Pediatric appendiceal ultrasound: maintaining accuracy, increasing determinacy and improving clinical outcomes following the introduction of a standardized reporting template.

BACKGROUND: Pediatric patients who underwent appendiceal US and received an equivocal interpretation had poorer clinical outcomes and higher medical costs compared to those to whom a definitive interpretation was given, either positive or negative. In an effort to reduce equivocal interpretations, we educated our group on the importance of increasing determinacy and encouraged the use of a reporting template with a definitive impression. OBJECTIVE: We hypothesized that educational sessions and implementation of an optional reporting template with only a definitive impression would reduce equivocal reporting and improve clinical outcomes without negatively impacting US diagnostic performance. MATERIALS AND METHODS: We retrospectively reviewed the charts of all patients <18 years old at Mayo Clinic Rochester whose initial evaluation for acute appendicitis was a US in the 3-year period following educational sessions and template implementation. All studies were interpreted by board-certified fellowship-trained pediatric radiologists. We performed statistical analysis to compare the pre- and post-implementation cohorts. RESULTS: Following intervention, the rate of equivocal US interpretations was reduced from 23.7% to 9.3% (P<0.001). For studies with a definitive interpretation, measures of diagnostic performance of appendiceal US were similar for the pre- and post-implementation groups. US performance parameters were independent of appendiceal visualization. Follow-up CT utilization decreased from 18.7% to 8.9% (P<0.001). The negative laparotomy rate resulting from false-positive US interpretations remained low (6.8% vs. 5.0%, P=0.31). CONCLUSION: Following education sessions and implementation of an appendiceal US reporting template encouraging definitive reporting, equivocation was reduced, excellent diagnostic performance was maintained, follow-up CT utilization was reduced, and a low negative laparotomy rate was preserved.

Percutaneous Kirschner Wire Repair of Failed Digital Arthrodesis Using Pulsed Electromagnetic Field Therapy A Case Report.

A case of a repaired failed toe arthrodesis is presented. A novel and previously unreported approach using a percutaneously placed Kirschner wire coupled with a pulsed electromagnetic field achieved healing of a painful pseudoarthrosis at 54 days. With a percutaneous technique, open debridement of the failed arthrodesis site can be avoided.

Pediatric appendiceal ultrasound: accuracy, determinacy and clinical outcomes.

BACKGROUND: Ultrasonography is considered the most appropriate initial imaging study in the evaluation of acute appendicitis in children but has recently come under criticism with reports of low specificity and high indeterminate study rates, particularly when used in obese patients and patients early in the course of their disease, or when performed by sonographers with limited experience. OBJECTIVE: To (1) assess the impact of patient factors (gender, age, body mass index, and symptom duration) and system factors (call status or year of exam) on pediatric appendiceal US accuracy and indeterminate study rate, (2) assess the impact of indeterminate study results on follow-up CT and negative laparotomy rates and (3) present strategies to reduce the rate of indeterminate US studies and improve accuracy. MATERIALS AND METHODS: We retrospectively reviewed all US reports performed for the assessment of acute appendicitis in children <18 years old at Mayo Clinic Rochester from January 2010 to June 2014. RESULTS: A total of 790 US examinations were performed in 452 girls (57%) and 338 boys (43%). The prevalence of appendicitis was 18.5% (146/790). There were 109 true-positive, 440 true-negative, 17 false-positive, 6 false-negative, 218 equivocal and 41 technically inadequate US studies. A definitive interpretation was made in 72% of the studies, with an accuracy, sensitivity and specificity of 0.960, 0.948 and 0.963, respectively. No patient or system factors significantly affected US accuracy. Indeterminate studies (28%) had significantly higher CT utilization (46% vs. 11%) and normal appendectomy rates (6.9% vs. 3.5%). CONCLUSION: US should be the initial imaging study of choice for pediatric appendicitis. When a definitive interpretation was given, the accuracy was 96%, was independent of patient and system factors and resulted in reduced follow-up CTs and negative laparotomies. Accuracy can be increased by requiring the presence of periappendiceal inflammatory changes prior to interpreting a mildly distended appendix as positive for acute appendicitis. The indeterminate study rate can be reduced by not requiring visualization of the normal appendix for the exclusion of acute appendicitis.

Proximal phalangeal osteotomy with proximal interphalangeal joint arthrodesis for multiplanar deformities of the second toe: historical perspectives and review of a case series.

Combined transverse and sagittal plane deformities of the second toe represent a common painful condition encountered by the foot surgeon. After a period of conservative management, surgical intervention is often required. Historically, a number of surgical options have been described for the treatment of this condition, with the universal acknowledgment that an ideal surgical outcome is difficult to achieve and prone to failure. In this report, a review of previously described surgical techniques is presented, along with a retrospective analysis of 20 second toe surgical reconstructions, in 16 patients, performed between June 2003 and October 2010. Subjective outcomes were assessed by means of a mailed questionnaire, and a subset (15 second toes in 11 patients) returned for follow-up evaluation, including ascertainment of American Orthopaedic Foot & Ankle Society Clinical Rating System for Lesser Metatarsophalangeal-Interphalangeal Joint Surgery scores. Overall, the duration of follow-up was 38.25 ± 25.82 months, and the subset was followed up for 36.07 ± 27.95 months. The preoperative visual analog pain score was 4.9 ± 2.7, whereas the postoperative pain score was 1.6 ± 2.47 (p < .001). The preoperative American Orthopaedic Foot & Ankle Society score was 44.57 ± 17.76, whereas the postoperative score was 91.27 ± 12.27 (p < .001). Based on the results of this investigation, pairing a basilar proximal phalangeal osteotomy with arthrodesis of the proximal interphalangeal joint, for correction of combined transverse and sagittal plane deformities, appears to yield satisfactory long-term results.