An International Survey of Quality and Safety Programs in Radiology.

PURPOSE: The aim of this study was to determine the status of radiology quality improvement programs in a variety of selected nations worldwide. METHODS: A survey was developed by select members of the International Economics Committee of the American College of Radiology on quality programs and was distributed to committee members. Members responded on behalf of their country. The 51-question survey asked about 12 different quality initiatives which were grouped into 4 themes: departments, users, equipment, and outcomes. Respondents reported whether a designated type of quality initiative was used in their country and answered subsequent questions further characterizing it. RESULTS: The response rate was 100% and represented Australia, Canada, China, England, France, Germany, India, Israel, Japan, the Netherlands, Russia, and the United States. The most frequently reported quality initiatives were imaging appropriateness (91.7%) and disease registries (91.7%), followed by key performance indicators (83.3%) and morbidity and mortality rounds (83.3%). Peer review, equipment accreditation, radiation dose monitoring, and structured reporting were reported by 75.0% of respondents, followed by 58.3% of respondents for quality audits and critical incident reporting. The least frequently reported initiatives included Lean/Kaizen exercises and physician performance assessments, implemented by 25.0% of respondents. CONCLUSION: There is considerable diversity in the quality programs used throughout the world, despite some influence by national and international organizations, from whom further guidance could increase uniformity and optimize patient care in radiology.

Overuse injuries of the lower extremity.

Overuse injuries are a common and important cause of morbidity in elite and recreational athletes. They are increasingly recognized in the sedentary population. This article reviews the major classes of overuse injuries of the lower extremity. The underlying pathologic condition is correlated with the imaging appearances, and the often variable relationship between the imaging appearances and patients' symptoms are reviewed. Attempts at imaged-based grading systems and the ability of imaging to predict patients' prognosis are considered. Image-guided injection therapy for tendinopathy is an important and rapidly changing area; the indications, risks, and potential benefits of these interventions are reviewed.

Magnetic resonance imaging in traumatic posterior hip dislocation.

OBJECTIVES: The objective was to report the ability of a magnetic resonance image to document the integrity of the obturator externus tendon after posterior hip dislocation as a potential predictor for preserved femoral head vascularity. DESIGN: Retrospective radiographic and clinical pilot study. SETTING: Level I trauma center. PATIENTS/PARTICIPANTS: Nineteen consecutive patients with traumatic posterior hip dislocation. OUTCOME EVALUATION: Intraoperative correlation of soft tissue damage and radiographic assessment of avascular necrosis of the femoral head 3 years postinjury. METHODS: Magnetic resonance imaging performed in the acute phase of posterior hip dislocation. Correlation with intraoperative findings during surgical hip dislocation and with avascular necrosis 3 years postinjury. RESULTS: The obturator externus tendon was intact in all cases with preserved femoral head vascularity. After a 3-year follow up, there were no cases of avascular necrosis. CONCLUSION: In this small series of patients, posterior hip dislocation did not imply a tear of the obturator externus muscle. An intact obturator externus tendon suggests preservation of the deep branch of the medial femoral circumflex artery to the femoral head.

Muscle denervation and nerve entrapment syndromes.

Nerve entrapment and muscle denervation syndromes are often hard to diagnose, presenting as pain or unusual weakness. In addition many of the clinically named syndromes are poorly defined and understood. An understanding of the clinical signs, the normal and variant anatomy, and the often variable relationship between the imaging findings and the clinical findings is essential in the accurate diagnosis and management of these disorders. MRI has proved sensitive to the presence of muscle denervation and can provide high resolution imaging along the course of the major nerves allowing demonstration of mass lesions or normal anatomical variations. The diagnosis of nerve entrapment and muscle denervation syndromes can be a substantial clinical challenge. Imaging, particularly MRI, can prove very useful in confirming a nerve lesion by demonstrating changes of muscle denervation. Identification of the muscles involved combined with knowledge of the normal patterns of innervation and their variations can allow localization of the site of the nerve lesion.

Nicolau syndrome in an athlete following intra-muscular diclofenac injection.

Nicolau Syndrome (also known as Embolia cutis medicamentosa and livedo-like dermatitis) is a rare but severe localized adverse drug reaction to a range of intra-muscular preparations. It manifests as acute pain, cutaneous, subcutaneous and intra-muscular inflammation and necrosis immediately following an injection, with potentially devastating sequelae. We describe the syndrome in a 21-year-old national level race walk athlete following an intramuscular diclofenac injection.

Magnetic resonance imaging analysis of kinematics in osteoarthritic knees.

Kinematics in osteoarthritic knees may be impeding efforts to reproduce "normal" knee kinematics in the prosthetic knee. Fourteen subjects with unilateral symptomatic knee osteoarthritis performed a supine leg press from 0 degrees to 90 degrees flexion against a 150-N load. The tibiofemoral contact pattern was recorded for both knees using sagittal T1-weighted magnetic resonance imaging. Severity of osteoarthritis ranged from Kellgren Lawrence grade 2 to 4 in the symptomatic knees and from 0 to 3 in the contralateral knees. Contact in the lateral and medial compartments of osteoarthritic knees was more anterior on the tibial plateau than healthy knees, both in knee extension and to 90 degrees flexion (P < .01). This anterior contact pattern was associated with severity of osteoarthritis (P < .01).

Osteitis pubis and assessment of bone marrow edema at the pubic symphysis with MRI in an elite junior male soccer squad.

OBJECTIVES: To assess bone marrow edema at the pubic symphysis with magnetic resonance imaging (MRI), and its relation to training and osteitis pubis in an elite group of junior soccer players. SETTING: Soccer players on scholarship at the Australian Institute of Sport (AIS). PATIENTS: Nineteen players from an elite junior men's soccer squad. INTERVENTION/ASSESSMENT: Serial MRI examinations of the pubic symphysis over a 4-month training and playing period, training session questionnaire, and review of clinical diagnosis, investigations, and records on presentation of athletes with groin pain at the Department of Sports Medicine. MAIN OUTCOME MEASURES: Assessment of bone marrow edema (4-point scale) on MRI scans, review of athlete questionnaires, and review of clinical records. RESULTS: Initial MRI scans showed moderate to severe bone marrow edema at the pubic symphysis in 11 of the 18 asymptomatic players. There was a greatly decreased risk of developing groin pain (osteitis pubis) with more training prior to entry of the AIS soccer program (odds ratio per 4 sessions of training, 0.003). The correlation between initial bone marrow edema grading and pre-AIS training was small. The increase in bone marrow edema grading from baseline over the scans was 0.5 (90% CL, 0.4). CONCLUSIONS: Substantial amounts of bone marrow edema at the pubic symphysis can occur in asymptomatic elite junior soccer players, but it is only weakly related to the development of osteitis pubis. Progressing training loads more slowly in athletes presenting with low current training loads may be a useful strategy for the prevention of osteitis pubis in junior soccer players.

Association between abnormal kinematics and degenerative change in knees of people with chronic anterior cruciate ligament deficiency: a magnetic resonance imaging study.

Progressive degeneration of the anterior cruciate ligament (ACL) deficient knee may be partly due to chondral trauma at the time of ACL rupture and repeat episodes of subluxation, but also due to aberrant kinematics altering the wear pattern at the tibiofemoral interface. The hypothesis that altered kinematics, represented by the tibiofemoral contact pattern, would be associated with articular cartilage degeneration in ACL-deficient knees was tested in a cross-sectional study of 23 subjects with a history of > 10 years ACL deficiency without knee reconstruction. Subjects were aged 31 to 67 years. Eleven were male, 12 were female. Sagittal magnetic resonance imaging (MRI) scans enabled tibiofemoral contact mapping as subjects performed a closed-chain leg-press. Images were acquired at 15 degree intervals from 0 degrees to 90 degrees knee flexion. Articular cartilage degeneration was assessed by diagnostic MRI and where possible, arthroscopy. The ACL-deficient knees had a posterior tibiofemoral contact pattern on the tibial plateau compared to the healthy knees (F((1,171)) = 9.2, p = 0.003). The difference appeared to be seen in the medial compartment (F((1,171)) = 3.2, p = 0.07), though this failed to reach significance. Articular cartilage degeneration in the medial compartment was related to the variation of the tibiofemoral contact pattern (r = -0.53, p = 0.01). Articular cartilage degeneration was not related to time since injury (r = -0.16, p = 0.65). The association between aberrant kinematics and degenerative change may stimulate thinking on the role of dynamic stability and neuromuscular co-ordination in joint protection.

Use of early magnetic resonance imaging in the diagnosis of occult scaphoid fractures: the CAST Study (Canberra Area Scaphoid Trial).

AIM: To establish the effectiveness of early magnetic resonance imaging (MRI) in the diagnosis of scaphoid fracture in patients with suggestive clinical findings (but a normal initial X-ray) in an Australian major-referral emergency department METHODS: A prospective study of patients who presented within 24 hours after trauma with clinical findings suggestive of a scaphoid fracture but no evidence of fracture on the initial X-ray. MRI was performed within 24 hours of presentation. Clinical review in patients with normal initial MRI was carried out in 10 days and repeat MRI was carried out when clinically indicated. RESULTS: A total of 22 patients were enrolled. Early MRI within 24 hours revealed 6 scaphoid fractures, 2 distal radial fractures and a hamate fracture. Thirteen patients had no fracture on the initial MRI. Upon clinical review in 10 days, 5 of these patients were clinically cleared and discharged. Eight of these patients underwent repeat MRI none of which revealed a fracture. CONCLUSIONS: In an Australian tertiary hospital with MRI facility, the early use of MRI is a sensitive and practical way to diagnose occult scaphoid fractures and saves unnecessary immobilisation.

Comparison of kinematics in the healthy and ACL injured knee using MRI.

Magnetic Resonance Imaging (MRI) was used to examine the characteristics of abnormal motion in the injured knee by mapping tibiofemoral contact. Eleven healthy subjects and 20 subjects with a unilateral ACL injury performed a leg-press against resistance. MRI scans of both knees at 15 degrees intervals from 0 degrees to 90 degrees of flexion were used to record the tibiofemoral contact pattern. The tibiofemoral contact pattern of the injured knees was more posterior on the tibial plateau than the healthy knees, particularly in the lateral compartment. The tibiofemoral contact pattern of the loaded knees did not differ from the unloaded knees. The difference in the tibiofemoral contact pattern in the ACL injured knee was associated with more severe knee symptoms, irrespective of the passive anterior laxity of the knee.

Comparison of kinematic analysis by mapping tibiofemoral contact with movement of the femoral condylar centres in healthy and anterior cruciate ligament injured knees.

Two methods of analysis of knee kinematics from magnetic resonance images (MRI) in vivo have been developed independently: mapping the tibiofemoral contact, and tracking the femoral condylar centre. These two methods are compared for the assessment of kinematics in the healthy and the anterior cruciate ligament injured knee. Sagittal images of both knees of 20 subjects with unilateral anterior cruciate ligament injury were analysed. The subjects had performed a supine leg press against a 150 N load. Images were generated at 15 degrees intervals from 0 degrees to 90 degrees knee flexion. The tibiofemoral contact, and the centre of the femoral condyle (defined by the flexion facet centre (FFC)), were measured from the posterior tibial cortex. The pattern of contact in the healthy knee showed the femoral roll back from 0 degrees to 30 degrees, then from 30 degrees to 90 degrees the medial condyle rolled back little, while the lateral condyle continued to roll back on the tibial plateau. The contact pattern was more posterior in the injured knee (p=0.012), particularly in the lateral compartment. The medial FFC moved back very little during knee flexion, while the lateral FFC moved back throughout the flexion arc. The FFC was not significantly different in the injured knee (p=0.17). The contact and movement of the FFC both demonstrated kinematic events at the knee, such as longitudinal rotation. Both methods are relevant to design of total knee arthroplasty: movement of the FFC for consideration of axis alignment, and contact pattern for issues of interface wear and arthritic change in ligament injury.

Evaluation of a method to map tibiofemoral contact points in the normal knee using MRI.

A technique using magnetic resonance imaging (MRI) is proposed for analysis of knee motion that is practical in the clinical situation. T1 weighted fast spin echo (FSE) and spoiled gradient echo (GE) sequences were compared to image both knees at 15 degrees intervals from 0 degrees to 90 degrees flexion, while unloaded and loaded. The medial and lateral tibiofemoral contact points were mapped reliably using both FSE sequences and GE sequences with intra-class correlation((2,1)) of 0.96 (CI 99%=0.94-0.97) and 0.94 (CI 99%=0.91-0.97), respectively. Results were consistent with the current literature on knee motion: the medial and lateral tibiofemoral contact pathways were different (F(1,80) = 253.9, p < 0.0001) reflecting the longitudinal rotation of the knee, the loaded and unloaded knees were not different in the healthy knee (F(1,80) = 0.007, p = 0.935), and the left and right knee were consistent for each individual (F(1,80) = 0.005, p = 0.943). Therefore, right to left differences may be attributed to pathology. MRI analysis of knee kinematics as described by this technique of tibiofemoral contact point mapping provides a robust and reliable method of recording the tibiofemoral contact pattern of the knee.

Patterns of injury in patients with radiographic occult fracture of neck of femur as determined by magnetic resonance imaging.

The purpose of the present study was to review retrospectively our experience with MRI in patients over the age of 50 who present to the emergency department with inability to weight bear following a fall and whose initial radiographs were normal. The study was designed to establish the incidence and pattern of bone and soft tissue injuries in these patients and to determine whether MRI could provide predictive information regarding length of hospital stay. The present study demonstrated the practicality of a protocol using MRI to obtain rapid definitive diagnosis in patients with occult fractures of the pelvic ring and neck of femur. The present study also suggests that significant prognostic information with regard to length of hospital stay can be obtained from an early MRI scan.

Image-guided spinal injection for diagnosis and therapy.

Over the past decade, major advances have been made in our ability to identify a putative cause of patients' spinal pain using image-guided injection techniques. These techniques might also provide a means of temporarily relieving patients' pain and facilitating increased mobility. This article aims to review the rationale for and the techniques of the more commonly used spinal injection techniques.