sign, the talar beak, or the tapered anterior calcaneal process provides additional diagnostic evidence. In the diagnostic approach of calcaneonavicular coalition, oblique foot radiography seems useful in initially detecting abnormal coalition (bony or not), and complementarily, CT emerges as the best modality to characterize TLAP syndrome.