Voriconazole-Induced Periostitis: A Case Report.

Voriconazole-induced periostitis (VIP) is an uncommon side effect typically seen in immunosuppressed patients requiring prolonged antifungal therapy. These patients can present with bone pain, fragility, and elevated alkaline phosphatase (ALP). We present a case of VIP in a 72-year-old immunocompromised female on antifungal therapy presenting with a comminuted intertrochanteric fracture after a ground-level fall. VIP, although rare, should be included as a differential diagnosis for patients presenting with bone pain and/or fractures with radiographic features of periostitis. This is particularly true when there is a history of or prior imaging suggesting a solid organ transplant. In these cases, a dedicated review of current medications noting long-term voriconazole use in the absence of underlying rheumatologic disease can result in a confident diagnosis.

Update on Imaging of Spinal Fixation Hardware.

This article discusses instrumented spinal surgeries, the radiologic assessment of spinal fixation hardware, and the potential complications of spinal hardware. Radiography is the standard for the postoperative assessment of spinal hardware. Computed tomography and magnetic resonance imaging play a valuable role in the detection of hardware and postsurgical-related complications such as infection, pseudarthrosis, and malpositioned instrumentation. Familiarity with the normal imaging appearance of implanted spinal hardware along with the expected progression of normal postoperative osseous arthrodesis enables recognition of potential complications and helps facilitate appropriate clinical management.

Diffusion Tensor Imaging of the Ankle as a Possible Predictor of Chemotherapy Induced Peripheral Neuropathy: Pilot Study.

PURPOSE: Chemotherapy induced peripheral neuropathy (CIPN) is seen in up to 75% of treated cancer patients and can drastically limit their medical management and affect quality of life. Clinical and electrodiagnostic testing for CIPN have many pitfalls. Magnetic resonance neurography (MRN) is being increasingly used in the evaluation of peripheral nerves. Diffusion tensor imaging (DTI) shows promise in the workup of peripheral nerves. In this prospective pilot study, we investigated a possible relationship between DTI and peripheral neuropathy of the ankle and foot in cancer patients treated with chemotherapy. METHODS: Nine cancer patients with and without CIPN were clinically evaluated using vibratory perception threshold (VPT) testing. VPT score of >25Volts defined presence of CIPN. The posterior tibial nerve and branches in both feet were imaged using MRN and DTI. Fractional anisotropy (FA) and apparent diffusion coefficient (ADC) values were measured at the posterior tibial, medial plantar, and lateral plantar nerves. Measurements for the CIPN group were compared to without CIPN by VPT cutoff. Correlations and possible relationships between DTI parameters and CIPN were analyzed. RESULTS: A total of 16feet of 9 enrolled patients were imaged (9feet with CIPN and 7feet without CIPN). Average age was 60.6 ± 13.4 years (range: 33-74). Posterior tibial nerve ADC values were significantly lower than the medial plantar nerve ADC values in all feet (F = 3.50, P = 0.04). We found a correlation with FA and ADC values at specific nerve locations with CIPN, with the left medial plantar nerve FA value and left lateral plantar nerve ADC value demonstrating the strongest positive correlations (0.73 and 0.62, respectively). CONCLUSIONS: The use of DTI for assessing CIPN is challenging but promising. This pilot study provides preliminary data showing correlations between FA and ADC measurements with CIPN and potential utility of DTI as a predictive marker of onset and severity of CIPN in the ankle and foot, which could aid in preventive strategies. Larger, prospective DTI studies are needed to draw definitive conclusions. CLINICAL RELEVANCE: MRN with DTI shows promising results as a potential predictive marker of CIPN in the ankle and foot.

Clinical Evaluation, Imaging, and Management of Adolescent Idiopathic and Adult Degenerative Scoliosis.

We provide a comprehensive review of the clinical presentation, imaging evaluation, classification, and management of adolescent idiopathic and adult degenerative scoliosis.

The Veil of Obscuration: Additional Radiographic Sign of Posterior Shoulder Dislocation.

OBJECTIVE: To describe a new radiographic sign, "veil of obscuration", associated with posterior glenohumeral joint (shoulder) dislocations and determine its incidence and validity compared to other known classic radiographic signs. METHODS: Four-year retrospective study identified 30 acute posterior shoulder dislocation patients. Radiographs reviewed in consensus by 2 musculoskeletal radiologists for the "veil of obscuration", seen on AP shoulder radiographs and representing a comminuted fracture of the lesser tuberosity projecting over the humeral head or glenohumeral joint. Incidence of this radiographic sign of posterior glenohumeral joint dislocation in addition to other previously described classic radiographic signs, and association with other fractures, surgery, and mechanism of injury were evaluated. Continuous data was analyzed with student t-test and categorical data with Chi-Square test. RESULTS: There were 20 right and 10 left posterior shoulder dislocations. Majority of injuries resulted from vehicle crash (44%). In most cases, reverse Hill-Sachs lesion (83%) and fixed internal rotation of the humeral head (76%) were present, followed by trough line (43%) and "veil of obscuration" (40%). Trough line was seen in significantly more major trauma and vehicle crashes (78% and 46%; P=0.015), while "veil of obscuration" was seen in more seizures (86%; P=0.037) and in all surgical patients. No significant difference in presence of other classic radiographic signs in regards to surgery. CONCLUSION: The newly described radiographic sign of posterior shoulder dislocations named the "veil of obscuration" has comparable incidence as other classic radiographic signs and may be useful in the recognition and diagnosis of these injuries.

Imaging of Postoperative Infection at the Knee Joint.

Postoperative infections of the knee are uncommon but may occur with joint arthroplasties, fracture fixation, or after arthroscopic procedures. The ultimate diagnosis is made by joint aspiration or tissue sampling. Joint aspiration and tissue sampling can be performed under imaging guidance or intraoperatively. Imaging is an important adjunct to clinical and laboratory findings and should start with radiographs. Cross-sectional imaging including magnetic resonance (MR) imaging, computed tomography (CT), nuclear studies, and ultrasound (US) are frequently used if the diagnosis is in doubt and to evaluate the extent of disease. We discuss the current algorithm in the diagnosis of various postoperative infections of the knee joint. The article addresses the utility of radiography, MR imaging, CT, US, and the most commonly used nuclear studies in the diagnosis of various postoperative knee infections and the imaging appearances of these infections on each of these diagnostic modalities.