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Aim: To evaluate patient satisfaction outcomes with respect to pain, discomfort, and quality of life with hematology/oncology referrals undergoing CT-guided bone marrow biopsy and compare these scores with those of patients undergoing in-office biopsy. Methods: A retrospective chart review was performed over 2 years with all patients who underwent CT-guided bone marrow biopsy at our university set-up. Age, gender, BMI, radiation dose (CTDI/DLP), number of in-office biopsies, number of CT-guided biopsies, type/amount of moderate sedation used, technical and pathologic success rates, and complication rates were recorded. All patients who underwent both in-office and CT-guided biopsy were contacted by telephone to answer a brief survey regarding pain, discomfort, quality of life, and future preference with respect to each biopsy. Results: A total of 32 patients underwent CT-guided bone marrow biopsy. Moderate sedation was utilized for all CT patients, and 19 patients underwent both in-office and CT-guided biopsies. Upon surveying the 19 patients who underwent both kinds of biopsies, on a scale of 1–10 (10 = highest discomfort and highest pain), the patients on an average reported 7.8 for in-office vs. 2.1 for CT for the discomfort level (p < 0.001) and 7.9 vs. 1.7 for the pain (p < 0.001). The patients reported an average quality-of-life score of 82 (out of a scale of 100) after CT procedures and 53 for in-office (p < 0.001). All patients reported that they would prefer CT-guided procedures with sedation versus in-office procedures in the future. Conclusion: CT-guided bone marrow biopsy is the preferred and more comfortable procedure, especially in low-pain-tolerant patients, although it involves more cost, conscious sedation, and radiation exposure.

Abstract Background Patient-reported outcomes are commonly used to assess patient symptoms. The effect of specific hip pathology on relationships between perceived and objectively measured symptoms remains unclear. The purpose of this study was to evaluate differences of function and pain in patients with FAIS and DDH, to assess the correlation between perceived and objective function, and to determine the influence of pain on measures of function. Methods This prospective cross-sectional study included 35 pre-operative patients (60% female) with femoroacetabular impingement syndrome (FAIS) and 37 pre-operative patients (92% female) with developmental dysplasia of the hip (DDH). Objectively measured function (6-min walk [6MWT], single leg hop [SLHT], Biodex sway [BST], hip abduction strength [HABST], and STAR excursion balance reach [STAR] tests), patient-reported function (UCLA Activity, Hip Outcome Score [HOS], Short Form 12 [SF-12], and Hip Disability and Osteoarthritis Outcome Score [HOOS]), and patient-reported pain (HOOS Pain, visual analogue scale (VAS), and a pain location scale) were collected during a pre-surgical clinic visit. Between-group comparisons of patient scores were performed using Wilcoxon Rank-Sum tests. Within-group correlations were analyzed using Spearman’s rank correlation coefficients. Statistical correlation strength was defined as low (r = ± 0.1–0.3), moderate (r = ± 0.3–0.5) and strong (r > ± 0.5). Results Patients with DDH reported greater pain and lower function compared to patients with FAIS. 6MWT distance was moderately-to-strongly correlated with a number of patient-reported measures of function (FAIS: r = 0.37 to 0.62, DDH: r = 0.36 to 0.55). Additionally, in patients with DDH, SLHT distance was well correlated with patient reported function (r = 0.37 to 0.60). Correlations between patient-reported pain and objectively measured function were sparse in both patient groups. In patients with FAIS, only 6MWT distance and HOOS Pain (r = -0.53) were significantly correlated. In patients with DDH, 6MWT distance was significantly correlated with VAS Average (r = -0.52) and Best (r = -0.53) pain. Conclusion Pain is greater and function is lower in patients with DDH compared to patients with FAIS. Moreover, the relationship between pain and function differs between patient groups. Understanding these differences is valuable for informing treatment decisions. We recommend these insights be incorporated within the clinical continuum of care, particularly during evaluation and selection of surgical and therapeutic interventions.

Category: Bunion; Midfoot/Forefoot Introduction/Purpose: The majority of hallux valgus (HV) corrections have been historically performed via a two-dimensional, transverse plane-focused approach, which has demonstrated high long-term recurrence rates. Recent research demonstrates that 87% of HV deformities are three-dimensional with abnormal frontal-plane rotation of the metatarsal, which cannot be completely addressed with a two-dimensional metatarsal osteotomy alone. While correction at the 1st tarsometatarsal (TMT) joint may provide the optimal surgical approach for 3D anatomic restoration at the apex of the deformity, 1st TMT fusion historically entails an extended period of non-weightbearing. This study evaluated the clinical, radiographic, and patient-reported outcomes in patients undergoing instrumented triplanar 1st TMT arthrodesis (TMTA) with a biplanar plating system and protected near- immediate weightbearing. Methods: A prospective multicenter study that will continue for 60 months post-operatively. Patients 14-58 years old with symptomatic HV (intermetatarsal and HV angles between 10-22° and 16-40°, respectively) and no prior HV surgery on the operative foot were eligible for this study. Patients were treated with an instrumented TMTA procedure using a biplanar plating system with protected early weightbearing. The primary endpoint of this study is radiographic recurrence of HV deformity at 24 months for subjects with successful correction (defined as IMA < 9°, HVA < 15° and TSP ≤ 3 at 6 weeks post-procedure). Recurrence is defined by any two of the three conditions: IMA of ≥12°, HVA ≥20° and TSP ≥4. Secondary outcomes (return to weightbearing and activities, pain measured by visual analog scale (VAS), Manchester-Oxford Foot Questionnaire (MOxFQ), and Patient Reported Outcomes Measurement Information System (PROMIS)) were evaluated post-operatively. Two independent fellowship trained musculoskeletal radiologists reviewed all radiographic data. Results: 173 patients underwent TMTA with mean age of 41.0 (range:14-58) years; 92% females. Median (range) time-to-follow-up is 25 (1.5-49.2) months. Eighteen (10.4%) patients have discontinued. Mean (SD) days to protected weightbearing in CAM boot and return to full work were 8.4 (7.4) and 57.9 (46.2), respectively. At 24 months post-procedure, 99.3% (134/135) of patients were recurrence-free. Statistically significant improvements from baseline in HVA, IMA, and TSP (Table 1), VAS score, MOxFQ and PROMIS domains were observed as early as 6 weeks post-operatively and maintained over time. In 143 patients, mean (95% CI) 24-month improvements were VAS: 3.9 (3.5, 4.2); Walking/Standing (MOxFQ): 39.2 (34.9, 43.4); Physical Function (PROMIS): 9.7 (8.3, 11.2). Nineteen (11.0%) patients experienced hardware complications yet maintained radiographic correction. Conclusion: The results of this study’s primary and secondary endpoints provide supporting evidence that TMTA with biplanar plating is successful in correcting the 3D hallux valgus deformity with early return to weightbearing and low recurrence while demonstrating favorable clinical and patient-reported outcomes. Patients exhibited meaningful pain reduction after surgery and were able to return to full, unrestricted work and activities in less than two months, on average. Statistically significant improvements in patients’ health-related quality-of-life were observed through 36 months, post-operatively. Patients will continue to be followed for up to 60 months with additional evaluations for complications, recurrence, and patient satisfaction.

AimsHip dysplasia (HD) leads to premature osteoarthritis. Timely detection and correction of HD has been shown to improve pain, functional status, and hip longevity. Several time-consuming radiological measurements are currently used to confirm HD. An artificial intelligence (AI) software named HIPPO automatically locates anatomical landmarks on anteroposterior pelvis radiographs and performs the needed measurements. The primary aim of this study was to assess the reliability of this tool as compared to multi-reader evaluation in clinically proven cases of adult HD. The secondary aims were to assess the time savings achieved and evaluate inter-reader assessment.MethodsA consecutive preoperative sample of 130 HD patients (256 hips) was used. This cohort included 82.3% females (n = 107) and 17.7% males (n = 23) with median patient age of 28.6 years (interquartile range (IQR) 22.5 to 37.2). Three trained readers’ measurements were compared to AI outputs of lateral centre-edge angle (LCEA), caput-collum-diaphyseal (CCD) angle, pelvic obliquity, Tönnis angle, Sharp’s angle, and femoral head coverage. Intraclass correlation coefficients (ICC) and Bland-Altman analyses were obtained.ResultsAmong 256 hips with AI outputs, all six hip AI measurements were successfully obtained. The AI-reader correlations were generally good (ICC 0.60 to 0.74) to excellent (ICC > 0.75). There was lower agreement for CCD angle measurement. Most widely used measurements for HD diagnosis (LCEA and Tönnis angle) demonstrated good to excellent inter-method reliability (ICC 0.71 to 0.86 and 0.82 to 0.90, respectively). The median reading time for the three readers and AI was 212 (IQR 197 to 230), 131 (IQR 126 to 147), 734 (IQR 690 to 786), and 41 (IQR 38 to 44) seconds, respectively.ConclusionThis study showed that AI-based software demonstrated reliable radiological assessment of patients with HD with significant interpretation-related time savings.Cite this article: Bone Jt Open 2022;3(11):877–884.

Abstract Purpose Acetabular dysplasia (AD) is a debilitating condition which results in impaired hip function, leading to hip-spine syndrome with anomalies identifiable on plain radiographs. However, no study to date has investigated the association between radiographic spine anomalies and functional outcomes in AD. We hypothesize that AD patients with radiographic evidence of lumbar spine anomalies are associated with decreased function in comparison to those without such radiographic findings. Patients and methods One hundred thirty-five hips underwent a full four-view hip radiograph series, and two observers analyzed hip and spine variables using standard radiographs and obtained Castellvi grade, assessment of spondylolisthesis, and L4-S1 interpedicular distance. A comprehensive hip questionnaire was administered which included Harris Hip Score (HHS) and Hip Disability and Osteoarthritis Outcome Score (HOOS) to assess patient function. Correlations between HHS and HOOS and radiographic spinal measurements were calculated, and p-values were corrected for multiple comparison using the Holm’s method. Results Out of 135 patients, 119 were female (88.1%) and 16 were male (11.9%). Average age of presentation was 34.2 years, and average BMI was 26. There was no statistically significant correlation between Castellvi grade, presence of spondylolisthesis, or L4-S1 interpedicular distance and the patient-reported outcome measures HHS or HOOS. Conversely, a significant correlation was observed between Femoro-Epiphyseal Acetabular Roof (FEAR) index and HOOS of the contralateral hip (correlation coefficient = 0.38, adjusted p = 0.03) and Tönnis angle of AD severity and HHS of the contralateral hip (correlation coefficient = − 0.33, adjusted p = 0.04). Conclusion Severity of spinal anomalies measured by Castellvi grade and spondylolisthesis in patients with AD was not associated with decreased patient function in the ipsilateral diseased hip. To our knowledge, this is the first study to date to report the relationship between radiographically identifiable lumbosacral abnormalities and hip function in AD.

Category: Bunion; Midfoot/Forefoot Introduction/Purpose: The majority of hallux valgus corrections are performed via a two dimensional approach with 1st metatarsal osteotomy and translation in the transverse plane. This approach has demonstrated high long-term recurrence rates. Recent research demonstrates that 87% of hallux valgus deformities are three-dimensional with abnormal frontal-plane rotation of the metatarsal, which cannot be completely addressed with a two dimensional metatarsal osteotomy alone. While correction at the 1st tarsometatarsal (TMT) joint may provide the optimal surgical approach for 3D anatomic restoration at the apex of the deformity, 1st TMT fusion historically entails an extended period of non-weightbearing. This study evaluated the clinical, radiographic, and patient-reported outcomes in patients undergoing instrumented triplanar 1st TMT arthrodesis (TMTA) with a biplanar plating system and protected near-immediate weightbearing. Methods: This is a prospective multicenter study that will continue for 60 months post-operatively. Patients between 14-58 years old with symptomatic hallux valgus (intermetatarsal and hallux valgus angles between 10.0-22.0° and 16.0-40.0°, respectively) and no prior hallux valgus surgery on the operative foot were eligible for this study. Patients were treated with an instrumented TMTA procedure using a biplanar plating system with protected near-immediate weightbearing. Several outcomes (radiographic, return to weightbearing and activities, pain measured by visual analog scale (VAS), Manchester-Oxford Foot Questionnaire (MOxFQ), and Patient Reported Outcomes Measurement Information System (PROMIS)) were evaluated post-operatively. Two independent fellowship trained musculoskeletal radiologists reviewed all radiographic data. These interim results are limited to patients completing at least 6 months of follow-up. Results: 165 patients underwent TMTA with at least 6 months follow-up (mean (SD): 17.8 (7.7); min, max: 5.8, 37.3). Mean age was 41.0 (range:14-58) years; 91.5% of patients were female. Mean (SD) days to protected weightbearing in CAM boot and return to full work were 8.4 (7.7) and 56.8 (45.6), respectively. Significant improvements from baseline in HVA, IMA, and TSP (Table 1), VAS score, MOxFQ and PROMIS domains were observed as early as 6 weeks post-procedure. At 12 months, mean (95% CI) change in VAS was -3.7(-4.0, -3.3); Walking/Standing (MOxFQ) change was -35.2 (-39.6, -30.8); and Physical Function (PROMIS) change was 8.7 (7.1, 10.3). Fifteen (9.1%) patients experienced hardware complications, yet maintained radiographic correction to date. No patients (0/58) with 24 months follow-up have experienced recurrence. Conclusion: These interim findings support that TMTA with biplanar plating is successful in correcting the 3D hallux valgus deformity with early return to weightbearing while demonstrating favorable clinical and patient-reported outcomes. Patients exhibited meaningful pain reduction after surgery and were able to return to full, unrestricted work and activities in less than two months, on average. Statistically significant improvements in patients' health-related quality of life were observed at 6 and 12 months, post-operatively. Patients will continue to be followed for up to 60 months with additional evaluations for complications, 24-month recurrence, and patient satisfaction.

Providing direct feedback to technologists has become challenging for radiologists due to geographic separation and other reasons. As such, there is a need for automated solutions to solve quality issues in radiography. We evaluated the feasibility of using a computer vision artificial intelligence (AI) algorithm to classify hand radiographs into quality categories in order to automate quality assurance processes in radiology. A bounding box was placed over the hand on 300 hand radiographs. These inputs were employed to train the computational neural network (CNN) to automatically detect hand boundaries. The trained CNN detector was used to place bounding boxes over the hands on an additional 100 radiographs, independently of the training or validation sets. A computer algorithm processed each output image to calculate unused air spaces. The same 100 images were classified by two musculoskeletal radiologists into four quality categories. The correlation between the AI-calculated unused space metric and radiologist-assigned quality scores was determined using the Spearman correlation coefficient. The kappa statistic was used to calculate the inter-reader agreement. The best negative correlation between the AI-assigned metric and the radiologists’ assigned quality scores was achieved using the calculation of the unused space at the top of the image. The Spearman correlation coefficients were −0.7 and −0.6 for the two radiologists. The kappa correlation coefficient for interobserver agreement between the two radiologists was 0.6. Automatic calculation of the percentage of unused space or indirect collimation at the top of hand radiographs correlates moderately well with radiographic collimation quality.

PURPOSEPiriformis syndrome is a common pain condition affecting the buttock and posterior hip with or without radiation to the leg, and management of the condition involves many treatments. In this study, we hypothesize that a CT-guided injection with botulinum toxin is more effective in providing pain relief than a CT-guided injection without Botox.METHODSOverall, 97 consecutive patients with piriformis syndrome presented for a CT-guided injection of the piriformis muscle and perineural injection of the sciatic nerve. After the injection, the patients received a visual analog scale pain log to record their pain level until the follow-up appointment. P values of less than 0.2 were considered as confounder and adjusted by inverse probability of treatment weighting (IPTW) via propensity score. The effect of botulinum toxin on 48-hour response and duration of response was tested using weighted chi-square test and weighted Kaplan-Meier analysis.RESULTSThere was a total of 97 patients in the study, and 111 injections, as some patients had bilateral injections. Patients in the Botox group had more 48-hour response than patients in the non-botulinum toxin group (P < 0.001 with IPTW, P = 0.005 without IPTW). Median pain-free survival was 30 days for Botox group and 1 day for non-Botox group (P = 0.059 with IPTW, P = 0.10 without IPTW).CONCLUSIONCT-guided injections with botulinum toxin for patients with piriformis syndrome are more likely to lead to a positive response and a longer duration of response than patients who receive a CT-guided injection without botulinum toxin. We hope that this study facilitates future prospective randomized blind trials for patients with suspected piriformis syndrome.

ABSTRACT Androgen deprivation therapy (ADT) is a cornerstone of advanced prostate cancer (PCa) therapy. Its use is associated with a loss of bone mineral density (BMD) and a greater risk of falls and osteoporotic fractures. In this prospective cohort study, we examined the impact of ADT on muscle and bone strength in men initiating ADT for PCa. Participants were evaluated at three time points: immediately before (week 0), and 6 and 24 weeks after ADT initiation. Study measures included fasting blood levels (for markers of muscle and bone metabolic activity), MRI and QCT imaging (for muscle fat content, and bone density and architecture), and validated clinical tests of muscle strength and gait. Sixteen men completed all study visits. At baseline and throughout the study, participants exercised a median of four times/week, but still experienced weight gain (+2.0 kg at week 24 versus week 0, p = 0.004). Biochemically, all men sustained dramatic early and persistent reductions in sex hormones post‐ADT, along with a progressive and significant increase in serum C‐telopeptide of type I collagen (CTX, +84% at week 24 versus week 0). There was a trend for rise in serum sclerostin (p = 0.09) and interleukin 6 (IL‐6) (p = 0.08), but no significant change in serum myostatin (p = 0.99). Volumetric BMD by QCT declined significantly at the femoral neck (−3.7% at week 24 versus week 0), particularly at the trabecular compartment. On MRI, there were no significant changes in thigh muscle fat fraction. On physical testing, men developed weaker grip strength, but experienced no worsening in lower extremity and lumbar spine muscle strength, or on functional tests of gait. In conclusion, in physically active men, ADT for 24 weeks results in a significant increase in bone resorption and reduction in BMD, but nonsignificant changes in thigh muscle quality (on imaging) or strength and gait (on functional testing). © 2021 The Authors. JBMR Plus published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research.

Category: Bunion; Midfoot/Forefoot Introduction/Purpose: The majority of hallux valgus corrections are performed via a two dimensional approach with 1st metatarsal osteotomy and translation in the transverse plane. This approach has demonstrated high long-term recurrence rates. Recent research demonstrates that 87% of hallux valgus deformities are three-dimensional with abnormal frontal-plane rotation of the metatarsal, which cannot be completely addressed with a two dimensional metatarsal osteotomy alone. While correction at the 1st tarsometatarsal (TMT) joint may provide the optimal surgical approach for 3D anatomic restoration at the apex of the deformity, 1st TMT fusion entails an extended period of non-weightbearing. This study evaluated the clinical, radiographic, and patient-reported outcomes in patients undergoing instrumented triplanar 1st TMT arthrodesis (TMTA) with a biplanar plating system and protected near-immediate weightbearing. Methods: This is a prospective multicenter study that will continue for 60 months post-operatively. Patients between 14-58 years old with symptomatic hallux valgus (intermetatarsal and hallux valgus angles between 10.0-22.0° and 16.0-40.0°, respectively) and no prior hallux valgus surgery on the operative foot are eligible for this study. Patients are treated with an instrumented TMTA procedure using a biplanar plating system with protected near-immediate weightbearing. Several outcomes (radiographic, range of motion (ROM), return to weightbearing and activities, pain measured by visual analog scale (VAS), Manchester-Oxford Foot Questionnaire (MOxFQ), and Patient Reported Outcomes Measurement Information System (PROMIS)) are evaluated post- operatively. Two independent fellowship trained musculoskeletal radiologists reviewed all radiographic data. These interim results are limited to patients completing at least 6 months of follow-up. Results: At time of analysis, 121 patients had undergone TMTA with at least 6 months of follow-up. Mean age was 40.6 (range:15- 58) years, and 91% of patients were female. Mean (SD) days to protected weightbearing in CAM boot, return to work, and return to full work were 8.2 (6.8), 24.0 (29.5), and 51.2 (44.0), respectively. Significant improvements (p

Elbow derangements are common. Clinical examination is supplemented by magnetic resonance imaging (MRI) for optimal diagnostic assessment of such disorders. 3-dimensional (3D) imaging is feasible on newer MR scanners in acceptable acquisition times. Isotropic high-resolution 3D MRI affords multiplanar reconstructions and aids in diagnostic evaluation of elbow disorders and pre-/post-surgical assessments. The article details technical considerations of 3D elbow MRI and discusses its role in diagnostic evaluation of elbow disorders with relevant comparisons to 2D MRI and emphasizes as to how such advanced imaging assists in pre- and post-surgical assessments of tendon and ligament derangements.

Background Chronic groin neuralgia is a life-debilitating condition that plagues patients worldwide. While groin neuralgia is usually traced to iatrogenic causes (inguinal hernia repairs, vasectomy, and hysterectomy), there is a unique subset of patients that present with noniatrogenic groin neuralgia. The diagnosis and treatment of these patients present a particular challenge. Methods A total of 30 patients (current mean age, 46.5 [range: 19–72] years) who presented with noniatrogenic groin neuralgia and received neurectomies on the iliohypogastric, ilioinguinal, and genitofemoral nerves between 2008 and 2017 were identified. A retrospective review of preoperative and immediate postoperative pain scores was compared with prospectively collected current pain on a Likert's scale (0–10). Additionally, patients were asked to complete a Short Form (SF)-20 and identify current pain medications. A two-sided Wilcoxon–Mann–Whitney test was used to analyze the data. Results Of the 30 patients identified, 16 could participate (mean follow-up = 61 months). The average pain reduction for the entire group was 62.7%. When using an established 30% reduction pain as a marker for clinical significance, 12 successful and 4 unsuccessful patients had an average reduction of 81.1 and 7.68%, respectively (success rate of 75%). Patients with successful group showed a statistically significant increased social functioning (p = 0.012) and near-significant increase in mental health (p = 0.063). Improvements, albeit nonsignificant, in mean scaled scores for every other SF-20 quality of life (QoL) category were observed when comparing both groups. Conclusion Neurectomy is a potentially beneficial surgery that can assuage pain and improve quality of life for patients with noniatrogenic groin neuralgia.

Purpose: To evaluate interreader performance in the measurement of the cross-sectional area and myosteatosis of pelvic skeletal muscles using fat quantification magnetic resonance imaging (MRI) and correlate with patient anthropomorphic characteristics. Materials and Methods: A Health Insurance Portability and Accountability Act–compliant retrospective cross-sectional study was performed. Between January and April 2016, 61 patients (26 males and 35 females) underwent a lumbosacral plexus 3T MRI with a modified three-dimensional spoiled gradient echo sequence dedicated to fat quantification (mDixon Quant; Philips Healthcare). Two independent reviewers outlined muscle cross-sectional area on axial images using a freehand region of interest tool and documented proton-density fat fraction (FF) and muscle area (cm2) of the psoas, gluteus medius, gluteus maximus, and rectus femoris muscles on each side. Interreader agreement was assessed by intraclass correlation coefficient (ICC), and correlation between the measurements and subject’s age, gender, and body mass index (BMI) was assessed using multiple linear regression analysis. Results: Excellent interreader agreement was obtained (ICC ≥0.74) for all muscle groups except for the left gluteus medius area and right psoas FF which showed good agreement (0.65 and 0.61, respectively). Statistically significant (P ≤ 0.05) positive correlation was seen between the gluteal muscle FF and area with BMI, and rectus muscle FF with age and BMI. Statistically significant negative correlation between the rectus femoris area and age was also observed. Conclusion: Fat quantification MRI is a highly reproducible imaging technique for the assessment of myosteatosis and muscle size. Intramuscular FF and cross-sectional area were correlated with age and BMI across multiple muscle groups.

Sickle cell anemia is an inherited disorder with many systemic complications. Peripheral neuropathy related to this disorder has been sparsely reported. We report an interesting case of upper limb peripheral neuropathy from sickle cell disease with emphasis on MR neurography appearances and electrophysiology correlation.

Category: Bunion; Midfoot/Forefoot Introduction/Purpose: The majority of hallux valgus corrections are performed via a uniplanar metatarsal osteotomy approach in which the metatarsal is cut and shifted over in the transverse plane. This approach has demonstrated high long-term recurrence rates. Recent research demonstrates that 87% of hallux valgus deformities are three-dimensional with abnormal frontal-plane rotation of the metatarsal, which cannot be fully addressed with a uniplanar metatarsal osteotomy. While correction at the 1st tarsometatarsal (TMT) joint may provide the optimal surgical approach for 3D anatomic restoration at the apex of the deformity, 1st TMT fusion has historically involved an extended period of non-weightbearing. This study evaluates the clinical, radiographic, and patient-reported outcomes in patients undergoing instrumented triplanar 1st TMT arthrodesis (TTA) with a biplanar plating system and protected near-immediate weightbearing. Methods: This is a prospective multicenter study that will continue for 60 months post-operatively. Patients between 14-58 years old with symptomatic hallux valgus (intermetatarsal and hallux valgus angles between 10.0-22.0° and 16.0-40.0°, respectively) and no prior hallux valgus surgery on the operative foot are eligible for this study. Patients are treated with an TTA procedure using a biplanar plating system with protected near-immediate weightbearing. Outcomes (radiographic, range of motion (ROM), pain measured by visual analog scale (VAS), Manchester-Oxford Foot Questionnaire (MOxFQ), return to weightbearing and activities) are evaluated post-operatively. Two independent musculoskeletal radiologists reviewed radiographic data. These interim results are limited to patients completing at least 6 weeks of follow-up. Results: At time of data cut-off, 74 patients had undergone TTA with at least 6 weeks follow-up. The majority of patients were women (95%) with mean age 41.7 years. The mean (95% confidence interval) time to protected weightbearing in CAM boot was 8.0 (6.4, 9.7) days, return to work was 19.0 (13.6, 24.4) days, and return to full work was 31.5 (22.7, 40.2) days. There was a significant change in radiographic measures pre vs. post procedure and changes were maintained over time (Table). VAS pain score decreased 4 and 6 months post-procedure by 3.9 (3.2, 4.6) and 4.2 (3.5, 5.0), respectively. The mean MOxFQ Index Score pre-procedure was 53.3 (49.5, 57.1) and at month 6 had decreased to 18.6 (12.9, 24.2). Conclusion: These interim findings support that TTA with biplanar plating is successful in correcting the 3D hallux valgus deformity with early return to weightbearing and demonstrated favorable clinical and patient-reported outcomes. Patients were able to return to full, unrestricted work and activities within just a few months and had meaningful pain reduction after surgery. Patients will continue to be followed for up to 60 months. Clinical/radiographic healing at 12 months and recurrence rates at 24 months, as well as complications and patient satisfaction, will be evaluated.

Category: Trauma; Hindfoot Introduction/Purpose: Fractures of the calcaneus are life-changing events with a major socioeconomic impact from lost productivity. Traditional operative treatment with the extensile lateral approach has shown relatively high rates of wound complications. Less invasive approaches can improve fracture alignment and decrease wound healing complications. The purpose of this study is to report our experience with the sinus tarsi approach in treating calcaneus fractures. Methods: We retrospectively identified patients at our institution treated with a limited sinus tarsi approach for calcaneus fractures from 2009-2018. Demographic and radiographic data were collected including: age, sex, mechanism of injury, occupation, presence of diabetes, smoking status, Sanders classification, Bohler and Gissane angles. Postoperatively, we recorded the presence of complications, return-to-work time, and radiographic measurements. Results: Our analysis included 105 fractures in 100 patients: 86% males, 42% smokers, 4% diabetics, with an average body mass index of 26.5. The fractures were: Sanders type 2 (32%), type 3 (48%), type 4 (18%), and 2% were a tongue-type variant. Preoperatively 38% of fractures displayed a negative angle, 50% had an angle 0-20 degrees, and 12% over 20 degrees; postoperatively 13% had an angle 0-20 degrees, and 87% had an angle over 20 degrees. Of patients working prior to the injury, 72% had returned to work by 6 months, and 89% by 12 months. The wound complication rate was 12% (12/100), with only 2% (2/100) requiring additional procedures. There was no significant difference in wound complication rates in smokers versus nonsmokers (11.9% vs 12.2%, p=0.55). Conclusion: The limited sinus tarsi approach for depressed calcaneus fractures allows radiographic restoration of calcaneal height with a low rate of wound complications, even amongst active smokers. To the authors’ best knowledge, this is the largest published case series of calcaneus fractures treated with the sinus tarsi approach. Further follow up is needed to determine the success of this approach in mitigating long term complications.

Periosteum is a fibrous sheath, coating the external bone, except in the articular surfaces, tendon insertions and sesamoid bone surface¹. It changes its aspects and characteristics with aging, becoming progressively less elastic and more firm. It is composed of two different layers: outer fibrous (firm, collagen-filled) and inner proliferative (cambium, containing osteoprogenitor cells)². Four vascular systems are responsible for the blood supply of the periosteum: the intrinsic periosteal system, located between fibrous and proliferative layer; the periosteocortical, the main nutritional arteries of the periosteum; the musculoperiosteal, responsible for the callus formation after fractures; the fascioperiosteal, specifically for each bone.³ It is crucial to bone formation and resorption, reacting to insults in the cortical bone, such as tumors, infections, traumas, medications and arthritic diseases. The aggressiveness of the reaction can be suggested by its radiological aspect and appearance4. The periosteum in children is looser compared to adults, resulting in earlier and more exuberant reactions. All these aspects will be detailed, so the essential information all radiologists need to know will be discussed.

Magnetic resonance neurography is a technique for identifying anatomy and pathologic lesions of nerves, and has emerged as a helpful technique for localizing lesions and elucidating the underlying etiology. Ganglioneuromas are highly differentiated benign tumors. This lesion is rare and exhibits undetermined symptoms, the features of using the magnetic resonance neurography are a great ally to determine its diagnosis. The authors illustrate a case of retroperitoneal ganglioneuroma emphasizing its image characteristics using magnetic resonance neurography with the diagnosis confirmed by histopathological examination. Keywords: Ganglioneuroma, Lumbosacral plexus, MRI, MRN

Abstract Background Cross-sectional imaging is not currently used in planning Total Hip Arthroplasty (THA). The aim of our study is to determine correlations between CT parameters and outcomes following THA. Methods A prospective registry of patients who underwent total joint arthroplasty was reviewed for patients who: (1) underwent THA, (2) had a CT between 1 year before and 6 months after surgery, and (3) completed perioperative WOMAC and Harris Hip Score (HHS) questionnaires. Two readers measured CT parameters, yielding mean Hounsfield Units, area, average diameter, and perimeter of the psoas major, gluteus medius and minimus muscles. A segmentation algorithm determined visceral and subcutaneous fat area, and waist circumference. ICC was calculated for each measurement to examine inter-reader agreement. Regression analyses were performed to select measurements with most impact on outcome scores. Results Twenty-eight patients met inclusion criteria (17 female, 11 male), having mean (+/− standard deviation) age of 54.4 +/− 14.8 years and BMI 29.0 +/− 6.3 kg/m2. Correlations were found between HHS and age (0.650, p = 0.018), height (−1.263, p = 0.009), visceral-to-subcutaneous fat area ratio at the psoas level (0.511, p = 0.018), and waist circumference at the psoas level (1.759, p = 0.002). Inter-reader analysis showed ICC > 0.850 for all measurements. Conclusion Age and height, as well as CT-derived visceral-to-subcutaneous fat area ratio and waist circumference significantly correlate with postsurgical HHS scores following THA. Our study suggests that parameters derived from cross-sectional CT imaging can be useful additional preoperative planning tool for THA.

Abstract Background Majority of musculoskeletal cross-sectional imaging requests have a non-revealing and non-specific clinical history of pain. However, the location of pain is very relevant towards arriving at a specific orthopedic diagnosis. The purpose of this research was to study the impact of skin marker placement and training of technologists prior to knee MRI in detection of clinically important findings. Methods Total 200 consecutive left knee MRIs were evaluated before and after technologist training with regards to marker placement at the site of clinical symptoms or palpable finding. Marker location in relation to the knee was recorded and important findings were classified as correlated important finding, non-correlated important finding, other compartment important finding in non-correlated cases, and diffuse abnormality, i.e. tri-compartmental cartilage defects in both correlated and non-correlated cases. Differences among scans before and after technologist training were analyzed. Results The marker placement was observed in higher proportion of patients in post-training scans (78% vs 60%, p = 0.00). The most common location of the marker was in anterior or anterolateral knee (32% and 34% cases, respectively). The marker-important finding correlation was also higher post training, but not statistically significant (53% versus 38%, p = 0.57). Important findings correlated with the marker in more than 50% of the scans in the post-training set. Conclusion Marker placement can aid in detection of clinically important imaging finding and technologist training aids in increased rates of marker placement and improved correlation.

Abstract Magnetic resonance (MR) imaging plays an important role in the evaluation of bacterial and tuberculous spondylodiscitis and associated complications. Owing to its high sensitivity and specificity, it is a powerful diagnostic tool in the early diagnosis of ongoing infections, and thus provides help in prompt initiation of appropriate, therapy which may be medical or surgical, by defining the extent of involvement and detection of complications such as epidural and paraspinal abscesses. More specifically, MR imaging helps in differentiating bacterial from tuberculous infections and enables follow up of progression or resolution after appropriate treatment. However, other non-infectious pathology can demonstrate similar MR imaging appearances and one should be aware of these potential mimickers when interpreting MR images. Radiologists and other clinicians need to be aware of these potential mimics, which include such pathologies as Modic type I degenerative changes, trauma, metastatic disease and amyloidosis. In this pictorial review, we will describe and illustrate imaging findings of bacterial and tuberculous spondylodiscitis, their complications and non-infectious pathologies that mimic these spinal infections.

Melorheostosis is an uncommon, sporadic, sclerosing bone lesion that may affect the adjacent soft tissues. It has been associated with many entities such as osteopoikilosis, soft tissue vascular malformations, bone and soft tissue tumors, nephrotic syndrome, segmental limb contractures, osteosarcoma, desmoid tumor, and mesenteric fibromatosis. Synovial osteochondromatosis is a benign neoplasia of the hyaline cartilage presenting as nodules in the subsynovial tissue of a joint or tendon sheath. The intra-articular extension of melorheostosis mimicking synovial osteochondromatosis has not been reported before. In this article, the authors describe an unusual case mimicking synovial chondromatosis arising as a result of melorheostosis and their characteristic imaging findings.

The Seddon and Sunderland classifications have been used by physicians for peripheral nerve injury grading and treatment. While Seddon classification is simpler to follow and more relevant to electrophysiologists, the Sunderland grading is more often used by surgeons to decide when and how to intervene. With increasing availability of high-resolution and high soft-tissue contrast imaging provided by MR neurography, the surgical treatment can be guided following the above-described grading systems. The article discusses peripheral nerve anatomy, pathophysiology of nerve injury, traditional grading systems for classifying the severity of nerve injury, and the role of MR neurography in this domain, with respective clinical and surgical correlations, as one follows the anatomic paths of various nerve injury grading systems.

Bone marrow lesions on magnetic resonance (MR) imaging are common and may be seen with various pathologies. The authors outline a systematic diagnostic approach with proposed categorization of various etiologies of bone marrow lesions. Utilization of typical imaging features on conventional MR imaging techniques and other problem-solving techniques, such as chemical shift imaging and diffusion-weighted imaging (DWI), to achieve accurate final diagnosis has been highlighted.

Ultrasound (US)-guided high intensity focused ultrasound (HIFU) has been proposed for noninvasive treatment of neuropathic pain and has been investigated in in-vivo studies. However, ultrasound has important limitations regarding treatment guidance and temperature monitoring. Magnetic resonance (MR)-imaging guidance may overcome these limitations and MR-guided HIFU (MR-HIFU) has been used successfully for other clinical indications. The primary purpose of this study was to evaluate the feasibility of utilizing 3D MR neurography to identify and guide ablation of peripheral nerves using a clinical MR-HIFU system.Volumetric MR-HIFU was used to induce lesions in the peripheral nerves of the lower limbs in three pigs. Diffusion-prep MR neurography and T1-weighted images were utilized to identify the target, plan treatment and immediate post-treatment evaluation. For each treatment, one 8 or 12 mm diameter treatment cell was used (sonication duration 20 s and 36 s, power 160-300 W). Peripheral nerves were extracted < 3 hours after treatment. Ablation dimensions were calculated from thermal maps, post-contrast MRI and macroscopy. Histological analysis included standard H&E staining, Masson's trichrome and toluidine blue staining.All targeted peripheral nerves were identifiable on MR neurography and T1-weighted images and could be accurately ablated with a single exposure of focused ultrasound, with peak temperatures of 60.3 to 85.7°C. The lesion dimensions as measured on MR neurography were similar to the lesion dimensions as measured on CE-T1, thermal dose maps, and macroscopy. Histology indicated major hyperacute peripheral nerve damage, mostly confined to the location targeted for ablation.Our preliminary results indicate that targeted peripheral nerve ablation is feasible with MR-HIFU. Diffusion-prep 3D MR neurography has potential for guiding therapy procedures where either nerve targeting or avoidance is desired, and may also have potential for post-treatment verification of thermal lesions without contrast injection.

High resolution and high field magnetic resonance neurography (MR neurography, MRN) is shown to have excellent anatomic capability. There have been considerable advances in the technology in the last few years leading to various feasibility studies using different structural and functional imaging approaches in both clinical and research settings. This paper is intended to be a useful seminar for readers who want to gain knowledge of the advancements in the MRN pulse sequences currently used in clinical practice as well as learn about the other techniques on the horizon aimed at better depiction of nerve anatomy, pathology, and potential noninvasive evaluation of nerve degeneration or regeneration.

Aim: To evaluate the pudendal nerve segments that could be identified on magnetic resonance neurography (MRN) before and after surgical marking of different nerve segments., Methods: The hypothesis for this study was that pudendal nerve and its branches would be more easily seen after the surgical nerve marking. Institutional board approval was obtained. One male and one female cadaver pelvis were obtained from the anatomy board and were scanned using 3 Tesla MRI scanner using MR neurography sequences. All possible pudendal nerve branches were identified. The cadavers were then sent to the autopsy lab and were surgically dissected by a peripheral nerve surgeon and an anatomist to identify the pudendal nerve branches. Radiological markers were placed along the course of the pudendal nerve and its branches. The cadavers were then closed and rescanned using the same MRN protocol as the pre-marking scan. The remaining pudendal nerve branches were attempted to be identified using the radiological markers. All scans were read by an experienced musculoskeletal radiologist., Results: The pre-marking MR Neurography scans clearly showed the pudendal nerve at its exit from the lumbosacral plexus in the sciatic notch, at the level of the ischial spine and in the Alcock's Canal in both cadavers. Additionally, the right hemorrhoidal branch could be identified in the male pelvis cadaver. The perineal and distal genital branches could not be identified. On post-marking scans, the markers were used as identifiable structures. The location of the perineal branch, the hemorroidal branch and the dorsal nerve to penis (in male cadaver)/clitoris (in female cadaver) could be seen. However, the visualization of these branches was suboptimal. The contralateral corresponding nerves were poorly seen despite marking on the surgical side. The nerve was best seen on axial T1W and T2W SPAIR images. The proximal segment could be seen well on 3D DW PSIF sequence. T2W SPACE was not very useful in visualization of this small nerve or its branches., Conclusion: Proximal pudendal nerve is easily seen on MR neurography, however it is not possible to identify distal branches of the pudendal nerve even after surgical marking.

Aim: To test the incremental value of 3T magnetic resonance neurography (MRN) in a series of unilateral radiculopathy patients with non-contributory magnetic resonance imaging (MRI)., Methods: Ten subjects (3 men, 7 women; mean age 54 year and range 22-74 year) with unilateral lumbar radiculopathy and with previous non-contributory lumbar spine MRI underwent lumbosacral (LS) plexus MRN over a period of one year. Lumbar spine MRI performed as part of the MRN LS protocol as well as bilateral L4-S1 nerves, sciatic, femoral and lateral femoral cutaneous nerves were evaluated in each subject for neuropathy findings on both anatomic (nerve signal, course and caliber alterations) and diffusion tensor imaging (DTI) tensor maps (nerve signal and caliber alterations). Minimum fractional anisotropy (FA) and mean apparent diffusion coeffcient (ADC) of L4-S2 nerve roots, sciatic and femoral nerves were recorded., Results: All anatomic studies and 80% of DTI imaging received a good-excellent imaging quality grading. In a blinded evaluation, all 10 examinations demonstrated neural and/or neuromuscular abnormality corresponding to the site of radiculopathy. A number of contributory neuropathy findings including double crush syndrome were observed. On DTI tensor maps, nerve signal and caliber alterations were more conspicuous. Although individual differences were observed among neuropathic appearing nerve (lower FA and increased ADC) as compared to its contralateral counterpart, there were no significant mean differences on statistical comparison of LS plexus nerves, femoral and sciatic nerves (P > 0.05)., Conclusion: MRN of LS plexus is useful modality for the evaluation of patients with non-contributory MRI of lumbar spine as it can incrementally delineate the etiology and provide direct objective and non-invasive evidence of neuromuscular pathology.

Aim: To investigate whether congenital lumbar spinal stenosis (CLSS) is associated with a specific degenerative changes of the lumbar spine., Methods: The lumbar spine magnetic resonance imaging studies of 52 subjects with CLSS and 48 control subjects were retrospectively evaluated. In each examination, the five lumbar levels were assessed for the presence or absence of circumferential or shallow annular bulges, annular tears, anterior or posterior disc herniations, epidural lipomatosis, Schmorl's nodes, spondylolisthesis, pars defects, and stress reactions of the posterior vertebral elements., Results: Compared to control individuals, subjects with CLSS exhibited increased incidence of circumferential and shallow annular bulges, annular tears, disc herniations and spondylolisthesis (P < 0.05)., Conclusion: CLSS is associated with increased incidence of degenerative changes in specific osseous and soft-tissue elements of the lumbar spine.

Melorheostosis is an uncommon, sporadic, sclerosing bone lesion that may affect the adjacent soft tissues. It has been associated with many entities such as osteopoikilosis, soft tissue vascular malformations, bone and soft tissue tumors, nephrotic syndrome, segmental limb contractures, osteosarcoma, desmoid tumor, and mesenteric fibromatosis. Synovial osteochondromatosis is a benign neoplasia of the hyaline cartilage presenting as nodules in the subsynovial tissue of a joint or tendon sheath. The intra-articular extension of melorheostosis mimicking synovial osteochondromatosis has not been reported before. In this article, the authors describe an unusual case mimicking synovial chondromatosis arising as a result of melorheostosis and their characteristic imaging findings.

Aim: To evaluate two simple angle measurements for predicting lumbosacral transitional vertebra (LSTV) in magnetic resonance imaging (MRI) studies of the spine., Methods: The lumbar spine MRI studies of 50 subjects with LSTV and 50 subjects with normal lumbosacral anatomy were retrospectively evaluated. In each study, the mid-sagittal T2-weighted image was used to measure the angle formed by a line parallel to the superior surface of the sacrum and a line perpendicular to the axis of the scan table (A-angle), as well as the angle formed by a line parallel to the superior endplate of the L3 vertebra and a line parallel to the superior surface of the sacrum (B-angle)., Results: The total study population consisted of 100 subjects (46 males, 54 females, 51 ± 16 years old). There were no differences in age and sex between the two groups. Both A-angle and B-angle were significantly increased in subjects with LSTV compared to controls (P < 0.05). The optimal cut-off values of A-angle and B-angle for the prediction of LSTV were 39.8° (sensitivity = 80%, specificity = 80%, accuracy = 83%; 95% confidence interval = 74%-89%, P = 0.0001) and 35.9° (sensitivity = 80%, specificity = 54%, accuracy = 69%; 95% confidence interval = 59%-78%, P = 0.0005), respectively., Conclusion: On sagittal MR images of the lumbar spine, an increased A-angle and/or B-angle should alert the radiologist to the presence of LSTV.