1.5 T augmented reality navigated interventional MRI: paravertebral sympathetic plexus injections.

PURPOSE: The high contrast resolution and absent ionizing radiation of interventional magnetic resonance imaging (MRI) can be advantageous for paravertebral sympathetic nerve plexus injections. We assessed the feasibility and technical performance of MRI-guided paravertebral sympathetic injections utilizing augmented reality navigation and 1.5 T MRI scanner. METHODS: A total of 23 bilateral injections of the thoracic (8/23, 35%), lumbar (8/23, 35%), and hypogastric (7/23, 30%) paravertebral sympathetic plexus were prospectively planned in twelve human cadavers using a 1.5 Tesla (T) MRI scanner and augmented reality navigation system. MRI-conditional needles were used. Gadolinium-DTPA-enhanced saline was injected. Outcome variables included the number of control magnetic resonance images, target error of the needle tip, punctures of critical nontarget structures, distribution of the injected fluid, and procedure length. RESULTS: Augmented-reality navigated MRI guidance at 1.5 T provided detailed anatomical visualization for successful targeting of the paravertebral space, needle placement, and perineural paravertebral injections in 46 of 46 targets (100%). A mean of 2 images (range, 1-5 images) were required to control needle placement. Changes of the needle trajectory occurred in 9 of 46 targets (20%) and changes of needle advancement occurred in 6 of 46 targets (13%), which were statistically not related to spinal regions (P = 0.728 and P = 0.86, respectively) and cadaver sizes (P = 0.893 and P = 0.859, respectively). The mean error of the needle tip was 3.9±1.7 mm. There were no punctures of critical nontarget structures. The mean procedure length was 33±12 min. CONCLUSION: 1.5 T augmented reality-navigated interventional MRI can provide accurate imaging guidance for perineural injections of the thoracic, lumbar, and hypogastric sympathetic plexus.

MR-guided perineural injection of the ganglion impar: technical considerations and feasibility.

OBJECTIVE: Perineural ganglion impar injections are used in the management of pelvic pain syndromes; however, there is no consensus regarding the optimal image guidance. Magnetic resonance imaging (MRI) provides high soft tissue contrast and the potential to directly visualize and target the ganglion. The purpose of this study was to assess the feasibility of MR-guided percutaneous perineural ganglion impar injections. MATERIALS AND METHODS: Six MR-guided ganglion impar injections were performed in six human cadavers. Procedures were performed with a clinical 1.5-Tesla MRI system through a far lateral transgluteus approach. Ganglion impar visibility, distance from the sacrococcygeal joint, number of intermittent MRI control steps required to place the needle, target error between the intended and final needle tip location, inadvertent punctures of non-targeted vulnerable structures, injectant distribution, and procedure time were determined. RESULTS: The ganglion impar was seen on MRI in 4/6 (66 %) of cases and located 0.8 mm cephalad to 16.3 mm caudad (average 1.2 mm caudad) to the midpoint of the sacrococcygeal joint. Needle placement required an average of three MRI control steps (range, 2-6). The average target error was 2.2 ± 2.1 mm. In 6/6 cases (100 %), there was appropriate periganglionic distribution and filling of the presacrococcygeal space. No punctures of non-targeted structures occurred. The median procedure time was 20 min (range, 12-29 min). CONCLUSION: Interventional MRI can visualize and directly target the ganglion impar for accurate needle placement and successful periganglionic injection with the additional benefit of no ionizing radiation exposure to patient and staff. Our results support clinical evaluation.

Percutaneous Cecostomy in Adult Patients: Safety and Quality-of-Life Results.

PURPOSE: To assess the safety and quality of life in adult patients undergoing cecostomy tube placement. MATERIALS AND METHODS: Percutaneous cecostomy was performed in 23 adults (10 men and 13 women) with neurogenic bowel for whom noninvasive therapeutic approaches for chronic refractory constipation or fecal incontinence had failed. Mean patient age was 41 years (range, 19-74 y). A retrospective, standardized questionnaire evaluated satisfaction and quality of life before and after cecostomy. RESULTS: All 23 cecostomy procedures were technically successful with no intraprocedural complications. At a mean follow-up of 42 months (range, 1-160 mo), there was one (5%) major complication, a pericecal abscess. One or more minor complications in 11 of 23 (48%) patients included leaking around the tube (5 of 23; 22%) and partial or complete dislodgment of the tube (3 of 23; 13%). In all cases, the cecostomy tube was exchanged successfully. Satisfaction scores improved from a mean of 2.2 points (range, 0-6 points; median, 1.5) to 7.6 points (range, 4-10 points; median, 8). The percentage of patients using laxative softeners decreased from 74% to 40%, and patients requiring assistance decreased from 52% to 35% after cecostomy placement. CONCLUSIONS: Percutaneous cecostomy is a safe procedure for the management of adult patients. Patients are able to achieve greater independence in their activities of daily living and are highly satisfied with the outcomes.

Accuracy of MRI in diagnosing peripheral nerve disease: a systematic review of the literature.

OBJECTIVE: MRI is increasingly being used to evaluate extracranial peripheral nerve disease in clinical practice. The objective of this study was to systematically review the accuracy of MRI in distinguishing normal from abnormal extracranial peripheral nerves. CONCLUSION: There is significant heterogeneity between studies investigating the accuracy of MRI. Studies have shown that nerve T2-weighted or STIR hyperintensity, nerve enlargement, and nerve flattening are associated with peripheral nerve disease.

Strategic improvements for gross anatomy web-based teaching.

Current generations of graduate students have been immersed in technology from their early school years and have high expectations regarding digital resources. To better meet the expectations of Gross Anatomy students at our institution, electronic radiology teaching files for first-year coursework were organized into a web site. The web site was custom designed to provide material that directly correlated to the Gross Anatomy dissection and lectures. Quick links provided sets of images grouped by anatomic location. Additionally, Lab and Study Companions provided specific material for the students to review prior to and after lectures and gross dissections. Student opinions of this education resource were compared to student opinions of the prior year's digital teaching files. The new content was ranked as more user friendly (3.1 points versus 2.3 points) and more useful for learning anatomy (3.3 points versus 2.6 points). Many students reported that using the web portal was critical in helping them to better understand relationships of anatomical structures. These findings suggest that a well-organized web portal can provide a user-friendly, valuable educational resource for medical students who are studying Gross Anatomy.

Reconstructive knee surgery literature as a tool for the orthopaedic in-training examination.

UNLABELLED: The Orthopaedic In-Training Examination (OITE) provides a standardized measure to assess the knowledge of orthopaedic residents regarding knee reconstruction surgery. However, there currently are limited resources for residents who are preparing for the knee reconstruction questions on the OITE. The present study assessed the character of the knee reconstruction questions tested and which literature resources may be recommended for residents preparing for this examination. MATERIALS AND METHODS: All knee reconstruction-related questions found during a 5-year period (2002 to 2006) on the OITE were characterized by the diagnosis and treatment discussed. The most frequently referenced journals were identified from the OITE exam key. The character of the OITE questions was compared to the literature in terms of overall proportion of articles and questions that were related to knee reconstruction, as well as to categories of diagnosis and treatment modality. RESULTS: There were 59 out of 1375 questions (4%) on the OITE over the 5 years that were related to knee reconstruction. Over half of the questions (54%) were related to primary total knee arthroplasty, with osteoarthritis being the most frequently tested diagnosis (30%). The top three referenced orthopaedic journals were The Journal of Bone and Joint Surgery-American, Clinical Orthopaedics and Related Research, and The Journal of Arthroplasty. Compared to the OITE, these journals covered higher percentages of overall knee reconstruction-related questions (18% versus 4%). In addition, the journal literature had a greater focus on treatment modalities (65% versus 41%) and less emphasis on biomechanics, materials, and basic science (18% versus 34%) than the OITE, respectively. The two most frequently cited textbooks represented approximately 78% of the total number of provided textbook references: Orthopaedic Knowledge Update (39%) and Instructional Course Lectures (39%). DISCUSSION: The results of this study suggest that residents may benefit from using general orthopaedic journals such as The Journal of Bone and Joint Surgery-American in preparation for the OITE. However, residents and residency directors who are preparing their educational programs should be aware that clinical journals may not refect the OITE in terms of the proportion of basic science and biomechanics articles and additional study resources may be necessary.

Osteonecrosis of the knee and related conditions.

Osteonecrosis (ON) of the knee is a progressive disease that often leads to subchondral collapse and disabling arthritis. Recent studies have identified three distinct pathologic entities, all of which were previously described as knee ON: secondary ON, spontaneous ON of the knee, and postarthroscopic ON. Radiographic and clinical assessment is useful for differentiating these conditions, predicting disease progression, and distinguishing these conditions from other knee pathologies. The etiology, pathology, and pathogenesis of secondary ON of the knee are similar to those found at other sites (eg, hip, shoulder). Spontaneous ON is a disorder of unknown etiology. Postarthroscopic ON has been described as an infrequent but potentially destructive complication. Various treatment modalities (eg, core decompression, bone grafting, high tibial osteotomy, arthroplasty), have been used with varying degrees of success for each type of ON. Secondary ON frequently progresses to end-stage disease, and early surgical intervention is recommended. Initial management of spontaneous ON of the knee and postarthroscopic ON is typically nonsurgical, with observation for clinical or radiographic progression.

Literature recommended as study aids for the hip reconstruction section of the orthopaedic in-training examination.

One section of the Orthopaedic In-Training Examination (OITE) assesses knowledge about hip reconstruction. In the investigation reported here, we examined OITE hip reconstruction questions and sought to identify which literature can be recommended as study aids for this section of the test. All hip reconstruction questions on the OITE from 2002 to 2006 were characterized according to diagnosis and treatment. Journals cited most often in this section were identified from the OITE key. This content domain was compared with the literature in terms of overall proportion of questions/articles related to hip reconstruction and in terms of diagnoses and treatments. Of the 1375 OITE questions asked over the 5 years, 79 were related to hip reconstruction. More than half of these hip reconstruction questions were related to primary total hip arthroplasty, with complications being the diagnosis tested most often. The results of this study suggest that residents may benefit from using general orthopedic journals when preparing for the OITE hip reconstruction section. When preparing an educational program, however, one should be aware that clinical journals may not reflect the OITE in terms of proportion of basic science and biomechanics articles.

Gram stains have limited application in the diagnosis of infected total knee arthroplasty.

BACKGROUND: The diagnosis of periprosthetic knee infections can present a challenge to surgeons, especially in the case of chronic presentation. Gram stains are regularly performed as part of the microbiological evaluation of suspected infected total knee arthroplasties. Recently, the utility of this test in diagnosing infections has been questioned. The purpose of this study was to assess the effectiveness of Gram stains performed from surgical site samples by comparing their results to the final diagnosis of infection. METHODS: The results of 347 Gram stains performed at a single center at the time of revision total knee arthroplasty for both septic and aseptic reasons were compared to the final diagnosis based on intra-operative findings and histological evaluation. RESULTS: Gram staining demonstrated a low sensitivity of 7% (95% confidence interval 4-12%), a specificity of 99% (95% confidence interval 97-100%), and positive and negative predictive values of 92% and 57%, respectively. CONCLUSIONS: This study confirmed previous findings of the poor utility of this test for the diagnosis of periprosthetic knee infections. The authors recommend that Gram staining no longer be performed at the time of suspected periprosthetic knee arthroplasty infection.

Review of the current literature as a preparatory tool for the trauma content of the Orthopaedic in-Training Examination.

Currently, the only standardized evaluation of trauma knowledge throughout orthopedic training is found in the Orthopaedic In-Training Examination, which is administered annually to all residents by the American Academy of Orthopaedic Surgeons. Our goals were to assess the Orthopaedic In-Training Examination to (1) determine the content of the trauma questions, (2) identify the content of the 3 most frequently referenced journals on the answer keys, and (3) evaluate the correlation between those contents.We reviewed the trauma-related Orthopaedic In-Training Examination questions and answer keys for 2002 through 2007. Content for test questions and cited literature was assessed with the same criteria: (1) category type, (2) anatomic location, (3) orthopedic focus, and (4) treatment type. For each of the 3 most frequently referenced journals, we weighted content by dividing the number of times it was referenced by the number of its trauma-related articles. We then compared the journal data individually and collectively to the data from the Orthopaedic In-Training Examination trauma questions. A chi-square analysis with Yates correction was used to determine differences. Questions and literature were similar in the most frequently addressed items in each of the 4 areas: category type (taxonomy 3, treatment), 52.4% and 60.7%, respectively; anatomic location (femur), 23.3% and 27.7%, respectively; orthopedic focus (fracture), 51.0% and 56.5%, respectively; and treatment type (multiple/nonspecific), 39.0% and 35.4%, respectively.The content correlation found between the questions and literature supports the idea that reviewing current literature may help prepare for the trauma content on the Orthopaedic In-Training Examination.

Augmented reality visualization using Image-Overlay for MR-guided interventions: system description, feasibility, and initial evaluation in a spine phantom.

OBJECTIVE: The purpose of this article is to provide a preliminary user assessment of Image-Overlay, an augmented reality system for MRI-guided needle placement, in a spine phantom. CONCLUSION: Image-Overlay can be used to successfully target lumbar facet joints with high accuracy and minimal insertions. This is potentially useful for other interventional MRI applications. Additional clinical assessment is needed.

Arthroscopic-assisted minimally invasive total knee arthroplasty.

This technical note describes an arthroscopic technique to enhance visualization during minimally invasive total knee arthroplasty. The arthroscope is used, with the aid of balloon catheter retractors, to allow intraoperative identification of potentially adverse findings, including retained bone and cement fragments. This technique has been used successfully to identify and treat knees with these findings. Although further study and refinement are needed, this technique shows promise in reducing postoperative complications and improving outcomes in total knee arthroplasty.

Osteonecrosis is not a predictor of poor outcomes in primary total hip arthroplasty: a systematic literature review.

The primary goals of this critical literature review were to determine whether revision rates of primary total hip arthroplasty in patients with osteonecrosis differ based on the underlying associated risk factors and diagnoses, whether the outcomes of this procedure have improved over the past two decades, and to compare outcomes based on study level of evidence. A systematic literature review yielded 67 reports representing 3,277 hips in 2,593 patients who had a total hip arthroplasty for osteonecrosis of the femoral head. Stratification of outcomes by associated risk factors or diagnoses revealed significantly lower revision rates in patients with idiopathic disease, systemic lupus erythematosus, and after heart transplant, and significantly higher rates in patients with sickle cell disease, Gaucher disease, or after renal failure and/or transplant. There was a significant decrease in revision rates between patients operated upon before 1990 versus those in 1990 or later, with rates of 17% and 3%, respectively. The results for arthroplasties performed in 1990 or later were similar to those for all hips in publicly reported national joint registries. Certain risk factors were associated with higher revision rates in patients with osteonecrosis who were treated by total hip arthroplasty. However, most patients (82%) do not have these associated negative risk factors. Overall, this critical literature review provides evidence that osteonecrosis itself, or when associated with the most common risk factors and/or diagnoses, is not associated with poor outcomes in total hip arthroplasty.

Prophylactic oral antibiotics reduce reinfection rates following two-stage revision total knee arthroplasty.

The purpose of this study was to compare the incidence of reinfection in patients who received oral antibiotic prophylaxis with those who did not following two-stage revision knee arthroplasty. Additional purposes included: (1) comparison of these findings to the infection rate in patients who underwent revision for aseptic reasons, and (2) characterisation of the organisms responsible for reinfection following revision procedures. Twenty-eight two-stage revision knee arthroplasty procedures were followed up by a mean of 33 days of oral antibiotics (range, 28-43 days), while the remaining 38 procedures received only 24-72 hours of in-patient antibiotics. The incidence of reinfection in each group within 12 months was compared. The reinfection rates were additionally compared to those of 237 patients who underwent revision for aseptic loosening over the same time period. Patients who were treated with postoperative antibiotic prophylaxis had a considerably lower reinfection rate, with one reinfection in the prophylaxis group (4%), compared to six reinfections in the no-prophylaxis group (16%). The reinfection rates remained higher compared to those found in patients who underwent revision knee arthroplasty for aseptic loosening (1 of 237 patients; 0.4%). Both high and low virulence organisms were identified in the patients who were subsequently reinfected. A minimum of 28 days of postoperative oral antibiotics appeared to decrease reinfection rates following two-stage revision knee arthroplasty. These results suggest that the use of oral antibiotic prophylaxis following re-implantation may be appropriate in all patients undergoing two-stage revision, even in the absence of any signs of active infection.

Serological markers can lead to false negative diagnoses of periprosthetic infections following total knee arthroplasty.

Periprosthetic infections following total knee arthroplasty (TKA) are diagnostically challenging. We evaluated the sensitivity and specificity of ESR and CRP, false negative rates, whether false negative rates differed between early post-operative and late infections, and the predictive ability of ESR and CRP to differentiate infected patients. Between 2000 and 2007, a prospectively collected database was reviewed to identify patients with suspected periprosthetic infections, and who had ESR and CRP laboratory values. One hundred and thirteen patients were identified. False negative rates were calculated. Finally, receiver operating characteristic curves were used to determine the predictive ability of ESR and CRP to differentiate infected from non-infected patients. CRP had a sensitivity of 95% and specificity of 20%. ESR had a sensitivity of 91% and a specificity of 33%. The false negative rate was 9.2% for ESR, 5.3% for CRP, and 11.1% for combined ESR and CRP. False negative rates were higher for early post-operative infections. Although ESR and CRP can be excellent adjunctive diagnostic tools, we emphasise that because some patients may not mount a sufficient immune response, the entire clinical picture must be evaluated, and periprosthetic infection should not be ruled out on the basis of ESR and CRP results alone.

Are component positioning and prosthesis size associated with hip resurfacing failure?

BACKGROUND: Recent studies suggest that there is a learning curve for metal-on-metal hip resurfacing. The purpose of this study was to assess whether implant positioning changed with surgeon experience and whether positioning and component sizing were associated with implant longevity. METHODS: We evaluated the first 361 consecutive hip resurfacings performed by a single surgeon, which had a mean follow-up of 59 months (range, 28 to 87 months). Pre and post-operative radiographs were assessed to determine the inclination of the acetabular component, as well as the sagittal and coronal femoral stem-neck angles. Changes in the precision of component placement were determined by assessing changes in the standard deviation of each measurement using variance ratio and linear regression analysis. Additionally, the cup and stem-shaft angles as well as component sizes were compared between the 31 hips that failed over the follow-up period and the surviving components to assess for any differences that might have been associated with an increased risk for failure. RESULTS: Surgeon experience was correlated with improved precision of the antero-posterior and lateral positioning of the femoral component. However, femoral and acetabular radiographic implant positioning angles were not different between the surviving hips and failures. The failures had smaller mean femoral component diameters as compared to the non-failure group (44 versus 47 millimeters). CONCLUSIONS: These results suggest that there may be differences in implant positioning in early versus late learning curve procedures, but that in the absence of recognized risk factors such as intra-operative notching of the femoral neck and cup inclination in excess of 50 degrees, component positioning does not appear to be associated with failure. Nevertheless, surgeons should exercise caution in operating patients with small femoral necks, especially when they are early in the learning curve.

The natural history of untreated asymptomatic osteonecrosis of the femoral head: a systematic literature review.

BACKGROUND: An asymptomatic hip with osteonecrosis is typically discovered as the contralateral hip of a patient with one symptomatic joint. Treatment of the asymptomatic hip is controversial. While some authors claim a benign natural history, others have reported a rate of femoral head collapse exceeding 50%. The purpose of this report was to systematically review the published literature regarding asymptomatic osteonecrosis of the femoral head to evaluate the overall prevalence of progression to symptomatic disease and/or femoral head collapse as well as to determine whether various radiographic and demographic factors influence progression of the disorder. METHODS: A comprehensive literature search was performed to identify prognostic studies evaluating asymptomatic hip osteonecrosis. Demographic, radiographic, and outcome data were extracted from all relevant studies. The prevalence of progression to symptomatic disease and/or femoral head collapse was determined. Next, outcomes were stratified by lesion size, lesion location, radiographic stage, associated risk factors and/or disease, and the level of evidence of the study. RESULTS: Sixteen studies that included a total of 664 hips were available for an analysis of outcomes. Overall, 394 hips (59%) had progression to symptoms or collapse. Differences in outcomes based on lesion size, lesion location, and radiographic stage at the time of diagnosis were seen. Small, medially located lesions had the best prognosis, with a prevalence of collapse of <10%. Patients with sickle cell disease had the highest frequency of progression, and those with a history of systemic lupus erythematosus had the most benign course. CONCLUSIONS: Data extracted from previously published studies suggest that asymptomatic osteonecrosis has a high prevalence of progression to symptomatic disease and femoral head collapse. While small, medially located lesions have a low rate of progression, the natural history of asymptomatic medium-sized, and especially large, osteonecrotic lesions is progression in a substantial number of patients. For this reason, it may be beneficial to consider joint-preserving surgical treatment in asymptomatic patients with a medium-sized or large, and/or laterally located, lesion.

Educational resources for the Orthopedic In-Training Examination.

OBJECTIVE: Various educational tools are available for the Orthopedic In-Training Examination (OITE). However, many residents are unsure of which resources are the most useful. This study assessed what educational resources residents consider to be most useful and how the top performers prepare for the examination. METHODS: A web-based survey was distributed to orthopedic residency programs. Residents indicated their program type, year in residency, and most recent OITE score. They also rated (0-4 points) the value of various educational resources. An chi(2) analysis identified resources that were used more frequently by residents who scored in the top 20%. We compared the useful educational resources identified by the entire group, as well as by the top 20% of residents, with what has been the most commonly cited recommended references for the OITE during a 5-year period. RESULTS: Three hundred and sixty residents completed the OITE questionnaire. The journal that was most commonly used by orthopedic residents to prepare for the OITE was the Journal of the American Academy of Orthopedic Surgeons (n = 257, 71%). However, this journal was the third most frequently cited reference for the OITE. Past OITE questions were the highest scored resource with 215 (60%) residents rating them as a 4 ("very useful"). The residents who scored in the top 20% participated in more surgical cases than the other residents (53% vs 35% with 350 or more cases in each group, respectively). CONCLUSIONS: The results of this study suggest that many residents, especially those who do well on the OITE, are using the American Academy of Orthopedic Surgeons self-assessment examinations. The results also support the educational importance of exposure to surgical cases in addition to reading and reviewing journals and/or textbooks.

Evaluation of the Orthopaedic In-Training Examination: spine questions.

BACKGROUND: The annual Orthopaedic In-Training Examination (OITE) is an objective evaluation administered annually to all residents by the American Academy of Orthopaedic Surgeons. To our knowledge, there are no guidelines for the type of material included on the examination; therefore, it is difficult for many academic centers to develop education programs directed toward improving resident performance on the OITE. Our goals were to determine the most commonly tested subjects in the spine portion of the OITE and to help direct development of an associated teaching program. METHODS: We analyzed the number, type, anatomic focus, subject matter, and visual diagnostic modalities of spine questions on the OITEs from 2002 through 2007 and identified the most commonly referenced journals. RESULTS: The average annual number of spine questions was 23.1 (8.4% of the examination). The most common types of spine questions related to knowledge (44.5%), evaluation and decision making (29.1%), and diagnosis (26.3%); the most common subject matters were trauma (15.1%) and anatomy (13.7%). The most frequently examined anatomic locations were the cervical (30.9% of questions) and lumbar (17.4%) spines. General spine information (no anatomic focus) accounted for 31.6% of questions. The most commonly referenced journals were Spine and The Journal of Bone and Joint Surgery, American Volume. CONCLUSIONS: Developing a study plan focusing on these journals and the most commonly tested topics and question types will better prepare orthopedic residents for the spine questions on the OITE.

Developing a radiology-based teaching approach for gross anatomy in the digital era.

RATIONALE AND OBJECTIVES: The purpose of this study was to assess the implementation of a digital anatomy lecture series based largely on annotated, radiographic images and the utility of the Radiological Society of North America-developed Medical Imaging Resource Center (MIRC) for providing an online educational resource. MATERIALS AND METHODS: A series of digital teaching images were collected and organized to correspond to lecture and dissection topics. MIRC was used to provide the images in a Web-based educational format for incorporation into anatomy lectures and as a review resource. A survey assessed the impressions of the medical students regarding this educational format. RESULTS: MIRC teaching files were successfully used in our teaching approach. The lectures were interactive with questions to and from the medical student audience regarding the labeled images used in the presentation. Eighty-five of 120 students completed the survey. The majority of students (87%) indicated that the MIRC teaching files were "somewhat useful" to "very useful" when incorporated into the lecture. The students who used the MIRC files were most likely to access the material from home (82%) on an occasional basis (76%). With regard to areas for improvement, 63% of the students reported that they would have benefited from more teaching files, and only 9% of the students indicated that the online files were not user friendly. CONCLUSIONS: The combination of electronic radiology resources available in lecture format and on the Internet can provide multiple opportunities for medical students to learn and revisit first-year anatomy. MIRC provides a user-friendly format for presenting radiology education files for medical students.