Promising results in a 3-year follow-up for adults undergoing a one-stage surgery for residual talipes equinovarus as part of a humanitarian mission in Vietnam.

BACKGROUND: Rigid talipes equinovarus (TEV) is a complex foot deformity in which the foot is fixed in a plantarflexed, inverted, and adducted position. This pathology has the potential to severely limit basic life activities, which can be devastating for patients in developing countries. The objective of this study was to present the outcomes of patients with mature bones presenting with severe rigid TEV deformity who were operated on during a humanitarian mission to Vietnam using a single lateral approach and a simple and inexpensive fixation technique. METHODS: This is a retrospective analysis of prospectively collected data. We analyzed the outcomes of patients who underwent surgery for a severe rigid TEV that prevented them from walking minimal distances unaided. All feet were fixed in a non-plantigrade position. The surgeries were conducted as part of two International Extremity Project (IEP) missions in Can Tho, Vietnam (2013 and 2018). Pre- and post-operative AOFAS scores were compared using the paired sample t-test. RESULTS: We operated on 14 feet of 12 patients, 6 (50%) of whom were males, aged 34.42 ± 11.7 (range 12 to 58). Four patients were followed for three months, two patients were followed for 12 months, and eight patients were followed for three years. On the final follow-up visit of each patient, all 14 operated feet were plantigrade with good alignment, and patients reported an improvement in daily activity. After 3 years of follow-up, the mean AOFAS score of eight patients with available data improved by 42.88 ± 3.91 points (95% CI 39.61 to 46.14, P < 0.01). Our patients also reported an improvement in mobility. At the final follow-up examination, no recurrence of the deformity was observed in any of the patients. CONCLUSIONS: Using low-technical surgical modalities, we were able to achieve plantigrade and walkable feet in patients with mature bones who had fixed rigid equinovarus. LEVEL OF EVIDENCE: Level IV- Case Series.

Can Tho Transfer Technique: Extensor Hallucis Longus to Tibialis Anterior Tenodesis for Footdrop.

BACKGROUND: Footdrop, or the inability to actively dorsiflex the foot, may result from numerous pathologic conditions, including poliomyelitis and cerebral palsy. Although the gait of patients with footdrop can be improved by performing an extensor hallucis longus (EHL) to tibialis anterior (TA) tendon transfer, the success rate of this procedure is relatively low. METHODS: Seven paralytic patients with footdrop were surgically treated using a new buttonhole-type technique that involves passing a loop of the EHL through a TA split using umbilical tape and suturing at the four corners of the EHL attaching to the TA while the foot is dorsiflexed. RESULTS: Eight years after surgery, all three patients who were available for follow-up displayed active dorsiflexion, improved mobility, and a palpable TA-EHL tenodesis, with no cockup deformity. CONCLUSIONS: This new approach, which we term Can Tho transfer, improves the mechanical strength of TA-EHL tenodesis.

Schwannoma of the Sural Nerve: A Case Report.

A schwannoma is a slow-growing, neurogenic tumor composed of Schwann cells arising from a peripheral nerve sheath. The authors present a rare finding of a schwannoma of the sural nerve that was overlooked in a 51-year-old female with radiating foot pain. This case highlights the clinical implications and important teaching points in recognizing a schwannoma of the foot.

Determining Follow-Up Imaging Study Using Radiology Reports.

Radiology reports often contain follow-up imaging recommendations. Failure to comply with these recommendations in a timely manner can lead to delayed treatment, poor patient outcomes, complications, unnecessary testing, lost revenue, and legal liability. The objective of this study was to develop a scalable approach to automatically identify the completion of a follow-up imaging study recommended by a radiologist in a preceding report. We selected imaging-reports containing 559 follow-up imaging recommendations and all subsequent reports from a multi-hospital academic practice. Three radiologists identified appropriate follow-up examinations among the subsequent reports for the same patient, if any, to establish a ground-truth dataset. We then trained an Extremely Randomized Trees that uses recommendation attributes, study meta-data and text similarity of the radiology reports to determine the most likely follow-up examination for a preceding recommendation. Pairwise inter-annotator F-score ranged from 0.853 to 0.868; the corresponding F-score of the classifier in identifying follow-up exams was 0.807. Our study describes a methodology to automatically determine the most likely follow-up exam after a follow-up imaging recommendation. The accuracy of the algorithm suggests that automated methods can be integrated into a follow-up management application to improve adherence to follow-up imaging recommendations. Radiology administrators could use such a system to monitor follow-up compliance rates and proactively send reminders to primary care providers and/or patients to improve adherence.

Flexor Digitorum Longus (FDL) or Flexor Hallucis Longus (FHL) Harvesting: Technical Tip and Case Studies.

BACKGROUND: Harvesting of the flexor digitorum longus (FDL) or the flexor hallucis longus (FHL) is a procedure used when tendon transfer is needed. It is commonly used in tibialis posterior reconstruction and Achilles tendon reconstruction. Harvesting of these tendons is sometimes difficult and time-consuming. It is important to obtain sufficient length to make a loop around the navicular bone or anchor it in the calcaneus. We describe a technique in which a loop is passed from proximal identification of the FDL or FHL through the tendon sheath, harvesting it from a minimal plantar approach. METHODS: After using this technique, we evaluated 10 consecutive patients for neurovascular damage. RESULTS: We found no postoperative neurovascular injuries. CONCLUSIONS: The technique described enables the surgeon to find the FDL/FHL tendon through the medial approach and obtain sufficient length for the procedure by cutting the distal portion of the tendon through an additional plantar incision. Our technical tip for passing the loop facilitates harvest of the tendon easily and safely using the plantar approach. LEVEL OF EVIDENCE: IV, case series.

Emergency radiology and mass casualty incidents-report of a mass casualty incident at a level 1 trauma center.

The aims of this article are to describe the events of a recent mass casualty incident (MCI) at our level 1 trauma center and to describe the radiology response to the event. We also describe the findings and recommendations of our radiology department after-action review. An MCI activation was triggered after an amphibious military vehicle, repurposed for tourist activities, carrying 37 passengers, collided with a charter bus carrying 45 passengers on a busy highway bridge in Seattle, WA, USA. There were 4 deaths at the scene, and 51 patients were transferred to local hospitals following prehospital scene triage. Nineteen patients were transferred to our level 1 trauma center. Eighteen casualties arrived within 72 min. Sixteen arrived within 1 h of the first patient arrival, and 1 casualty was transferred 3 h later having initially been assessed at another hospital. Eighteen casualties (94.7 %) underwent diagnostic imaging in the emergency department. Of these 18 casualties, 15 had a trauma series (portable chest x-ray and x-ray of pelvis). Whole-body trauma computed tomography scans (WBCT) were performed on 15 casualties (78.9 %), 12 were immediate and performed during the initial active phase of the MCI, and 3 WBCTs were delayed. The initial 12 WBCTs were completed in 101 min. The mean number of radiographic studies performed per patient was 3 (range 1-8), and the total number of injuries detected was 88. The surge in imaging requirements during an MCI can be significant and exceed normal operating capacity. This report of our radiology experience during a recent MCI and subsequent after-action review serves to provide an example of how radiology capacity and workflow functioned during an MCI, in order to provide emergency radiologists and response planners with practical recommendations for implementation in the event of a future MCI.

Expectations Among Academic Clinicians of Inpatient Imaging Turnaround Time: Does it Correlate with Satisfaction?

RATIONALE AND OBJECTIVES: Imaging report turnaround time (RTAT) is an important measure of radiology performance and has become the leading priority in customer satisfaction surveys conducted among nonradiologists, who may not be familiar with the imaging workflow. Our aim was to assess physicians' expected RTAT for commonly ordered studies and determine if satisfaction correlates with met expectations. MATERIALS AND METHODS: Retrospective review of inpatient imaging was conducted at a single academic institution, and RTAT for 18,414 studies was calculated. Examinations were grouped by study type, priority, and time of day. A cross-sectional survey instrument was completed by 48 internal medicine and surgery resident physicians with questions regarding RTAT and their level of satisfaction with various examinations. RESULTS: Actual RTAT ranged from 1.6 to 26.0 hours, with chest radiographs and computed tomographies generally faster than magnetic resonance images and ultrasounds. Urgent (STAT) examinations and those ordered during business hours have shorter RTAT. The time for image interpretation largely contributed to the RTAT because of the lack of night-time radiology coverage. Referring physician expectations were consistently shorter than actual RTAT, ranging from 30 minutes to 24 hours. Overall satisfaction scores were inversely correlated with RTAT, with a strong correlation to the time from study order to imaging (r(2) = 0.63) and a weak correlation to the image interpretation time (r(2) = 0.17). Satisfaction scores did not correlate with whether the actual RTAT met expectations (r(2) = 0.06). CONCLUSIONS: Referring physician satisfaction is likely multifactorial. Although RTAT has been reported as a priority, shortening turnaround time alone may not directly improve clinician satisfaction.

Vertebral Artery Transection in Nonpenetrating Trauma: A Series of 4 Patients.

Blunt cerebrovascular injury is a common and potentially devastating consequence of nonpenetrating trauma to the head and neck. The degree of injury ranges from minimal intimal disruption to complete transection with free extravasation. Although blunt carotid transection has been well characterized in clinical reports and radiologic studies, the computed tomographic angiography (CTA) features of blunt vertebral artery transection have not been well described. We report a series of 4 patients presenting to our level I trauma center with blunt vertebral artery transection, with an emphasis on their CTA imaging findings at presentation and their respective clinical courses. A brief review of the pertinent literature is provided.

Improving Outcomes in the Patient with Polytrauma: A Review of the Role of Whole-Body Computed Tomography.

Whole-body computed tomography (WBCT) is used for the workup of the patient with blunt polytrauma. WBCT is associated with improved patient survival and reduces the emergency department length of stay. However, randomized studies are needed to determine whether early WBCT improves survival, to clarify which patients benefit the most, and to model the costs of this technique compared with traditional workup. Advancements in modern multidetector computed tomography technology and an improved understanding of optimal protocols have enabled one to scan the entire body and achieve adequate image quality for a comprehensive trauma assessment in a short period.

Imaging of Urinary System Trauma.

Computed tomography (CT) imaging of the kidney, ureter, and bladder permit accurate and prompt diagnosis or exclusion of traumatic injuries, without the need to move the patient to the fluoroscopy suite. Real-time review of imaging permits selective delayed imaging, reducing time on the scanner and radiation dose for patients who do not require delays. Modifying imaging parameters to obtain thicker slices and noisier images permits detection of contrast extravasation from the kidneys, ureters, and bladder, while reducing radiation dose on the delayed or cystographic imaging. The American Association for the Surgery of Trauma grading system is discussed, along with challenges and limitations.

Core curriculum illustration: blunt cerebrovascular injury.

This is the 15th installment of a series that will highlight one case per publication issue from the bank of cases available online as part of the American Society of Emergency Radiology (ASER) educational resources. Our goal is to generate more interest in and use of our online materials. To view more cases online, please visit the ASER Core Curriculum and Recommendations for Study online at http://www.aseronline.org/curriculum/toc.htm .

Subperitoneal extension of disease processes between the chest, abdomen, and the pelvis.

The subserous space is a large, anatomically continuous potential space that interconnects the chest, abdomen, and pelvis. The subserous space is formed from areolar and adipose tissue, and contains branches of the vascular, lymphatic, and nervous systems. As such, it provides one large continuous space in which many disease processes can spread between the chest, abdomen, and the pelvis.

Imaging of complications of common bariatric surgical procedures.

Several techniques for the surgical management of obesity are available to bariatric surgeons. These interventions are performed more frequently with worsening of the obesity epidemic. Radiologists should be familiar with the surgical techniques, normal postoperative appearances, and potential complications for which imaging may be employed to establish a diagnosis to optimize patient care.

A randomized comparison of long-axis and short-axis imaging for in-plane ultrasound-guided popliteal-sciatic perineural catheter insertion.

PURPOSE: Ultrasound-guided long-axis in-plane sciatic perineural catheter insertion has been described but not validated. For the popliteal-sciatic nerve, we hypothesized that a long-axis in-plane technique, placing the catheter parallel and posterior to the nerve, results in faster onset of sensory anesthesia compared to a short-axis in-plane technique. METHODS: Preoperatively, patients receiving a popliteal-sciatic perineural catheter were randomly assigned to either the long-axis or short-axis technique. Mepivacaine 2% was administered via the catheter following insertion. The primary outcome was time to achieve complete sensory anesthesia. Secondary outcomes included procedural time, onset time of motor block, and pain on postoperative day 1. RESULTS: Fifty patients were enrolled. In the long-axis group (n = 25), all patients except 1 (4%) had successful catheter placement per protocol. Two patients (8%) in the long-axis group and 1 patient (4%) in the short-axis group (n = 25) did not achieve sensory anesthesia by 30 min and were withdrawn. Seventeen of 24 (71%) and 17 of 22 (77%) patients in the short-axis and long-axis groups, respectively, achieved the primary outcome of complete sensory anesthesia (p = 0.589). The short-axis group (n = 17) required a median (10th-90th ‰) of 18.0 (8.4-30.0) min compared to 18.0 (11.4-27.6) min for the long-axis group (n = 17, p = 0.208) to achieve complete sensory anesthesia. Procedural time was 6.5 (4.0-12.0) min for the short-axis and 9.5 (7.0-12.7) min for the long-axis (p < 0.001) group. There were no statistically significant differences in other secondary outcomes. CONCLUSION: Long-axis in-plane popliteal-sciatic perineural catheter insertion requires more time to perform compared to a short-axis in-plane technique without demonstrating any advantages.

Multimodality imaging of diseases of the duodenum.

The duodenum is a unique segment of intestine, occupying both intra and extra-peritoneal locations. There is a wide spectrum of abnormalities of the duodenum that range from congenital anomalies to traumatic, inflammatory, and neoplastic entities. The duodenum may be overlooked on cross-sectional imaging due to its location and small size. Duodenal pathologies may, therefore, be missed or wrongly diagnosed. Knowledge about duodenal pathologies and optimal imaging techniques can increase diagnostic yield and permit optimal patient management. Conventionally, the duodenum was evaluated with upper GI studies on fluoroscopy; however, endoluminal evaluation is better performed with endoscopy. Additionally, a broad array of cross-sectional imaging modalities permits comprehensive assessment of the duodenum and surrounding viscera. While endoscopic sonography is increasingly used to locally stage duodenal malignancies, MDCT remains the primary modality widely used in the detection and characterization of duodenal abnormalities. MRI is used as a "problem solving" modality in select conditions. We present a comprehensive review of duodenal abnormalities with an emphasis on accurate diagnosis and management.

Core curriculum illustration: testicular torsion.

This is the 7th installment of a series that will highlight one case per publication issue from the bank of cases available online as part of the American Society of Emergency Radiology (ASER) educational resources. Our goal is to generate more interest in and use of our online materials. To view more cases online, please visit the ASER Core Curriculum and Recommendations for Study online at http://www.aseronline.org/curriculum/toc.htm .

Variability in management recommendations for incidental thyroid nodules detected on CT of the cervical spine in the emergency department.

PURPOSE: Incidental thyroid nodules are common on CT. Variability in management recommendations for these nodules due to a lack of accepted CT base guidelines has not been demonstrated. METHODS: Consecutive CT cervical spine radiology reports describing thyroid nodules performed in an emergency department from January 1, 2009, to December 31, 2011, were retrospectively reviewed. Number of nodules, nodule size, and type of recommended management were recorded. RESULTS: Three hundred fifteen examinations met the inclusion criteria. The mean study age was 64 ± 20 years. Fifty-eight percent were women. Thirty percent (n = 95) of thyroid nodules measured <10 mm, 20% (n = 63) were ≥10 but <15 mm, 11% (n = 36) were ≥15 but <20 mm, and 15.5% (n = 49) were ≥20 mm. Size was not reported for 22.9% (n = 72). Two hundred twenty-seven recommendations were made in 181 (57.5%) studies. Recommendations were made for 51.6% (49 of 95) of nodules <10 mm, for 52.4% (33 of 63) of those ≥10 but <15 mm, for 83.3% (30 of 36) of those ≥15 but <20 mm, and for 81.6% (40 of 49) of those ≥20 mm. Management was recommended in 40.0% (29 of 72) of nodules with no size reported. Fifty-four percent (123 of 227) of recommendations were for ultrasound, followed by no follow-up recommended (17.2% [39 of 227]), clinical correlation (13.7% [31 of 227]), thyroid serology (6.2% [14 of 227]), clinical follow-up (4.8% [11 of 227]), comparison with prior studies (2.2% [5 of 227]), fine-needle aspiration (1.3% [3 of 227]), and nuclear scintigraphy (0.4% [1 of 227]). Nodule size was significantly associated with the likelihood of recommendation (odds ratio, 1.79; 95% confidence interval, 1.37-2.35). CONCLUSIONS: Management recommendations for incidental thyroid nodules detected on cervical spine CT are made inconsistently, and the type of management recommended is variable.

Minimal aortic injury of the thoracic aorta: imaging appearances and outcome.

The aim of this study is to describe the frequency, computed tomographic angiography (CTA) imaging appearance, management, and outcome of patients who present with minimal thoracic aortic injury. This retrospective study was Institutional Review Board-approved. Eighty-one patients with blunt traumatic aortic injuries (BTAI) were identified between 2004 and 2008, comprising 23 patients with minimal aortic injury (MAI) (mean age, 43.2 years ±18.2 years; 12 males and 11 females) and 58 patients with non-minimal aortic injury (mean age, 42.6 years ±22.7 years). CTA imaging was reviewed for each patient to differentiate those with MAI from those with non-MAI BTAI. Inclusion criteria for MAI on CTA were: post-traumatic abnormality of the internal contour of the aorta wall projecting into the lumen, intimal flap, intraluminal filling defect, intramural hematoma, and no evidence of an abnormality to the external contour of the aorta. Relevant follow-up imaging for MAI patients was also reviewed for resolution, stability, or progression of the vascular injury. The electronic medical record of each patient was reviewed and mechanism of injury, injury severity score, associated injuries, type and date of management, outcome, and days from injury to last medical consultation. Minimal aortic injury represented 28.4 % of all BTAI over the study period. Mean injury severity score (37.1), age (43.2 years), and gender did not differ significantly between MAI and non-MAI types of BTAI. Most MAI occurred in the descending thoracic aorta (16/23, 69 %). Without operative or endovascular repair, there was no death or complication due to MAI. One death occurred secondary to MAI (4.4 %) in a patient who underwent endovascular repair and surgical bypass, compared with an overall mortality rate of 8.6 % in the non-MAI BTAI group (p = 0.508). The most common CT appearance of MAI was a rounded or triangular intra-luminal aortic filling detect (18/23 patients, 78 %). In a mean of 466 days of clinical follow-up, no complications were observed in survivors treated without endovascular repair or operation. Minimal aortic injury is identified by multi-detector row CT in more than a quarter of cases of BTAI and has a low mortality. Conservative management is associated with an excellent outcome.