Timing of magnetic resonance imaging affects the accuracy and interobserver agreement of anterolateral ligament tears detection in anterior cruciate ligament deficient knees

Purpose@#We aimed to identify the anterolateral ligament (ALL) tears in anterior cruciate ligament (ACL)-deficient knees using standard 1.5-Tesla magnetic resonance imaging (MRI). @*Methods@#We included all patients who underwent primary ACL reconstruction at our center between 2012 and 2015. Exclusion criteria included patients with multiple ligament injuries, lateral collateral ligament, posterolateral corner, and infections, and patients who underwent MRI more than 2 months after their injury. All patients (n = 148) had ACL tears that were subsequently arthroscopically reconstructed. The magnetic resonance (MR) images of the injured knees performed within 2 months of injury were reviewed by a musculoskeletal radiologist and an orthopedic surgeon. The patients were divided into two groups. The first group of patients had MRI performed within 1 month of injury. The second group of patients had MRI performed 1–2 months after the index injury. Both assessors were blinded and the MR mages were read separately to assess the presence of ALL, presence of a tear and the location of the tear. Based on their readings, interobserver agreement (kappa statistic (K)), sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy were compared. @*Results@#The ALL was identified in 100% of the patients. However, there was a discrepancy of up to 15% in the identification of tear of the ALL. In the first group in which MRI scans were performed within 1 month of injury, the ALL tear was identified by the radiologist in 92% of patients and by the surgeon in 90% of patients (Κ = 0.86). In the second group in which MRI scans were performed within 1–2 months of the injury, the ALL tear was identified by the radiologist in 78% of patients and by the surgeon in 93% of patients (K = 0.62). @*Conclusion@#The ALL can be accurately identified on MRI, but the presence and location of ALL tear and its location cannot be reliably identified on MRI. The accuracy in identification and characterization of a tear was affected by the interval between the time of injury and the time when the MRI was performed.Level of evidence: Diagnostic, level IIIb, retrospective.

Timing of magnetic resonance imaging affects the accuracy and interobserver agreement of anterolateral ligament tears detection in anterior cruciate ligament deficient knees

Purpose@#We aimed to identify the anterolateral ligament (ALL) tears in anterior cruciate ligament (ACL)-deficient knees using standard 1.5-Tesla magnetic resonance imaging (MRI). @*Methods@#We included all patients who underwent primary ACL reconstruction at our center between 2012 and 2015. Exclusion criteria included patients with multiple ligament injuries, lateral collateral ligament, posterolateral corner, and infections, and patients who underwent MRI more than 2 months after their injury. All patients (n = 148) had ACL tears that were subsequently arthroscopically reconstructed. The magnetic resonance (MR) images of the injured knees performed within 2 months of injury were reviewed by a musculoskeletal radiologist and an orthopedic surgeon. The patients were divided into two groups. The first group of patients had MRI performed within 1 month of injury. The second group of patients had MRI performed 1–2 months after the index injury. Both assessors were blinded and the MR mages were read separately to assess the presence of ALL, presence of a tear and the location of the tear. Based on their readings, interobserver agreement (kappa statistic (K)), sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy were compared. @*Results@#The ALL was identified in 100% of the patients. However, there was a discrepancy of up to 15% in the identification of tear of the ALL. In the first group in which MRI scans were performed within 1 month of injury, the ALL tear was identified by the radiologist in 92% of patients and by the surgeon in 90% of patients (Κ = 0.86). In the second group in which MRI scans were performed within 1–2 months of the injury, the ALL tear was identified by the radiologist in 78% of patients and by the surgeon in 93% of patients (K = 0.62). @*Conclusion@#The ALL can be accurately identified on MRI, but the presence and location of ALL tear and its location cannot be reliably identified on MRI. The accuracy in identification and characterization of a tear was affected by the interval between the time of injury and the time when the MRI was performed.Level of evidence: Diagnostic, level IIIb, retrospective.

Clinics in diagnostic imaging (201). Small bowel intramural haematoma induced by anticoagulation therapy with associated reactive ileus

A 74-year-old woman receiving long-term anticoagulation with warfarin for chronic atrial fibrillation presented with severe acute abdominal pain, diarrhoea and vomiting. Initial laboratory workup revealed a deranged coagulation profile. Computed tomography of the abdomen and pelvis demonstrated spontaneous distal jejunal intramural haematoma with associated reactive ileus. No overt pneumatosis intestinalis, intraperitoneal free gas or haemoperitoneum was seen. Based on clinical and imaging findings, a diagnosis of over-anticoagulation complicated by small bowel intramural haematoma was made. The patient was managed non-operatively with analgesia, cessation of warfarin and reversal therapy with vitamin K. Warfarin therapy was recommenced upon resolution of symptoms and optimisation of coagulation status. The clinical presentation, radiological features and overall management of anticoagulation-induced bleeding are further discussed in this article.

Spectrum of computed tomography manifestations of appendiceal neoplasms: acute appendicitis and beyond

Appendiceal neoplasms are rare and often only discovered incidentally during surgery performed for acute appendicitis. Computed tomography (CT) has been demonstrated to be a reliable technique for accurately establishing the preoperative diagnosis of appendiceal neoplasms that manifest as acute appendicitis through the presence of certain imaging findings. Other manifestations of appendiceal neoplasms include appendiceal mass, mucocoele, localised abscess formation, ileus, increasing abdominal girth from pseudomyxoma peritonei, and intussusception. This pictorial essay illustrates varied CT findings of neoplasms of the appendix, with emphasis on the more commonly encountered manifestations of these tumours.

Clinics in diagnostic imaging (179). Severe rhabdomyolysis complicated by myonecrosis

A 32-year-old man presented to the emergency department with severe right lower limb pain and swelling of three days' duration. He had multiple prior admissions for recurrent seizures and suicide attempts. Markedly elevated serum creatine kinase levels and urine myoglobinuria were consistent with a diagnosis of rhabdomyolysis. Initial magnetic resonance imaging of the right lower limb revealed diffuse muscle oedema and features of myositis in the gluteal muscles and the adductor, anterior and posterior compartments of the thigh. Follow-up magnetic resonance imaging performed 11 days later showed interval development of areas of myonecrosis and haemorrhage. The causes, clinical presentation and imaging features of rhabdomyolysis are discussed.

Clinics in diagnostic imaging (165). Oesophageal rupture secondary to malposition of an SB tube gastric balloon

Oesophageal rupture is a life-threatening complication of balloon tamponade for bleeding oesophageal varices. We herein describe the clinical course and imaging findings in a 33-year-old Indian man who had a Sengstaken-Blakemore (SB) tube inserted for uncontrolled haematemesis, which was unfortunately complicated by malposition of the gastric balloon with resultant oesophageal rupture. The inflated SB tube gastric balloon was visualised within the right hemithorax on chest radiography after the SB tube insertion. Further evaluation of the thorax on computed tomography confirmed the diagnosis of oesophageal rupture associated with right-sided haemopneumothorax. It is crucial for both the referring clinician and reporting radiologist to recognise early the imaging features of an incorrectly positioned SB tube gastric balloon, so as to ensure prompt intervention and a reduction in patient morbidity and mortality.

Clinics in diagnostic imaging (171). Caecal volvulus with underlying intestinal malrotation

A 46-year-old Chinese woman with a history of cholecystectomy and appendicectomy presented to the emergency department with symptoms of intestinal obstruction. Physical examination revealed central abdominal tenderness but no clinical features of peritonism. Plain radiography of the abdomen revealed a grossly distended large bowel loop with the long axis extending from the right lower abdomen toward the epigastrium, and an intraluminal air-fluid level. These findings were suspicious for an acute caecal volvulus, which was confirmed on subsequent contrast-enhanced computed tomography (CT) of the abdomen and pelvis. CT demonstrated an abnormal positional relationship between the superior mesenteric vein and artery, indicative of an underlying intestinal malrotation. This case highlights the utility of preoperative imaging in establishing the diagnosis of an uncommon cause of bowel obstruction. It also shows the importance of recognising the characteristic imaging features early, so as to ensure appropriate and expedient management, thus reducing patient morbidity arising from complications.

Clinics in diagnostic imaging (167). Total shoulder arthroplasty glenoid component loosening with secondary rotator cuff failure

A 59-year-old woman who had previously undergone an anatomic left total shoulder arthroplasty presented with increasing left shoulder pain and significant reduction in motion of the left shoulder joint. No evidence of prosthetic loosening or periprosthetic fracture was detected on the radiographs or fluoroscopic arthrogram images. Dual-energy computed tomography (DECT) images revealed evidence of loosening of the glenoid component and secondary rotator cuff failure. This case illustrates how a combination of detailed clinical history, careful physical examination and DECT arthrogram evaluation may be used to identify complications of an anatomic total shoulder arthroplasty.

Concomitant early avascular necrosis of the femoral head and acute bacterial arthritis by enteric Gram-negative bacilli in four oncologic patients

We present four cases of concomitant early (modified Ficat-Arlet stage I) avascular necrosis of the femoral head and acute bacterial arthritis of the hip joint by Gram-negative enteric bacilli. This was found in immunosuppressed oncologic patients whose clinical presentations and radiological findings were not entirely specific for joint sepsis. It is important to recognise the coexistence of these two pathologies, so as to avoid a delay in diagnosis and prevent significant morbidity and mortality.

Clinics in diagnostic imaging (147). Male breast carcinoma

A 51-year-old man with no significant medical history was referred to our institution for further management of a palpable, painless right breast lump that had been gradually increasing in size for a period of six months. Physical examination revealed a firm right breast lump and bloody right nipple discharge, but no skin involvement or axillary lymphadenopathy was observed. Subsequent mammography and breast ultrasonography demonstrated a discrete, heterogeneous and vascular right breast mass with spiculated and angulated margins. The breast mass was found to be an invasive ductal carcinoma on ultrasonography-guided core needle biopsy. This case illustrates that a combination of detailed clinical history, careful physical examination and radiological assessment using mammography and breast ultrasonography may be used to identify cases suspicious for male breast carcinoma that warrant biopsy.