Systematic review of artificial intelligence development and evaluation for MRI diagnosis of knee ligament or meniscus tears.

OBJECTIVE: The purpose of this systematic review was to summarize the results of original research studies evaluating the characteristics and performance of deep learning models for detection of knee ligament and meniscus tears on MRI. MATERIALS AND METHODS: We searched PubMed for studies published as of February 2, 2022 for original studies evaluating development and evaluation of deep learning models for MRI diagnosis of knee ligament or meniscus tears. We summarized study details according to multiple criteria including baseline article details, model creation, deep learning details, and model evaluation. RESULTS: 19 studies were included with radiology departments leading the publications in deep learning development and implementation for detecting knee injuries via MRI. Among the studies, there was a lack of standard reporting and inconsistently described development details. However, all included studies reported consistently high model performance that significantly supplemented human reader performance. CONCLUSION: From our review, we found radiology departments have been leading deep learning development for injury detection on knee MRIs. Although studies inconsistently described DL model development details, all reported high model performance, indicating great promise for DL in knee MRI analysis.

Total Joint Arthroplasty Outcomes in Eligible Patients Versus Patients Who Failed to Meet at Least 1 Eligibility Criterion: A Single-Center Retrospective Analysis.

BACKGROUND: This study looks to investigate how not meeting eligibility criteria affects postoperative outcomes following total joint arthroplasty surgery. METHODS: A retrospective review was conducted of total joint arthroplasty patients at a single academic institution. Demographics, laboratory values, and complications were recorded. Continuous and categorical variables were compared using the Student's T-test and the Chi-Square test, respectively. Multivariable analysis was used to control for confounding variables. RESULTS: Our study included 915 total hip and 1,579 total knee arthroplasty patients. For total hip and total knee arthroplasty, there were no significant differences in complications (P = .11 and .87), readmissions (P = .83 and .2), or revision surgeries (P = .3 and 1) when comparing those who met all criteria to those who did not. Total hip arthroplasty patients who did not meet two criteria had 16.1 higher odds (P = .02) of suffering a complication. There were no differences in complications (P = .34 and .41), readmissions (P = 1 and .55), or revision surgeries (P = 1 and .36) between ineligible patients treated by total joint arthroplasty surgeons and those who were not. Multivariable analysis demonstrated no eligibility factors were associated with outcomes for both total hip and knee arthroplasty. CONCLUSIONS: There was no significant difference in outcomes between those who met all eligibility criteria and those who did not. Not meeting two criteria conferred significantly higher odds of suffering a complication for total hip arthroplasty patients. Total joint arthroplasty surgeons had similar outcomes to non-total joint surgeons, although their patient population was more complex. LEVEL OF EVIDENCE: III.

Open Ankle Fractures in Older Individuals: A Multi-center Study.

The purpose of this study is to identify demographics, etiology, comorbidities, treatment, complications, and outcomes for older patients with open ankle fractures. Patients ≥60 years old who sustained an open ankle fracture between January 1, 2004 - March 31, 2014 at 6 Level 1 trauma centers were retrospectively reviewed. Univariate analysis using Chi-squared or Student's T-test was performed to identify associations between preoperative variables and two postoperative outcomes of interest: amputation and 1-year mortality. Multivariate analysis was performed using stepwise logistical regression to identify independent predictors of postoperative amputation and 1-year mortality. Of the 162 total patients, the most common mechanism of injury was a ground-level fall (51.9%). The most common fracture types were bimalleolar fractures (52.5%) followed by trimalleolar fractures (26.5%), with 41.5% of the fractures classified as Gustilo Anderson Classification Type 2 and 38.6% classified as Type 3A. The average number of surgeries required per patient was 2.1. Complications included: 15.4% superficial infection rate, 9.9% deep infection rate, and 9.3% amputation rate. The 1-year mortality rate was 13.6% and the overall mortality rate was 25.9%. Male gender and fracture type were found to be independent predictors for amputation after surgery (P = 0.009, 0.005, respectively). Older age and having diabetes were independent predictors for 1-year mortality after surgery (P = 0.021, 0.005 respectively). Overall, open ankle fractures in older individuals were associated with high rates of amputation and mortality.

CT-Guided Core Needle Biopsy of Nonspinal Bone Lesions: Comparison of Occult and Visible Bone Lesions.

BACKGROUND. CT guidance may be used for biopsy of indeterminate bone lesions detected by MRI or PET/CT that are not visible (i.e., occult) on CT owing to equipment-, patient-, and operator-related factors. OBJECTIVE. The purpose of this study was to assess diagnostic yield (DY) and diagnostic performance of CT-guided core needle biopsy (CNB) of occult nonspinal bone lesions and to identify the most common benign and malignant diagnoses for occult lesions undergoing CNB. METHODS. This retrospective study included 1033 adult patients who underwent CT-guided nonspinal bone CNB between January 2004 and December 2020. Lesions were classified as occult or visible on CT; biopsies of occult lesions were performed by targeting anatomic landmarks using prebiopsy MRI or PET/CT. Pathologic results of CNB were classified as diagnostic or nondiagnostic to calculate DY of CNB. For nondiagnostic CNBs, final diagnoses were established by subsequent pathologic, clinical, and imaging follow-up. RESULTS. The sample included 70 patients with occult lesions (mean age, 56.8 years; 38 women, 32 men) and 963 patients with visible lesions (mean age, 59.6 years; 475 women, 488 men). Malignancy rate was lower for occult than for visible lesions (42.9% vs 60.9%, p = .004). DY was lower for occult than for visible lesions (37.1% vs 76.9%, p < .001). Diagnostic performance for detecting malignancy on the basis of final diagnoses was lower for occult than for visible lesions in terms of sensitivity (76.7% vs 93.7%, p = .003), specificity (7.9% vs 56.5%, p < .001), and accuracy (38.2% vs 80.0%, p < .001). Final diagnoses among malignant occult and visible lesions included metastasis (frequencies of 63.3% vs 65.4%), leukemia/lymphoma (33.3% vs 11.6%), and myeloma (3.3% vs 10.4%); final diagnoses among benign occult and visible lesions included red marrow (34.2% vs 8.2%), reactive marrow (26.3% vs 11.8%), and fracture (18.4% vs 3.8%). Occult lesions detected by MRI versus PET/CT had lower malignancy rate (39.3% vs 68.0%, p = .03) and lower DY (30.4% vs 60.0%, p = .01). CONCLUSION. At CT-guided CNB, malignancy rate and DY are lower for occult than for visible lesions. Leukemia/lymphoma and red marrow are more common among occult than visible lesions. CLINICAL IMPACT. Understanding these characteristics can help guide radiologists', referring providers', and patients' expectations when CNB of occult bone lesions is requested and performed.

Direct Oral Anticoagulants Versus Warfarin in the Treatment of Cerebral Venous Thrombosis (ACTION-CVT): A Multicenter International Study.

BACKGROUND: A small randomized controlled trial suggested that dabigatran may be as effective as warfarin in the treatment of cerebral venous thrombosis (CVT). We aimed to compare direct oral anticoagulants (DOACs) to warfarin in a real-world CVT cohort. METHODS: This multicenter international retrospective study (United States, Europe, New Zealand) included consecutive patients with CVT treated with oral anticoagulation from January 2015 to December 2020. We abstracted demographics and CVT risk factors, hypercoagulable labs, baseline imaging data, and clinical and radiological outcomes from medical records. We used adjusted inverse probability of treatment weighted Cox-regression models to compare recurrent cerebral or systemic venous thrombosis, death, and major hemorrhage in patients treated with warfarin versus DOACs. We performed adjusted inverse probability of treatment weighted logistic regression to compare recanalization rates on follow-up imaging across the 2 treatments groups. RESULTS: Among 1025 CVT patients across 27 centers, 845 patients met our inclusion criteria. Mean age was 44.8 years, 64.7% were women; 33.0% received DOAC only, 51.8% received warfarin only, and 15.1% received both treatments at different times. During a median follow-up of 345 (interquartile range, 140-720) days, there were 5.68 recurrent venous thrombosis, 3.77 major hemorrhages, and 1.84 deaths per 100 patient-years. Among 525 patients who met recanalization analysis inclusion criteria, 36.6% had complete, 48.2% had partial, and 15.2% had no recanalization. When compared with warfarin, DOAC treatment was associated with similar risk of recurrent venous thrombosis (aHR, 0.94 [95% CI, 0.51-1.73]; P=0.84), death (aHR, 0.78 [95% CI, 0.22-2.76]; P=0.70), and rate of partial/complete recanalization (aOR, 0.92 [95% CI, 0.48-1.73]; P=0.79), but a lower risk of major hemorrhage (aHR, 0.35 [95% CI, 0.15-0.82]; P=0.02). CONCLUSIONS: In patients with CVT, treatment with DOACs was associated with similar clinical and radiographic outcomes and favorable safety profile when compared with warfarin treatment. Our findings need confirmation by large prospective or randomized studies.

Image-Guided Core Needle Biopsy of Adipocytic Tumors: Diagnostic Accuracy and Concordance With Final Surgical Pathology.

OBJECTIVE. Diagnostic accuracy of core needle biopsy (CNB) for adipocytic tumors can be low because of sampling error from these often large, heterogeneous lesions. The purpose of this study was to evaluate the diagnostic accuracy of image-guided CNB for various adipocytic tumors in comparison with excisional pathology. MATERIALS AND METHODS. Adipocytic tumors (n = 77) of all adult patients undergoing image-guided CNB and subsequent surgical excision of an adipocytic tumor at a tertiary referral center between 2005 and 2019 were studied. To determine concordance, we compared pathologic diagnoses based on CNB to the reference standard of pathologic diagnoses after surgical excision. Tumors were divided into three categories (benign lipomatous tumors [lipoma, lipoma variants, hibernomas], atypical lipomatous tumors [ALTs] or well-differentiated liposarcomas [WDLs], and higher grade liposarcomas [myxoid, dedifferentiated, pleomorphic]), and diagnostic accuracy was calculated for each category. RESULTS. In 73 of 77 adipocytic tumors (95%), diagnosis at CNB and diagnosis after excision were concordant. Accuracy of diagnosis was poorer for ALTs and WDLs than for the other two categories, and the difference was statistically significant (p < .002). For the 29 benign lipomatous tumors and the 27 higher-grade liposarcomas, diagnoses at CNB and after excision were concordant in all cases (100%). Seventeen of the 21 tumors (81%) diagnosed as ALTs or WDLs at CNB had a concordant diagnosis after excision; four of the 21 were upgraded (dedifferentiated liposarcoma, n = 3; myxoid liposarcoma, n = 1). CONCLUSION. CNB provides high diagnostic accuracy for adipocytic tumors, particularly for benign lipomatous tumors and higher grade liposarcomas. However, though still high at 81%, diagnostic accuracy of CNB is not as high for tumors diagnosed as ALTs or WDLs. Awareness of this limitation is important when determining management, particularly of cases of ALT or WDL for which surgery is not planned.

Association of aspirin and other non-steroidal anti-inflammatory drugs with bleeding complications in image-guided musculoskeletal biopsies.

OBJECTIVE: To evaluate the safety of continuing aspirin and other non-steroidal anti-inflammatory drugs (NSAID) in patients undergoing image-guided musculoskeletal biopsies. MATERIAL AND METHODS: Prior to October 2017, patients undergoing image-guided musculoskeletal biopsy had aspirin and NSAIDs withheld for the preceding 5-7 days. The policy changed in October 2017 based on new guidelines from the Society of Interventional Radiology such that aspirin and other NSAIDs were not withheld. A retrospective review of patient records was performed for all biopsies prior to and after the policy change to assess for differences in biopsy-related bleeding complications. Additional clinical and biopsy factors including age, gender, liver disease, coagulopathy, biopsy tissue type, and histological diagnosis were assessed. RESULTS: In the pre-policy change group, there were 1853 total biopsies with 43 biopsy-related bleeding complications (2.3%). Within this group, 362 patients were on aspirin with 7 bleeding complications (1.9%) and 260 patients were on NSAIDs with 5 bleeding complications (1.9%). There were 409 total biopsies in the post-policy change group and 7 bleeding complications (1.7%). Within this group, 71 patients were on aspirin with 1 bleeding complication (1.4%). No bleeding complications were recorded in patients on NSAIDs (0%). There was no significant difference in bleeding complication between the pre- and post-policy change groups overall (p = 0.58) and in patients on aspirin (p = 1.00) or other NSAIDs (p = 1.00). CONCLUSION: Bleeding complications for musculoskeletal biopsies are rare. Leaving patients on aspirin or other NSAIDs during a musculoskeletal biopsy does not increase the incidence of bleeding complications.

High Risk of Mismatch Between Sanders and Risser Staging in Adolescent Idiopathic Scoliosis: Are We Guiding Treatment Using the Wrong Classification?

BACKGROUND: Despite known limitations, Risser staging has traditionally been the primary marker of skeletal maturity utilized in decision-making for treatment of adolescent idiopathic scoliosis (AIS). The purpose of this study is to assess the incidence and factors associated with mismatch between Risser Staging and Sanders classification, and determine interobserver reliability. METHODS: We reviewed the medical records of consecutive patients aged 10 to 18 referred to our institution for evaluation of AIS from January to June 2016 with a closed triradiate cartilage. Data collected included sex, age, race, height, weight, body mass index percentile, menarchal status, Risser stage, Sanders classification, and major curve. Risser and Sanders stage was determined by 2 fellowship-trained pediatric spine surgeons and 1 pediatric orthopaedic nurse practitioner. Mismatch was defined as Risser stage 2 to 4 corresponding to Sanders 3 to 5, and Risser 0 to 1 corresponding to Sanders 6 to 7. RESULTS: A total of 165 consecutive patients were identified (mean age: 13.9±1.7 y, major curve 28.2±15.4 degrees, 76% female). The risk of skeletal maturity mismatch, based on the criteria of Risser 2 to 5 (limited growth remaining) corresponding to Sanders 3 to 5 (significant growth remaining) was 21.8%, indicating that 1 of 5 patients would be undertreated if managed by Risser criteria. Conversely, the mismatch risk for Risser 0 to 1 corresponding to Sanders 6 to 7 was 3.6%, leading such patients to be treated conservatively longer than necessary. Males and those of Hispanic ethnicity were at a higher risk of mismatch (23.1% vs. 11.9%, P=0.08; 33.3% vs. 8.8%, P=0.04, respectively). Body mass index percentile, race, and major curve were not associated with mismatch. The unweighted and weighted interobserver κ for Risser staging was 0.74 and 0.82, respectively, and 0.86 and 0.91 for Sanders classification, respectively. CONCLUSION: Given the limited sensitivity of Risser staging during peak growth velocity, high mismatch risk, and lower interobserver reliability, the Sanders classification should be utilized to guide treatment options in patients with AIS. Compared with Sanders, utilizing Risser staging results in mistreatment in a total of 1 of 4 patients, with the vast majority being undertreated. LEVEL OF EVIDENCE: Level II.

Safety of omitting routine bleeding tests prior to image-guided musculoskeletal core needle biopsy.

PURPOSE: To evaluate the safety of withholding preprocedure international normalized ratio (INR) and platelet testing in patients undergoing musculoskeletal (MSK) core needle biopsy (CNB). MATERIAL AND METHODS: Initially, a retrospective review of 1,162 consecutive patients undergoing MSK CNB with preprocedural INR and platelet testing was performed. Clinical (age, gender, bleeding disorder, liver disease, anticoagulation use, INR > 2, platelet count <50,000/ul) and biopsy factors (imaging modality, lesion type, biopsy needle gauge, number biopsy samples) were tested for association with bleeding complications. During the second phase, an additional 188 biopsies performed without preprocedural coagulation testing were studied. Categorical variables were compared using Chi-squared or Fisher's exact tests, continuous variables with a student t-test. Multivariate analysis was performed using logistic regression. RESULTS: In the first phase, there was a complication rate of 2.6%, 30/1162. Of the 11 clinical and biopsy factors, soft tissue lesions (p = 0.029) and lesions biopsied under ultrasound (p = 0.048) had a higher rate of bleeding than bone lesions or lesions biopsied under CT, respectively. Only three patients had an INR >2, 0.3% (3/1162) and only four patients had platelet count <50,000/ul, 0.3% (4/1162). No patient with a bleeding complication had an abnormal preprocedure bleeding test. In the second phase, there was a bleeding complication rate of 1.1% (2/188). CONCLUSION: Bleeding complications from MSK biopsy are low, even when preprocedure coagulation testing is omitted.

JOURNAL CLUB: Utility of Repeat Core Needle Biopsy of Musculoskeletal Lesions With Initially Nondiagnostic Findings.

OBJECTIVE: The purpose of the present study is to assess the utility of repeat image-guided core needle biopsy (CNB) of musculoskeletal lesions in the setting of initially nondiagnostic CNB findings. MATERIALS AND METHODS: A retrospective review was conducted of 1302 consecutive CNBs performed on bone or soft-tissue lesions at a single institution. Pediatric cases and spine lesions were not included. All cases for which a repeat biopsy of the same lesion was performed because biopsy results were nondiagnostic were included in the study. Tumor characteristics, such as lesion size and type (i.e., bone vs soft tissue), were correlated with the diagnostic yield on repeat biopsy. Technical factors, including the modality used, the number of passes performed, the gauge of the biopsy device, the time between biopsies, the radiologist performing the procedure, and the portion of the lesion biopsied, were also correlated. RESULTS: Twenty-six of the 1302 CNBs (2.0%) performed had been referred for repeat biopsy. A diagnosis was obtained for 10 of these 26 cases (38.5%) after repeat CNB. For five of the cases (19.2%), repeat CNB yielded a diagnosis of malignancy. Overall, 11 cases ultimately had histologic findings indicating malignancy, and five of these cases (45.4%) had diagnostic findings after rebiopsy. Of the 14 cases that were found to be benign, five (35.7%) had diagnostic findings after rebiopsy. One case was lost to follow-up. A statistically significant difference in the diagnostic yield was found in association with an increase in the number of passes (p = 0.047) and an increase in time (p = 0.020) between biopsies. CONCLUSION: Repeat CNB of musculoskeletal lesions with initially nondiagnostic biopsy findings can be useful. Increasing the number of passes on the second biopsy attempt is recommended.

Comparison of Battery-Powered and Manual Bone Biopsy Systems for Core Needle Biopsy of Sclerotic Bone Lesions.

OBJECTIVE: The purpose of this study was to compare manual and battery-powered bone biopsy systems for diagnostic yield and procedural factors during core needle biopsy of sclerotic bone lesions. MATERIALS AND METHODS: A total of 155 consecutive CT-guided core needle biopsies of sclerotic bone lesions were performed at one institution from January 2006 to November 2014. Before March 2012, lesions were biopsied with manual bone drill systems. After March 2012, most biopsies were performed with a battery-powered system and either noncoaxial or coaxial biopsy needles. Diagnostic yield, crush artifact, CT procedure time, procedure radiation dose, conscious sedation dose, and complications were compared between the manual and battery-powered core needle biopsy systems by Fisher exact test and t test. One-way ANOVA was used for subgroup analysis of the two battery-powered systems for procedure time and radiation dose. RESULTS: The diagnostic yield for all sclerotic lesions was 60.0% (93/155) and was significantly higher with the battery-powered system (73.0% [27/37]) than with the manual systems (55.9% [66/118]) (p = 0.047). There was no significant difference between the two systems in terms of crush artifact, procedure time, radiation dose, conscious sedation administered, or complications. In subgroup analysis, the coaxial battery-powered biopsies had shorter procedure times (p = 0.01) and lower radiation doses (p = 0.002) than the coaxial manual systems, but the noncoaxial battery-powered biopsies had longer average procedure times and higher radiation doses than the coaxial manual systems. CONCLUSION: In biopsy of sclerotic bone lesions, use of a battery-powered bone drill system improves diagnostic yield over use of a manual system.

Imaging of adult flatfoot: correlation of radiographic measurements with MRI.

OBJECTIVE. The purpose of this study is to determine whether radiographic foot measurements can predict injury of the posterior tibial tendon (PTT) and the supporting structures of the medial longitudinal arch as diagnosed on MRI. MATERIALS AND METHODS. After institutional review board approval, 100 consecutive patients with radiographic and MRI examinations performed within a 2-month period were enrolled. Thirty-one patients had PTT dysfunction clinically, and 69 patients had other causes of ankle pain. Talonavicular uncoverage angle, incongruency angle, calcaneal pitch angle, Meary angle, cuneiform-to-fifth metatarsal height, and talar tilt were calculated on standing foot or ankle radiographs. MRI was used to assess for abnormalities of the PTT (tenosynovitis, tendinosis, and tear) and supporting structures of the medial longitudinal arch (spring ligament, deltoid ligament, and sinus tarsi). Statistical analysis was performed using the chi-square and Fisher exact tests for categoric variables; the Student t test was used for continuous variables. RESULTS. There was a statistically significant association of PTT tear with abnormal talonavicular uncoverage angle, calcaneal pitch angle, Meary angle, and cuneiform-to-fifth metatarsal height. PTT tendinosis and isolated tenosynovitis had a poor association with most radiologic measurements. If both calcaneal pitch and Meary angles were normal, no PTT tear was present. An abnormal calcaneal pitch angle had the best association with injury to the supporting medial longitudinal arch structures. CONCLUSION. Radiographic measurements, especially calcaneal pitch and Meary angles, can be useful in detecting PTT tears. Calcaneal pitch angle provides the best assessment of injury to the supporting structures of the medial longitudinal arch.

A Practical Guide to MR Imaging Safety: What Radiologists Need to Know.

Magnetic resonance (MR) imaging can provide critical diagnostic and anatomic information while avoiding the use of ionizing radiation, but it has a unique set of safety risks associated with its reliance on large static and changing magnetic fields, high-powered radiofrequency coil systems, and exogenous contrast agents. It is crucial for radiologists to understand these risks and how to mitigate them to protect themselves, their colleagues, and their patients from avoidable harm and to comply with safety regulations at MR imaging sites. Basic knowledge of MR imaging physics and hardware is necessary for radiologists to understand the origin of safety regulations and to avoid common misconceptions that could compromise safety. Each of the components of the MR imaging unit can be a factor in injuries to patients and personnel. Safety risks include translational force and torque, projectile injury, excessive specific absorption rate, burns, peripheral neurostimulation, interactions with active implants and devices, and acoustic injury. Standards for MR imaging device safety terminology were first issued in 2005 and are required by the U.S. Food and Drug Administration, with devices labeled as "MR safe," "MR unsafe," or "MR conditional." MR imaging contrast agent safety is also discussed. Additional technical and safety policies relate to pediatric, unconscious, incapacitated, or pregnant patients and pregnant imaging personnel. Division of the MR imaging environment into four distinct, clearly labeled zones--with progressive restriction of entry and increased supervision for higher zones--is a mandatory and key aspect in avoidance of MR imaging-related accidents. All MR imaging facilities should have a documented plan to handle emergencies within zone IV, including cardiac arrest or code, magnet quench, and fires. Policies from the authors' own practice are provided for additional reference. Online supplemental material is available for this article.

Graphic representation of clinical symptoms: a tool for improving detection of subtle fractures on foot radiographs.

OBJECTIVE: The purpose of this study was to assess changes in accuracy, degree of confidence, and evaluation time in radiography of subtle foot fractures when the text history is supplemented by a graphic indicating the site of pain. MATERIALS AND METHODS: Radiographs from 226 foot examinations (three views), including 126 examinations showing one subtle fracture (< 1-mm displacement) and 100 examinations with normal findings were selected. In the first interpretation session, only a text history was given for 112 examinations, and both text and a graphic indicating the site of pain for 114 examinations. Six months later, a graphic and text history were provided for the 112 cases interpreted without a graphic in the first session, and only text was provided for the other 114 cases. Seven radiologists evaluated the study sets. Sensitivity, specificity, degree of confidence (1-10 scale), and mean interpretation time in seconds were calculated. RESULTS: Use of a graphic increased overall sensitivity for any subtle fracture from 67% to 73% (p < 0.001), increased degree of confidence from 8.1 without a graphic to 8.4 with a graphic (p < 0.0001), and decreased the time for interpretation by 6%, from 53 seconds without a graphic to 50 seconds with a graphic (p = 0.006). Specificity changed from 93% without a graphic to 94% with a graphic (p = 0.33). Fractures of the third metatarsal were missed most frequently (74%); this percentage improved to 61% with use of a graphic. CONCLUSION: A graphic complements the text history by improving sensitivity, degree of confidence, and time for interpretation.

Radiographic scoring system to evaluate union of distal radius fractures.

PURPOSE: To evaluate the intra- and interobserver reliability of a scoring system for distal radius fracture union based on specific radiographic parameters obtainable from x-rays. METHODS: Two sets of 35 anteroposterior and lateral x-rays were obtained by retrospective review of consecutive patients with distal radius fractures (AO types A and C) treated by a single surgeon in 2009. One set was assembled for those patients treated nonsurgically and 1 set for those treated with open reduction and internal fixation (ORIF) with volar plating. Radius union scoring system (RUSS) scores were compiled from a 5-person review panel consisting of hand surgeons and musculoskeletal radiologists. Union of each of the 4 cortices was graded on a 3-point scale (0, fracture line visible with no callus; 1, callus formation but fracture line present; 2, cortical bridging without clear fracture line). Reviewers also recorded their overall impression of fracture union (united or not united). Each set of radiographs was reviewed twice by the 5 reviewers, 2 weeks apart. Inter- and intraobserver reliability were determined using intraclass correlation coefficients. RESULTS: For nonsurgically treated fractures, substantial agreement in union scores was found with regard to both intra- and interobserver reliability. For fractures treated with ORIF, substantial agreement was found in union scores with regard to intraobserver reliability and moderate agreement with regard to interobserver reliability. In addition, when using the reviewers' overall assessment of union as a reference standard, RUSS had a statistically significant predictive value in being able to differentiate between united and not united fractures. CONCLUSIONS: This radiographic union tool demonstrated substantial intra- and interobserver reliability for the determination of fracture union in the distal radius. The RUSS is a simple method for a standardized assessment of radiographic union of DRF treated nonsurgically or with ORIF. TYPE OF STUDY/LEVEL OF EVIDENCE: Economic/decision analysis IV.

Spectrum and detection of musculoskeletal findings on trauma-related CT torso examinations.

This study aims (1) to evaluate the spectrum of musculoskeletal (MSK) findings detected on trauma-related torso CT exams performed in the emergency department and (2) to identify the findings of high clinical importance that are underreported. Following IRB approval, two fellowship-trained MSK radiologists independently reviewed 200 consecutive trauma CT torso examinations performed at a level 1 trauma center, focusing on MSK findings. Discrepancies were resolved by consensus. Findings were categorized as of high, moderate, or low clinical importance based on criteria established with an orthopedic trauma surgeon. Findings evident on only one series (scout, axial, or sagittal/coronal reformations) were documented. The consensus reading was compared to the final report. Unreported findings of high clinical importance were entered into our departmental QA system. Eighty-two percent (164/200) of the studies had at least one MSK finding. There were 433 total findings of varying importance and the overall detection rate was 61 % (266/433). The detection rate for high importance findings was 80 % (177/221) with the majority representing acute fractures (99 %). For findings of high clinical importance, the lowest detection rates were for fractures of the sternum, proximal humerus, and forearm. Of the high severity findings, 6.3 % (14/221) were detected only on sagittal or coronal reformatted or scout images. Twenty percent of musculoskeletal findings of high clinical importance on trauma-related CT torso exams were not reported. Fractures of the sternum, proximal humerus, and forearm were the most commonly missed fractures and review of scout and multiplanar reformations can increase detection.

The Intrinsic Value of Diversity in Team Leadership.

Despite the demonstrated benefit of diversity within a team structure, there is a lack of diversity among leadership in professional organizations. An increase in diversity among leadership teams would allow for more effective communication with team members, better problem-solving skills, increased trust within a team environment, and greater inspiration for future generations. Therefore, diversity should be a core concept within a leadership team.

Patient-Reported Outcome Measurement Information System Depression and Anxiety in Elective Knee Surgery Patients.

Mental health has been shown to play an important role in patient-reported outcomes (PRO); however, there is a general lack of literature describing patient-reported outcome measurement information system (PROMIS) depression and anxiety computer adaptive tests in elective knee surgery patients. The purpose of our study was to assess the prevalence of depression and anxiety symptoms before and after elective knee surgery and to determine whether these symptoms influence postoperative functional outcomes. An institutional review board-approved prospective orthopaedic registry was retrospectively queried for patients undergoing elective knee surgery from June 2015 to November 2018. Electronic surveys collecting patient demographic information and PROs were administered pre- and postoperatively. Of the 663 patients that completed baseline questionnaires, 466 completed 2-year follow-up (70.3%). PROs included PROMIS depression, PROMIS anxiety, International Knee Documentation Committee Subjective Knee Form (IKDC), and PROMIS physical function (PF). Wilcoxon rank sum and Spearman's rank order correlation were utilized to determine associations between variables. Multivariable analysis was used to control for confounding variables. Average PROMIS depression and anxiety scores significantly improved 2 years after surgery. PROMIS depression and anxiety scores significantly correlated with each other. PROMIS depression and anxiety scores significantly correlated with PROMIS PF and IKDC scores. After controlling for confounders on multivariable analysis, worse 2-year PROMIS anxiety was predictive of less functional improvement and worse 2-year PF and IKDC, while worse 2-year PROMIS depression was predictive of less improvement in IKDC. This study confirms the important relationship between mental health and functional outcomes. Given that psychiatric comorbidities are potentially modifiable with treatment, proper recognition could potentially lead to better orthopaedic outcomes. In addition, the prevalence of depression and anxiety symptoms postoperatively, as documented by PROMIS computer adaptive tests, may act as a barrier to achieving optimal functional outcomes after elective knee surgery. LEVEL OF EVIDENCE: Level III.

On-call musculoskeletal radiographs: discrepancy rates between radiology residents and musculoskeletal radiologists.

OBJECTIVE: The purpose of this study was to determine the rate of discrepancy between radiology residents and attending musculoskeletal radiologists in interpretation of on-call musculoskeletal radiographs. MATERIALS AND METHODS: We performed a retrospective review of 2219 consecutive musculoskeletal radiology reports on patients who visited the emergency department between January 2009 and December 2010. The images were initially interpreted overnight by on-call residents (postgraduate years 3-5), and a final interpretation was rendered the next morning by a musculoskeletal radiologist. The reports were evaluated for major discrepancies, such as missed fractures, osteomyelitis, foreign bodies, tumors, and acute arthritic conditions, which were defined as cases in which a change in clinical management was needed and required notification of the emergency care provider. RESULTS: The overall discrepancy rate was 1.8% (40/2219). Fractures accounted for 62.5% (25/40) of missed findings. Fractures involving the upper extremity, particularly the hand and wrist (2.2% [9/405]), were the most frequently missed. Radial fractures accounted for 50% (7/14) of the missed upper extremity fractures. Foreign bodies (10% [4/40]) and tumorlike lesions (7.5% [3/40]) accounted for the next most common misses. Finally, independent resident readings in the on-call setting had little adverse effect on patient care. CONCLUSION: In the on-call setting, the low discrepancy rate between interpretations of musculoskeletal radiographs by residents and by musculoskeletal attending radiologists is comparable to that reported for other body parts and modalities. Residents should be aware of the relatively high rate of missed pathologic findings in the upper extremity, especially the radius.

Lipomatosis of the sciatic nerve secondary to compression by a desmoid tumor.

Lipomatosis of nerve is a rare benign tumor-like process characterized by infiltration of the epineurium by adipose and fibrous tissue leading to nerve enlargement. We describe a case of lipomatosis of the sciatic nerve compressed by an adjacent desmoid tumor. This case supports the hypothesis that lipomatosis of nerve may form as a result of irritation or compression by adjacent structures.