Preliminary evaluation of dual-energy CT to quantitatively assess bone marrow edema in patients with diabetic foot ulcers and suspected osteomyelitis.

OBJECTIVES: The purpose of this study is to evaluate the value of dual-energy CT (DECT) with virtual non-calcium (VNCa) in quantitatively assessing the presence of bone marrow edema (BME) in patients with diabetic foot ulcers and suspected osteomyelitis. METHODS: Patients with a diabetic foot ulcer and suspected osteomyelitis that underwent DECT (80 kVp/Sn150 kVp) with VNCa were retrospectively included. Two observers independently measured CT values of the bone adjacent to the ulcer and a reference bone not related to the ulcer. The patients were divided into two clinical groups, osteomyelitis or no-osteomyelitis, based on the final diagnosis by the treating physicians. RESULTS: A total of 56 foot ulcers were identified of which 23 were included in the osteomyelitis group. The mean CT value at the ulcer location was significantly higher in the osteomyelitis group (- 17.23 ± 34.96 HU) compared to the no-osteomyelitis group (- 69.34 ± 49.40 HU; p < 0.001). Within the osteomyelitis group, the difference between affected bone and reference bone was statistically significant (p < 0.001), which was not the case in the group without osteomyelitis (p = 0.052). The observer agreement was good for affected bone measurements (ICC = 0.858) and moderate for reference bone measurements (ICC = 0.675). With a cut-off value of - 40.1 HU, sensitivity was 87.0%, specificity was 72.7%, PPV was 69.0%, and NPV was 88.9%. CONCLUSION: DECT with VNCa has a potential value for quantitatively assessing the presence of BME in patients with diabetic foot ulcers and suspected osteomyelitis. KEY POINTS: • Dual-energy CT (DECT) with virtual non-calcium (VNCa) is promising for detecting bone marrow edema in the case of diabetic foot ulcers with suspected osteomyelitis. • DECT with VNCa has the potential to become a more practical alternative to MRI in assessing the presence of bone marrow edema in suspected osteomyelitis when radiographs are not sufficient to form a diagnosis.

Routine follow-up radiographs for distal radius fractures are seldom clinically substantiated.

INTRODUCTION: The value of routine radiographs during follow-up after distal radius fractures is unclear. The aim of this study was to evaluate whether routine radiographs performed during the follow-up period in patients with a distal radius fracture influenced clinical decision making. METHODS: This retrospective cohort study included patients aged ≥18 years who were treated for a distal radius fracture at four hospitals in The Netherlands in 2012. Demographic and clinical and radiographic characteristics were collected from medical records. RESULTS: 1042 patients were included. In 121 (14%) of the 841 radiographs, a clinical indication was reported. Treatment was affected by 22 (2.6%) radiographs, including 11 (1.5%) radiographs that were categorized as routine, 9 (1.2%) of which led to prolonged cast immobilization and 2 (0.2%) to surgery for conservatively treated patients. CONCLUSION: Although it is common practice to take radiographs after distal radius fractures, the study results indicate that routine radiographs seldom affect treatment. This finding should be weighed against the high health care costs associated with these fractures. We hope that the results of our study will trigger the awareness among surgeons that in the current practice, many radiographs are taken on routine without influencing clinical decision making and can probably be omitted. LEVEL OF EVIDENCE: Level III.

Functional bracing treatment for stable type B ankle fractures.

BACKGROUND: In general, stable type B ankle fractures are treated conservatively with cast immobilization or a walking boot during six weeks. Some disadvantages of casting are joint stiffness, muscle wasting and lack of comfort. This study was designed to evaluate whether functional treatment with a removable brace is a safe and more comfortable alternative. MATERIAL AND METHODS: Randomized controlled trial. In the period March 2013 - May 2015, 44 patients visiting the emergency department due to a stable type B ankle fracture were included. During the first week both groups received a splint. After one week the patients were randomized: one group received a cast, the other a removable brace. For outcome Olerud & Molander Ankle Score, Visual Analogue Score for comfort and pain, American Academy of Orthopaedic Surgeons (AAOS) Foot and Ankle score questionnaire, EuroQol-5D and range of motion were used. RESULTS: 44 patients participated (21 cast, 23 brace). There were no differences in baseline characteristics. After 6 weeks, VAS for comfort (cast vs brace; 5.74 vs 7.21; p = 0.02) and total range of motion (40° vs 49°; p = 0.00) showed significant differences in favour of the brace. VAS pain (3.15 vs 2.05; p = 0.16), OMA-score (51.75 vs 61.32; p = 0.22) en EuroQoL-5D (7.26 vs 6.74; p = 0.33) did not show significant differences. Week 52 showed no significant differences at OMA-score (89.29 vs 96.18; p = 0.16), EuroQoL-5D (6.00 vs 5.35; p = 0.15), VAS pain (1.07 vs 0.82; p = 0.69) and AAOS score (91.71 vs 96.06; p = 0.21). No complications occurred in both groups. CONCLUSION: Functional bracing showed significant differences for the VAS comfort score and range of motion at 6 weeks compared to casting. After a year no significant differences were found. Treatment with a brace is a safe and more comfortable option for stable type B ankle fractures.

Radiographic fracture features predicting failure of internal fixation of displaced femoral neck fractures.

INTRODUCTION: Fixation-related complications of displaced femoral neck fractures treated by internal fixation are accompanied by high mortality and morbidity. The aim of this study is to investigate the pre- and postoperative radiographic fracture characteristics in relation to patient age and the occurrence of reoperation caused by fixation failure. METHODS: The preoperative radiographs of all patients presenting with a proximal femur fracture between January 2004 and December 2012 were retrospectively assessed for fracture type and dislocation (AP and lateral view). Patients with a displaced femoral neck fracture treated by closed reduction and internal fixation were included. The postoperative radiographs were assessed on adequate fracture reduction and correct position of the implant. Patient characteristics and outcome in terms of occurrence of fixation failure (implant breakout, non-union) and reoperation rate were recorded. RESULTS: Hundred and-forty-nine patients were admitted with a displaced femoral neck fracture and treated by internal fixation. Fixation failure was seen in 34 (23%) patients; 9 patients suffered from osteonecrosis. In total, 37 (25%) patients underwent reoperation caused by fixation-related complications. Taking the different age categories into account, 44% of the patients >75 years suffered fixation failure compared with 17% of the patients <65 years. Postoperative incorrect reduction, with persisting dorsoventral dislocation and/or lack of medial support resulted in reoperation in 37% of the patients, compared to 19% reoperations in patients with adequate reduction. CONCLUSION: The results of this study show that patient age and fracture reduction are important predictors for reoperation. In the preoperative treatment plan, patient age should be taken into account and surgeons should strive for anatomical reduction. Patients over 75 should always undergo arthroplasty. In patients aged 65-75, conversion to arthroplasty should be strongly considered if anatomical reduction is impossible.