Sports Hernias: A Comprehensive Review for Clinicians.

Sports hernias are a complex cause of chronic groin pain in athletes, posing diagnostic and treatment challenges for clinicians. This review article synthesizes current knowledge on sports hernias, exploring pathogenesis, diagnostic approaches, and management strategies. Despite the growing body of research, sports hernias continue to present a significant challenge, necessitating a multidisciplinary approach and further research to improve clinical outcomes. This comprehensive review aims to equip clinicians with an updated understanding of sports hernias, ensuring optimal patient care and informing future research.

Radiographic evaluation of reactive osteitis in traumatic injury of sacroiliac joints.

OBJECTIVES: After traumatic Sacroiliac (SI) joint injury, follow up radiographic imaging can demonstrate subchondral bone resorption resembling inflammatory sacroiliitis. No studies have described the incidence of marginal SI post-traumatic osteitis, the probable temporal relationship to the initial traumatic injury, or the possible effect of unilateral hardware fixation on the contralateral SI joint. METHODS: A Level 1 trauma center imaging database was queried to identify patients with pelvic bony trauma between 2005 and 2017 with CT baseline preserved SI cortication and unilateral/bilateral traumatic SI diastasis. Serial radiographs were retrospectively evaluated by 2 musculoskeletal-trained radiologists at initial, 6 weeks, 3 months and 6 months following trauma, with documentation of diastasis, subchondral resorption, and operative fixation. RESULTS: 206 SI joints in 106 total patients met inclusion criteria. There was a statistically significant association between injury and presence of resorption at 6 weeks post-trauma for the right SI joint only. There was no other statistically significant relationship between injury and presence of resorption at any other post-trauma evaluation. There was no statistical relationship between resorption and surgical fixation. There was a statistically significant increased incidence of resorption in the post-traumatic population when compared to an atraumatic population undergoing CT pelvis study for non-SI related indications as well as compared to the incidence of inflammatory sacroiliitis in a general population. CONCLUSIONS: This study confirms an incidence of sub-acute subchondral bone resorption following traumatic joint injury above that expected for a general, non-traumatic population. Accurate interpretation of this traumatic finding minimizes inappropriate consultation and intervention for inflammatory sacroiliitis.

Multi-focal Lytic Lesions in a Patient with Myelofibrosis: A Case Report.

Myelofibrosis is a rare disorder that is classified as one of the myeloproliferative disorders. This particular disorder results in the abnormal proliferation of hematopoietic stem cells in the bone marrow. In some cases, such as ours, pathologic fractures can occur due to skeletal manifestations. We report on a rare finding of rapidly progressive lytic lesions in multiple regions throughout the body. This presentation of myelofibrosis behaving in a metastatic-like fashion has not been previously described.

Body Composition, Serum Biomarkers of Inflammation and Quality of Life in Clinically Stable Women with Estrogen Receptor Positive Metastatic Breast Cancer.

Limited data exist regarding body composition and associated patient-reported outcomes for women with metastatic BC. Demographic, clinical, blood, and questionnaire data were collected to quantify body composition and explore associations with symptoms, inflammation, and quality of life (QOL) in 41 women with ER + metastatic BC. Diagnostic/surveillance computed tomography (CT) images including the third lumbar region (L3) were obtained to evaluate skeletal muscle (SM) quantity and quality, and abdominal adipose tissue. Frequencies, medians and interquartile ranges are presented, stratified by sarcopenia and obesity (Body mass index (BMI) ≥ 30.0 kg/m2). Overall, 34% (n = 14/41), 49% (n = 20/41), and 34% (n = 14) of women had sarcopenia, myosteatosis, and obesity, respectively. Handgrip strength was compromised in 24% of subjects (n = 10/41). Women with sarcopenia had significantly lower body weight (P = 0.01), BMI (P ≤ 0.001), and whole body SM (P < 0.001), yet reported greater engagement in leisure time exercises (P = 0.05) vs. nonsarcopenic women. Women with obesity had significantly higher levels of abdominal obesity (all values P < 0.0001) and serum biomarkers of inflammation (P values <0.06), yet lower QOL (P = 0.02) vs. women without obesity. The abPGSGA did not differentiate women with sarcopenia. Future interventions should test if improvements in body composition are associated with better outcomes for this vulnerable, emerging population.

Radiologic Evaluation of Lower Leg, Ankle, and Foot Fracture Fixation Hardware.

Radiologists should be familiar with basic principles of fracture fixation and the normal imaging appearances of implant constructs and their complications. The surgeon's selection of external fixation, intramedullary nail fixation, open reduction and internal fixation, or some combination depends on patient factors, fracture configuration, injury to the soft tissue envelope, and surgeon experience. Complications including loss of fixation with resultant malalignment, nonunion, infection, and posttraumatic osteoarthritis present additional challenges for the surgeon as well as the radiologist. This article reviews the rationale behind fracture fixation in fractures of the lower leg, ankle, and foot. Examples of postoperative complications are also reviewed.

Spectrum of Voriconazole-Induced Periostitis With Review of the Differential Diagnosis.

OBJECTIVE: Voriconazole is an antifungal medication used primarily for the treatment of Candida and Aspergillus infections. A fairly newly described side effect of long-term voriconazole use is periostitis. The purpose of this article is to describe the main differential consideration-hypertrophic osteoarthropathy-and other differential diagnoses, including venous stasis, thyroid acropachy, and hypervitaminosis A. CONCLUSION: With knowledge of imaging appearance, clinical manifestations, and outcomes, radiologists can make an accurate diagnosis of voriconazole-induced periostitis, and clinical teams can initiate appropriate management.

A practical radiographic visual estimation technique for the prediction of developmental narrowing of cervical spinal canal.

OBJECTIVES: To determine if visual spinal canal percentage of facet overlap could be used as a rapid visual pre-screening test to detect developmental bony spinal canal narrowing on lateral cervical radiographs. METHODS: Lateral cervical spine radiographs with radiology report documenting developmental narrowing of the spine canal were retrospectively identified. Cohort was supplemented with additional images without such documentation. Utilizing a radiology work station, one reader (Orthopaedics) calculated the Torg ratio at C3-C6. Two readers (Radiology, Primary Care Sports Medicine) visually estimated percentage (≥80, ≥90, 100%) of spinal canal overlaid by facet articulations C3-C6 for all cases independently. Statistical analysis included accuracy tests and kappa test for comparing the gold standard and inter-, intra-observer reliability, respectively. RESULTS: 96 lateral images were included; 25 had abnormal radiology reports. High specificity (range, 91-93%) and true negative predictive values (range, 88-93%) achieved consistent statistical significance for relationship between facet/canal overlap and Torg ratio for both combined and individual data points. Sensitivity values (range, 59-75%) showed a trend toward association, with statistical significance for only the C3 level at 80% overlap. Interobserver agreement was substantial. Intra-observer reliability was moderate to perfect. CONCLUSION: Visual estimation of percentage of facet overlap of the spinal canal is a valid tool to identify individuals with potential developmental narrowing of the spinal canal as a screening prompt to select which patients may need formal calculation utilizing accepted metrics. Advances in knowledge Visual estimation of percentage of facet overlap from lateral radiographs can predict developmental narrowing of cervical spinal canal.

Practicality of exchanging transparent 3D CT for radiography for pelvic fractures.

OBJECTIVE: We assess the utility of transparent 3D reconstructed CT images for evaluation of traumatic pelvic bony injuries compared to traditional radiographs. METHODS: Radiographs and 3D reconstructed CT were anonymized and randomized before review by 4 board certified physicians using a standardized questionnaire and compared to a gold-standard axial CT by a fifth board certified physician. RESULTS: 49 patients were included. We found significant agreement (K=[0.5-0.92], p<0.001) and comparable accuracy (K=[0.36-0.38], p<0.02) and ghost images of radiographs and transparent 3D reconstructed CT without a difference in confidence (p=0.38). CONCLUSION: Transparent 3D reconstructed CT images may be sufficient for pelvic trauma injury without the use of radiographs.

Examining the Potential Use of a Novel Radiographic Scoring System for Determining Surgical Intervention in Diabetic Charcot Arthropathy.

INTRODUCTION: Although Eichenholtz and the Schon systems are commonly used to evaluate foot Charcot arthropathy on radiographs, a novel system with expanded characterization may have added benefit. METHODS: Patients with Charcot arthropathy and foot radiographs were grouped in nonsurgical group 1 (imaging sets at minimum 2-year interval) and surgical group 2 (imaging preceding fusion and/or amputation). Radiographs were scored with Eichenholtz and Schon systems, and a novel scoring system (summation of 0-3 rank for bone density, distention/swelling, debris, disorganization, and dislocation/subluxation). Summative scores of the 2 groups were compared. Differences in scores of each system from serial images of group 1 were compared and average scores from each of the systems for preoperative imaging sets of group 2 were compared. RESULTS: A total of 111 patients were included (group 1, 19 patients; group 2, 92 patients). The novel system provided a broad numerical characterization of the radiographs (range 1-15). Summative scores of the novel system for groups 1 and 2 were statistically different with lower median score in the nonsurgical group (nonsurgical median score 6 vs surgical median score 9). Individual characteristic scores from 4 (distention, debris, disorganization, and dislocation) of 5 categories for the novel system were statistically different, with lower scores for the nonoperative group. The narrower numerical scores from the Eichenholtz and Schon systems did not yield statistically significant results. CONCLUSION: The novel scoring system provides a broad numerical description of radiographic findings in Charcot arthropathy of the foot and has potential advantage for surgical predictive value. LEVELS OF EVIDENCE: Level IV: Retrospective.

Team Approach: Treatment of Diabetic Foot Ulcer.

At any point in time, 3% to 4% of the 29.1 million diabetic patients in the United States (9.3% of the population) will have a foot ulcer. Diabetes-associated foot ulcers and infection lead to >70,000 lower-extremity amputations yearly in the United States. Between one-third and one-half of diabetic patients undergoing a major lower-extremity amputation will die within 2 years after the amputation. Multidisciplinary population health-management strategies have been developed to decrease the rate and magnitude of this important comorbidity in the diabetic population. The goal of the present review is to provide the reader with a framework for the development of a health-care-system strategy for addressing this complex patient population.

Erdheim Chester disease with appendicular skeletal, renal and pleural involvement responding to Zelboraf (BRAF inhibitor) treatment: case report.

Erdheim Chester disease is a rare non-Langerhans cell histiocytosis which may involve multiple organs including bone, soft tissue, lungs, cardiovascular system, kidneys (retroperitoneum), skin, and central nervous system. Bone involvement is most common followed by other organs. This case report describes a 58-year-old man who presented with progressive renal dysfunction presumed due to obstruction. The patient failed multiple urinary tract interventions, and clinical course was complicated by recurrent low-grade fevers, and bilateral knee pain. Advanced imaging and histopathological features on bone biopsy were consistent with Erdheim Chester disease. Molecular studies of tissue showed BRAF V600 mutation. This patient was treated with Zelboraf (vemurafenib) BRAF inhibitor with subsequent improvement in renal and pleural dysfunction as well as decreased histiocytic soft tissue masses on CT.

Clinical and surgical correlation of hip MR arthrographic findings in adolescents.

OBJECTIVE: The purpose of this study was to analyze the utility of MRA-H in adolescents by comparing the results of imaging with surgical findings and/or clinical outcome. MATERIAL AND METHODS: After obtaining appropriate IRB approval, the Radiologic Information System database was queried for all patients 13-18 years of age who underwent MRA-H from 2004 through 2013. The electronic medical record was reviewed for clinical history, clinical examination findings, and operative notes. MRA-H images were reviewed for soft tissue abnormalities (labral tear, paralabral ganglion, articular cartilage loss, synovitis, ligament tears) and bony abnormalities (cam-type femoroacetabular impingement (FAI), pincer-type FAI, hip dysplasia). MRA-H findings were correlated with surgical findings and with clinical outcomes. RESULTS: Twenty-six patients with labral tears by MRA-H were included in study and grouped as follows: Group I) patients who underwent surgical management (n=10); group II) patients managed non-surgically (medication, intra-articular injection, physical therapy) (n=9); group III) patients lost to follow up after being advised to have surgery (n=7). With regard to presenting symptomatology, 87.5% of patients with labral tear had groin pain. Of those patients who were diagnosed with a labral tear, 52% were categorized as idiopathic labral tears, 26% as secondary tears (secondary to abnormal bony morphology), and 22% as traumatic labral tears. The labral tears were found to be anterior in 61% and posterior in 22%. Associated articular cartilage lesions were found in 29% of patients. In group I (surgical patients), MRA-H labral findings were confirmed at surgery in 9/10. Seventy percent of labral tears in our study had some form of abnormal bony morphology. Nine of the 12 patients with bone abnormalities were derived from group I patients. Six out of 7 patients with cam-type FAI had a labral tear. CONCLUSION: Labral tears diagnosed by MRA-H in the adolescent population correlated well with clinical examination and surgical findings. Also, MRA-H contributed by defining bony morphology that was directly applied to surgical management. Non-surgical management of labral tears diagnosed on MRA-H had a generally favorable outcome.

Effects of motion segment level, Pfirrmann intervertebral disc degeneration grade and gender on lumbar spine kinematics.

MRI allows non-invasive assessment of intervertebral disc degeneration with the added clinical benefit of using non-ionizing radiation. What has remained unclear is the relationship between assessed disc degeneration and lumbar spine kinematics. Kinematic outcomes of 54 multi-segment (L1-Sacrum) lumbar spine specimens were calculated to discover if such an underlying relationship exists with degeneration assessed using the Pfirrmann grading system. Further analyses were also conducted to determine if kinematic outcomes were affected by motion segment level, gender or applied compressive preload. Range of motion, hysteresis, high flexibility zone size and rotational stiffness in flexion-extension, lateral bending and axial rotation were the kinematic outcomes. Caudal intervertebral discs in our study sample were more degenerative than cranial discs. L5-S1 discs had the largest flexion-extension range of motion (p < 0.005) and L1-L2 discs the lowest flexion high flexibility zone size (p < 0.013). No other strict cranial-caudal differences in kinematic outcomes were found. Low flexibility zone rotational stiffness increased with disc degeneration grade in extension, lateral bending and axial rotation (p < 0.001). Trends towards higher hysteresis and lower range of motion with increased degeneration were observed in flexion-extension and lateral bending. Applied compressive preload increased flexion-extension hysteresis and augmented the effect of degeneration on hysteresis (p < 0.0005). Female specimens had about one degree larger range of motion in all rotational modes, and higher flexion extension hysteresis (p = 0.016). These results suggest that gender differences exist in lumbar spine kinematics. Additionally high disc loads, applied compressive preload or applied moment, are needed to kinematically distinguish discs with different levels of degeneration. © 2016 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 34:1389-1398, 2016.

Is Cervical Sagittal Imbalance a Risk Factor for Adjacent Segment Pathomechanics After Multilevel Fusion?

STUDY DESIGN: A biomechanical study using human spine specimens. OBJECTIVE: The aim of this study was to assess whether the presence of cervical sagittal imbalance is an independent risk factor for increasing the mechanical burden on discs adjacent to cervical multilevel fusions. SUMMARY OF BACKGROUND DATA: The horizontal offset distance between the C2 plumbline and C7 vertebral body (C2-C7 Sagittal Vertical Axis (SVA)) or the angle made with vertical by a line connecting the C2 and C7 vertebral bodies (C2-C7 tilt angle) are used as radiographic measures to assess cervical sagittal balance. There is level III clinical evidence that sagittal imbalance caused by kyphotic fusions or global spinal sagittal malalignment may increase the risk of adjacent segment pathology. METHODS: Thirteen human cadaveric cervical spines (Occiput-T1; age: 50.6 years; range: 21-67) were tested first in the native intact state and then after instrumentation across C4-C6 to simulate in situ two-level fusion. Specimens were tested using a previously validated experimental model that allowed measurement of spinal response to prescribed imbalance. The effects of fusion on segmental angular alignments and intradiscal pressures in the C3-C4 and C6-C7 discs, above and below the fusion, were evaluated at different magnitudes of C2-C7 tilt angle (or C2-C7 SVA). RESULTS: When compared with the pre-fusion state, in situ fusion across C4-C6 segments required increased flexion angulation and resulted in increased intradiscal pressure at the C6-C7 disc below the fusion in order to accommodate the same increase in C2-C7 tilt angle or C2-C7 SVA (P < 0.05). The adjacent segment mechanical burden due to fusion became greater with increasing C2-C7 tilt angle or SVA. CONCLUSION: Cervical sagittal imbalance arising from regional and/or global spinal sagittal malalignment may play a role in exacerbating adjacent segment pathomechanics after multilevel fusion and should be considered during surgical planning. LEVEL OF EVIDENCE: N/A.

Systemic Lead Toxicity.

A 4-year-old girl with slow mentation had increasing knee tenderness and limping gait.

Gastrocnemius tendinosis--A frequent finding on MRI knee examination.

OBJECTIVE: Gastrocnemius tendinosis (GT) is one potential cause for posterior knee pain, commonly overlooked on clinical examinations and imaging. This study assesses the frequency of GT on MR imaging in a convenience sample based on a database search and associations with other articular pathologies and clinical findings. SUBJECTS AND METHODS: With IRB approval, retrospective review was completed on 300 randomly selected MR knee exams performed from February 2009 to June 2010. Following de-identification, axial T2 and sagittal PD images, with or without fat suppression, were reviewed by 2 radiologists. The gastrocnemius tendon femoral attachments were graded as normal, mild (few cysts, thickening, intermediate signal) or severe GT (multiple cysts, marrow edema, tear). Select associated MR findings of internal derangement were documented. Clinical charts were reviewed for clinical presentation, physical exam findings, and select demographics. RESULTS: The inter-observer reliability for presence/grading of GT was very high (kappa statistic=0.97). Frequency of GT was 50.33%, most frequently involving medial head of gastrocnemius (63.6%). Grades of GT were 41.7% and 17.2% for mild and severe respectively. Univariate analysis showed statistically significant relationship between grade of GT with arthrosis (p=0.05) and clinical joint effusion (p=0.02). Multivariate analysis showed higher odds of severe GT for individuals with medial plus lateral GT. Statistical significance was noted for presence of both GT and ACL tear (13.9%; p=0.02). CONCLUSION: Significant findings of our analysis included GT presented with predominant involvement of medial head of gastrocnemius tendon, mild in severity, strong association with ACL tear, presented frequently as posterior knee pain, limited joint motion and clinical joint effusion. However, there was no statistically significant association between demographic features and medical comorbidities in the patients. Increased understanding of frequency of GT allows more accurate reporting of MR knee exam and systematic search for associated abnormalities.

Investigation of bone quality of the first and second sacral segments amongst trauma patients: concerns about iliosacral screw fixation.

BACKGROUND: Iliosacral screw fixation has become a common method for surgical stabilization of acute disruptions of the pelvic ring. Placement of iliosacral screws into the first sacral (S1) body is the preferred method of fixation, but size limitations and sacral dysmorphism may preclude S1 fixation. In these clinical situations, fixation into the second sacral (S2) body has been recommended. The objective of this study was to evaluate the bone quality of the S1 compared to S2 in the described "safe zone" of iliosacral screw fixation in trauma patients. MATERIALS AND METHODS: The pelvic computed tomography scans of 25 consecutive trauma patients, ages 18-49, at a level 1 trauma center were prospectively analyzed. Hounsfield units, a standardized computed tomography attenuation coefficient, was utilized to measure regional cancellous bone mineral density of the S1 and S2. No change in the clinical protocol or treatment occurred as a consequence of inclusion in this study. RESULTS: A statically significant difference in bone quality was found when comparing the first and second sacral segment (p = 0.0001). Age, gender, or smoking status did not independently affect bone quality. CONCLUSION: In relatively young, otherwise healthy trauma patients there is a statistically significant difference in the bone density of the first sacral segment compared to the second sacral segment. This study highlights the need for future biomechanical studies to investigate whether this difference is clinically relevant. Due to the relative osteopenia in the second sacral segment, which may impact the quality of fixation, we feel this technique should be used with caution.

Three-Dimensional Computed Tomography-Based Specimen-Specific Kinematic Model for Ex Vivo Assessment of Lumbar Neuroforaminal Space.

STUDY DESIGN: Cadaveric study to accurately measure lumbar neuroforaminal area and height throughout the flexion-extension range of motion (ROM). OBJECTIVE: Create a new computed tomography (CT)-based specimen-specific model technique to provide insight on the effects of kinematics on lumbar neuroforamen morphology during flexion-extension ROM. SUMMARY OF BACKGROUND DATA: Nerve root compression is a key factor in symptomatic progression of degenerative disc disease because these changes directly affect neuroforaminal area. Traditional techniques to evaluate the neuroforamen suffer from poor accuracy, have inherent limitations, and fail to provide data throughout the ROM. METHODS: Six cadaveric specimens (L1-sacrum) were instrumented with radiopaque spheres and CT scanned. 3-Dimensional reconstructions were made of each vertebra and the sphere locations determined. During kinematic testing, the spheres were located in relation to optoelectronic targets attached to each vertebra. The result was a 3-dimensional representation of the specimen's CT reconstruction moving in response to experimental data. Bony contours of the L2-L3 and L4-L5 neuroforamen were digitized producing continuous neuroforaminal area and height data throughout the ROM. RESULTS: Neuroforaminal area and height linearly increased in flexion and decreased in extension. There was significant correlation between flexion-extension motion and percent change in area (L2-L3: 3.1%/deg, R = 0.94, L4-L5: 2.5%/deg, R = 0.90) and neuroforaminal height (L2-L3: 2.1%/deg, R = 0.95, L4-L5: 1.6%/deg, R = 0.93). Regression analysis showed that the ratio between neuroforaminal height and area is at least 1:1.5 such that a 100% increase in height is associated with an area increase of more than 150%. CONCLUSION: This is the first study to measure lumbar neuroforaminal area and height throughout flexion-extension ROM. The CT-based specimen-specific model technique can accurately evaluate the effect of kinematics on morphological features of the spine. The demonstrated increase in neuroforaminal dimension in flexion is consistent with treatment modalities used in clinical therapies to relieve radicular symptoms. LEVEL OF EVIDENCE: N/A.