The Clinical Utility of MRI in Evaluating for Osteomyelitis in Patients Presenting with Uncomplicated Cellulitis.

Magnetic resonance imaging (MRI) is vital in the diagnosis of osteomyelitis (OM) in patients presenting with cellulitis. Typically, cellulitis is treated with oral antibiotics; however, patients with concomitant OM may require long-term intravenous antibiotics or surgical intervention. We reviewed lower extremity MRIs in patients presenting with cellulitis and clinical concern for OM. We found 488 patient examinations spanning 5 years (2011 to 2016); 47 patients were excluded (final N = 441). Each MRI was interpreted by a radiologist to determine the rate of OM, abscess, ulceration, and imaging diagnosis of cellulitis. Concurrent assessment of the electronic medical record was performed to review patient demographics, the presence of abscess and/or ulceration, and comorbidities such as diabetes, hyperlipidemia (HLD), atherosclerotic disease, and peripheral vascular disease. Of the 441 lower extremity MRIs included, 170 (39%) were diagnosed with OM, 236 (54%) had ulcers, and 66 (15%) had abscesses. Age, laterality, and reporting physician were not statistically significant independent variables in the rate of reported OM. Diabetes and HLD/atherosclerotic disease were both statistically significant variables with regard to OM rates. Clinical documentation and MRI diagnosis of ulceration were both statistically significant variables in the rate of OM. Regression analysis determined that body part, ulceration, HLD/atherosclerosis, and sex were independent predictors of OM. In our study, of the population of patients with a high clinical suspicion for OM, 39% had OM diagnosed on MRI. However, the incidence of OM in uncomplicated cellulitis was only 11.8% compared with 43.9% in complicated cellulitis. When considering the forefoot alone, patients with ulceration at MRI were 5.6 times more likely to have underlying OM than those without.

Radiographic and surgical findings of type I obturator hernias in patients with refractory groin pain.

Groin pain is a common complaint in the general population, with an underlying etiology that may be difficult to diagnose. Although uncommon, type I obturator hernias may be a significant source of chronic or refractory groin pain. In this review, we discuss the commonly missed findings of type I obturator hernias at CT and MRI, as well as correlate these findings with images obtained at the time of laparoscopic repair.

Endoscopic Proximal Adductor Lengthening for Chronic Adductor-Related Groin Pain.

Proximal adductor injuries are relatively common groin injuries in athletes. Various tenotomy techniques have been described including open, partial, and percutaneous approaches. Current techniques help most athletes return to sport; however, many develop adductor weakness. Moreover, the procedures lack full visualization of the tendon and do not allow for return to athletes' preinjury level of play. We describe an endoscopic z-lengthening of the proximal adductor tendon with the potential to minimize complications associated with open procedures such as incisional pain and neurovascular injury while affording a more complete tenotomy than current percutaneous techniques. This is a safe and reproducible technique that allows for release of tension as a result of pathologic adductor tendon pathologies.

Effect of Intraoperative Platelet-Rich Plasma Treatment on Postoperative Donor Site Knee Pain in Patellar Tendon Autograft Anterior Cruciate Ligament Reconstruction: A Double-Blind Randomized Controlled Trial.

BACKGROUND: Donor site morbidity in the form of anterior knee pain is a frequent complication after bone-patellar tendon-bone (BPTB) autograft anterior cruciate ligament (ACL) reconstruction. Hypothesis/Purpose: The purpose was to examine the effect of the intraoperative administration of platelet-rich plasma (PRP) on postoperative kneeling pain. It was hypothesized that PRP treatment would reduce knee pain. STUDY DESIGN: Randomized controlled trial; Level of evidence, 2. METHODS: Fifty patients (mean ± SD age, 30 ± 12 years) undergoing BPTB ACL autograft reconstruction were randomized to the PRP (n = 27) or sham (n = 23) treatment. In either case, 10 mL of venous blood was drawn before the induction of anesthesia and either discarded (sham) or processed (PRP) for preparation of a PRP gel to be later mixed with donor site bone chips and inserted into the patellar defect. At 12 weeks, 6 months, 1 year, and 2 years after surgery, patients completed International Knee Documentation Committee (IKDC) forms and visual analog scale pain scores for activities of daily living and kneeling. Healing indices at the donor site were assessed by routine noncontrast magnetic resonance imaging (MRI) at 6 months. Mixed-model analysis of variance was used to assess the effect of PRP on patient symptoms and MRI indices of donor site healing, as measured by the width of the donor site defect. RESULTS: Kneeling pain, pain with activities of daily living, and IKDC scores were not different between treatment groups at any of the time intervals ( P = .08-.83). Kneeling pain improved from 12 weeks to 6 months and from 1 to 2 years ( P < .05). IKDC scores improved substantially from 12 weeks to 6 months ( P < .001) and continued to improve to 2 years (PRP, 86 ± 19; sham, 89 ± 10). MRI indices of donor site healing were not different between treatment groups ( P = .53-.90). CONCLUSION: Whether randomized to receive PRP in their patellar defect or not, patients continued to have similar levels of kneeling pain and patellar defect sizes after autograft BPTB ACL reconstruction. Registration: NCT01765712 ( ClinicalTrials.gov identifier).

Referral Patterns for Chronic Groin Pain and Athletic Pubalgia/Sports Hernia: Magnetic Resonance Imaging Findings, Treatment, and Outcomes.

Chronic groin pain is a common problem and has been well-described in high-performance athletes. Its presentation in the recreational athlete has been less frequently described. We present the experience of a tertiary group of physicians specializing in groin pain and athletic pubalgia. Dynamic magnetic resonance imaging (MRI) protocol was employed. Surgery was performed in patients failing non-surgical management. A retrospective review was performed. Of 117 mostly non-professional athletes, there were 79 MRI-positive cases of athletic pubalgia (68%). Other common findings were acetabular labral tear (57%) and inguinal hernia (35%). Employment of a dynamic MRI protocol increased sensitivity for certain pathologies. Of positive athletic pubalgia cases, 49% went on to have surgical repair. The satisfaction rate in the surgical group was 90% at follow up. Advances in MRI have increased our ability to characterize and diagnose specific injuries causing groin pain. We present our diagnostic algorithm, including an MRI protocol that not only evaluates the groin, but has increased sensitivity for additional findings such as inguinal hernia and abdominal wall deficiencies. A targeted work-up and subsequent surgical treatment in the appropriate patient, even in the recreational athletic population, has yielded a 90% satisfaction rate.

The MRI geyser sign: acromioclavicular joint cysts in the setting of a chronic rotator cuff tear.

We present the case of a 71-year-old man with a large acromioclavicular (AC) joint cyst successfully managed with surgical excision. AC joint cysts are soft tissue masses generally signifying underlying rotator cuff pathology. Traditionally, these cysts were identified with shoulder arthrography as a "geyser" of fluid escaping through the AC joint. Magnetic resonance imaging (MRI) is today's preferred imaging modality; we describe the MRI equivalent of the "geyser sign," signifying synovial fluid escaping through the cuff defect, across the subacromial bursa, and decompressing superiorly through a degenerated AC joint. Surgical management is preferred for symptomatic cysts. Based on a review of limited retrospective case series, recommendations for management of these lesions are as follows. Repair of the rotator cuff is preferable whenever possible. In the case of an irreparable defect, good results can be achieved through excisional AC joint arthroplasty and resection of the cyst base. Aspiration of these cysts should not be attempted, due to the high recurrence rate and potential for a draining sinus. Hemiarthroplasty also may be effective in indirectly decompressing these cysts; but given the invasive nature of this procedure, it should be reserved for patients who are also symptomatic from cuff arthropathy.

SPECT/CT in the management of osteochondral lesions of the talus.

BACKGROUND: The treatment of osteochondral lesion of the talus (OLT) is mainly based upon the stage of the disease so accurate imaging is crucial. SPECT/CT combines bone scan with high-resolution CT and can provide functional-anatomical images in a single stage. The purpose of this study was to assess the value of SPECT/CT in the management of OLT. MATERIALS AND METHODS: From 2004 to 2009, 22 patients with OLT were identified that had both SPECT/CT and MRI of the foot and ankle. All charts were reviewed to ascertain the reason for ordering the SPECT/CT and the additional information obtained. AOFAS outcome scores were calculated at the time of followup. RESULTS: Twelve patients underwent ankle arthroscopy for debridement or drilling of the osteochondral lesion. The mean AOFAS score in these 12 patients was 83.6. SPECT/CT helped preoperative planning by identifying the exact location of the active lesion, especially in multifocal disease or revision surgeries while showing the depth of the active lesion. Ten patients had conservative management due to minimal or no activity over the lesion on SPECT/CT images. The mean AOFAS score in these ten patients was 78.8 which was comparable to the operative group. CONCLUSION: We believe SPECT/CT was able to provide additional diagnostic value by demonstrating a co-existing pathology as a potential cause of pain and in preoperative planning by showing the depth of activity and the precise location of the active segment in multiple lesions.

Intra-articular hip injection: does pain relief correlate with radiographic severity of osteoarthritis?

OBJECTIVE: Intra-articular injection is being used widely for both diagnostic and therapeutic purposes in the hip. However, its efficacy is not always predictable in patients with hip osteoarthritis (OA). The purpose of this study was to determine whether the degree of radiographic severity of OA was predictive of the response to intra-articular injection of local anesthetic with corticosteroid and to determine the relationship between immediate pain relief resulting from the anesthetic and delayed pain relief resulting from corticosteroid administration. MATERIALS AND METHODS: This retrospective study included 217 patients (220 injections) with diagnosis of hip OA who underwent a fluoroscopically guided therapeutic hip injection of local anesthetic and corticosteroid. Hip radiographs were scored using the Kellgren-Lawrence scale. Immediate and delayed pain relief was documented using a visual analog scale. Logistic regression analysis was performed to investigate whether age, gender or radiographic severity of OA were independent predictors of pain relief. Degree of agreement between immediate and delayed response was assessed with the kappa coefficient. RESULTS: Immediate pain relief was reported in 68.2% of hips and delayed relief in 71.4% of hips. A high level of agreement was observed between immediate and delayed pain relief (kappa = 0.80, p < 0.001). 94% of patients reporting immediate relief also reported relief 2 weeks later. Univariate and multivariate analysis revealed that neither gender nor age was related to immediate or delayed pain relief. Only severity of OA (based on radiographic analysis) was observed to be predictive of pain relief. CONCLUSION: Pain relief following intra-articular hip injection correlated with radiographic severity of OA. This intervention may be of therapeutic and prognostic value in patients awaiting hip arthroplasty.

Accuracy of diagnostic injection in differentiating source of atypical hip pain.

It is not uncommon to encounter patients with atypical hip or lower extremity pain, ill-defined clinicoradiological features, and concomitant hip and lumbar spine arthritis. The purpose of this study is to present our experience using the response resulting from a combined anesthetic-steroid hip injection for treatment selection in these patients. A retrospective analysis of 204 consecutive diagnostic hip injections was undertaken. Patient charts were scrutinized for outcomes of injection and treatment. Our findings suggest that the relief of symptoms following injection of local anesthetic and steroid into the hip joint has a sensitivity of 91.5%, specificity and positive predictive value of 100%, and negative predictive value of 84.6% for response to total hip arthroplasty. We thereby believe that this is a reliable test with low morbidity and can predict the potential benefit of total hip arthroplasty in this diagnostically challenging group of patients.

The effect of international teleradiology attending radiologist coverage on radiology residents' perceptions of night call.

PURPOSE: The purpose of this study was to determine the effects of international teleradiology attending radiologist coverage (ITARC) of emergency examinations on radiology residents' perceptions of night call. METHODS: A survey was administered at 2 different radiology residency programs that have attending radiologists who cover the night shift via teleradiology from Israel 5 nights per week. The survey consisted of 12 questions concerning residents' education and anxiety during on-call shifts and the effects of ITARC on these aspects of residency training. The questions were answered on a scale ranging from 1 to 5, with 3 being neutral. RESULTS: The radiology residents felt that ITARC improved the on-call learning experience (score = 3.7; 1 = much worse, 5 = much improved). The residents felt neutral about the statements "Review of cases with the attending radiologist over the telephone is comparable educationally to having the attending radiologist in person at the workstation" (score = 3.0) and "Having an attending radiologist easily available diminishes the need for me to commit to a diagnosis on my own and is therefore detrimental to my education" (score = 2.9; 1 = strongly disagree, 5 = strongly agree). The residents' stress levels on call were high without ITARC (score = 1.8; 1 = very high, 5 = very low) and moderate with ITARC (score = 2.7). The residents' anxiety levels before a night on call were moderate without ITARC (score = 2.9; 1 = very high, 5 = very low) and low with ITARC (score = 3.7). CONCLUSIONS: Radiology residents felt that ITARC improved their educational experience. International teleradiology attending radiologist coverage also decreased radiology residents' stress and anxiety related to on-call shifts.