Achilles Tendon Injuries in the Pediatric Population.

BACKGROUND: Achilles tendon injuries are common in adults, and there is extensive literature describing the injury characteristics and treatment of these adult injuries. However, Achilles injuries are rare in the pediatric population and as a result, there is limited research reported on this age group. We therefore sought to characterize the injury presentation, treatment and outcomes for pediatric patients with partial and complete Achilles injuries. METHODS: A retrospective chart review was conducted of patients aged 0-18 treated for Achilles tendon injuries at 2 geographically distinct tertiary institutions between 2008 and 2021. Data collected included demographics, injury characteristics, and treatment course. Injury types were separated into 2 cohorts: traumatic Achilles injuries and ruptures due to muscular contraction. Traumatic injuries were further delineated into 2 injury mechanisms: open injuries related to penetrating trauma and closed injuries related to blunt trauma. Standard descriptive analyses were utilized to summarize findings. RESULTS: Thirty-nine patients (43.6% female, median age 15 years) were identified, 29 (74.4%) of whom had complete tears. Twenty-five patients (64.1%) presented with traumatic injuries; among these, 48.0% (n=12/25) were ≤12 years. All patients ≤12 years sustained a traumatic injury. The most common traumatic mechanism was an open laceration due to penetrating trauma (68.0%), followed by closed ruptures associated with blunt trauma (32.0%). Fourteen patients (35.9%) presented with closed ruptures due to muscular contraction. Four patients (10.2%) had a prior history of clubfoot treated with Achilles tenotomy. Thirty-five patients (89.7%) were surgically treated with an open repair. The median immobilization period across all patients was 11 weeks (interquartile range: 10-12), starting most commonly with a posterior splint (46.2%) and concluding with a CAM boot (94.9%). Of patients with full follow-up data (n=22/39), all resumed normal activities, with a median clearance time of 6 months (interquartile range: 5-7.9). CONCLUSIONS: We found that older adolescents (≥14 y) were more likely to rupture their Achilles tendon through a forceful muscular contraction, whereas younger patients (≤12 y) were more likely to injure their Achilles via a traumatic mechanism. Most patients were treated operatively and returned to sports at a median time of 6 months. A further prospective study is warranted to better characterize treatment protocols and patient outcomes in this population. LEVEL OF EVIDENCE: Level-IV.

Outcomes of bioabsorbable fixation in the treatment of osteochondral lesions of the knee in adolescent patients.

BACKGROUND: Bioabsorbable fixation in managing osteochondral lesions is increasing in popularity. The purpose was to report on outcomes using bioabsorbable fixation nails for osteochondral lesions of the knee in a pediatric and adolescent population. METHODS: A retrospective review of pediatric patients undergoing surgery with bioabsorbable fixation for knee osteochondral lesions was performed. Demographic, clinical, and surgical data was collected including symptom duration, lesion location, size, use of bone grafting, and number of implants. Return to activities was documented. Patients recommended revision surgery were compared to those who were not. RESULTS: 47 patients with median age 13.9 years and 25.5% female were included with median clinical follow-up of 47.3 weeks. 87.2% of patients were cleared for full activities. Four male patients (8.5%) were recommended revision surgery, of whom three underwent surgery including removal of loose bioabsorbable fixation. Demographic data did not differ between the group with successful versus failed primary surgery (p > 0.05). Symptom duration was more acute (<1 month) in the four recommended revision surgery (75% versus 9.3%, p = 0.008). The group recommended revision also had larger lesion size (median 5.4 cm2 versus 2 cm2, p = 0.04). Distal femoral physeal status, lesion location, necessity for bone grafting, and number of implants did not differ between groups. CONCLUSIONS: Adolescents had a high return to activity following bioabsorbable fixation for knee osteochondral lesions with 87.2% cleared for full return. In the 8.5% of patients who were deemed to have failed primary fixation, symptoms were more likely to be acute in nature with larger lesion sizes.

Younger Patients Are More Likely to Undergo Arthroscopic Meniscal Repair and Revision Meniscal Surgery in a Large Cross-Sectional Cohort.

PURPOSE: To evaluate recent trends in the treatment of meniscal tears with arthroscopic repair and debridement and to assess revision surgery within 2 years using a large cross-sectional database. METHODS: Patients with a diagnosis of meniscal tear from 2010 to 2017 were queried using the Mariner data set from PearlDiver. Patient demographic data were analyzed and tracked via International Classification of Diseases, Tenth Revision codes to investigate subsequent ipsilateral meniscal procedures and conversion to total knee arthroplasty within 2 years after index meniscal surgery. RESULTS: Of the 1,383,161 patients with a diagnosis of meniscal tear, 53.0% underwent surgical treatment. Surgical treatment consisted of meniscal debridement in 96.6% of patients and meniscal repair in 3.4%. The percentage of meniscal repairs increased from 2.7% to 4.4% over the 8-year period evaluated, whereas the percentage of meniscal debridement decreased from 97.3% to 95.6% (P < .0001). Younger patients were more likely to undergo meniscal repair (23% of those aged 10-19 years) than older patients (<1% of those aged ≥60 years). Among the 191,729 patients with International Classification of Diseases, Tenth Revision coding and 2-year follow-up, 10.6% of patients with index meniscal repair required a revision meniscal operation and 1.2% underwent conversion to arthroplasty. Subsequent meniscal procedures within 2 years after index meniscal repair included meniscal debridement in 81.6% of patients and revision repair in 18.4%. Patients who initially underwent meniscal debridement were less likely to undergo revision meniscal surgery (5.1%), but 4.7% required conversion to arthroplasty. Patients aged 10 to 19 years were most likely to undergo revision meniscal procedures after both index meniscal repair (12.8%) and meniscal debridement (8.8%). CONCLUSIONS: The rate of meniscal repair is increasing over time, with patients younger than 30 years most likely to undergo repair for a meniscal tear. Revision surgery for meniscal repair or debridement is more common in adolescents and patients who undergo an index meniscal repair. LEVEL OF EVIDENCE: Level III, retrospective cohort study.

Surgical Complications After Reverse Total Shoulder Arthroplasty and Total Shoulder Arthroplasty in the United States.

INTRODUCTION: Shoulder arthroplasty has become popular in the treatment of degenerative shoulder conditions in the United States. Shoulder arthroplasty usage has expanded to younger patients with increased surgical indications. METHODS: Reverse total shoulder arthroplasty (RTSA) and TSA patient records with the 1-year follow-up between 2015 and 2018 were queried from the nationwide PearlDiver Mariner Shoulder Database using International Classification of Disease-10 codes. Chi-square analysis was done to compare the demographics, surgical complications, and revision procedures between RTSA and TSA. RESULTS: From 2010 to 2018, there was an increase in shoulder arthroplasty cases because of RTSA. The overall surgical complication and revision procedure rates were 2.26% and 3.56% for RTSA, and 6.36% and 2.42% for TSA. Patients older than 50 years had statistically lower surgical complications after RTSA than TSA (2.25% versus 3.94%, P < 0.05), whereas no statistical difference between RTSA and TSA for patients younger than 50 years (10.06% versus 7.45%, P = 0.19). Male patients had higher RTSA complication rates (3.12% versus 2.28%, P < 0.05), whereas female patients had higher TSA (4.86% versus 5.92%, P < 0.05). History of tobacco, depression, and obesity were risk factors for higher complications. CONCLUSION: RTSA has become more commonly done than TSA in the United States. Older patients who underwent shoulder arthroplasty had lower surgical complication. TSA had a higher surgical complication rate than RTSA for patients older than 50 years.

Arthroscopic Glenoid Reconstruction With Iliac Crest Bone Block Transfer in the Beach Chair Position.

Large anterior glenoid defects pose significant challenges for shoulder stability. Arthroscopic glenoid reconstruction techniques using distal tibia allograft have been proposed as alternatives to open or arthroscopic Latarjet procedures but can increase operating room costs. Iliac crest bone block autograft is a cost-effective option without concern for the graft being undersized. Previous techniques have described arthroscopic glenoid reconstruction in the lateral position, but the beach chair position provides ease of access to both the iliac crest bone graft harvest and arthroscopic bone transfer, as well as facilitates possible conversion to an open approach if necessary. We present our surgical technique for performing an arthroscopic glenoid reconstruction with iliac crest autograft bone block transfer in the beach chair position.

Comparing Patient-Reported Outcome Measurements for Femoroacetabular Impingement Syndrome.

BACKGROUND: There is much debate in the current literature with regard to the most appropriate hip-specific patient-reported outcome (PRO) measurement for assessment of femoroacetabular impingement syndrome (FAIS) and outcomes after surgical treatment. Despite systematic reviews assessing the validity of classic hip-specific PROs as well as newer PROs developed to target the young, active population, there lacks a direct comparison of the question content between each PRO. PURPOSE: To compare the question composition and degree of overlap between commonly used PROs for FAIS. STUDY DESIGN: Cross-sectional study. METHODS: A literature review yielded the 6 most commonly cited PROs for assessment of FAIS: modified Harris Hip Score (mHHS), Hip disability and Osteoarthritis Outcome Score (HOOS), Copenhagen Hip and Groin Outcome Score (HAGOS), Nonarthritic Hip Score (NAHS), international Hip Outcome Tool (iHOT-33), and Hip Outcome Score (HOS). Questions from each PRO were classified as identical, similar, or unique after pooled comparison, and the number of overlapping (identical or similar) questions between each PRO was determined. Questions were then classified into 5 domains: pain, symptoms, functional activities, sports, and quality of life, and variations in questions assessing each domain based on PRO were analyzed. RESULTS: Analysis of 164 total questions from 6 PROs showed that 87 questions (53%) were identical between 2 or more PROs, 39 (24%) were similar, and 38 (23%) were unique. The iHOT-33 contained the highest number of unique questions, with 13 of 33 (39.4%), while the HOOS contained the lowest number of unique questions, with 3 of 40 (7.5%). The HOOS, HAGOS, and iHOT-33 contained questions assessing all 5 domains of patient outcomes; the NAHS did not evaluate quality of life; the mHHS only assessed pain, symptoms, and functional activities; and the HOS only assessed functional activities and sports. CONCLUSION: As there is a high percentage of overlapping (identical or similar) questions between the most commonly used hip-specific PROs for FAIS, multiple tests may be appropriate for use. The iHOT-33, HOOS, and HAGOS are well suited for the general population as they offer comprehensive assessments across all domains, while the HOS provides added focus to sports/activity assessments for athletes and highly active patients.

A Systematic Approach to Arthroscopic Femoroplasty With Conservative Management of the Hip Capsule.

As hip arthroscopy has become increasingly used to treat femoroacetabular impingement, the importance of a complete femoroplasty to properly address cam impingement has been demonstrated. In doing so, different capsulotomy techniques have been described for gaining access to the hip joint as well as the peripheral compartment for cam resection. The periportal capsulotomy technique allows joint access while preserving the structural integrity of the iliofemoral ligament, obviating the need for capsular closure. We present a systematic approach and surgical technique for performing a complete arthroscopic femoroplasty while maintaining conservative hip capsule management through a periportal capsulotomy.

High Rate of Overlapping Question Content Among Commonly Used Patient-Reported Outcome Measurements for Anterior Cruciate Ligament Injury.

PURPOSE: To precisely compare the questions and content between the most commonly cited knee-specific patient-reported outcome measurements (PROs) for anterior cruciate ligament (ACL) injury. METHODS: A literature review through Medline from November 1, 2018, to November 1, 2020, was performed to find the most cited knee-specific PROs for assessment of ACL injuries. Each question was then classified as 1) identical, similar, or unique; 2) pertaining to 1 of 6 domains (pain, symptoms, functional activities, occupational activities, sports/recreation, and quality of life). The PROs were then compared to each other to assess question overlap and domain coverage. RESULTS: A total of 133 questions were analyzed from the seven most common PROs: International Knee Documentation Committee (IKDC) form, Knee Injury and Osteoarthritis Outcome Score (KOOS), Lysholm Knee Scoring Scale, Tegner Activity Scale, Marx Scale, Knee Outcome Survey (KOS), and Cincinnati Knee Rating System (CKRS). The total distribution of identical (31.6%), similar (31.6%), and unique (36.8%) questions was found to be relatively even. However, this distribution varied within each PRO. KOS and Lysholm had the highest percentages of identical questions (64% and 62.5%, respectively). KOOS had the highest number of unique questions (26/42, 61.9%), while Tegner held the highest percentage (11/16, 68.8%). Sports/recreation was the only domain assessed by all PROs. CONCLUSION: Nearly two-thirds of questions overlap between the commonly used PROs for ACL injury. Although sports/recreation is assessed by all PROs, each has its own pattern of coverage across this and other domains. LEVEL OF EVIDENCE: IV, cross-sectional study.

Comparison of the accuracy of telehealth examination versus clinical examination in the detection of shoulder pathology.

HYPOTHESIS/BACKGROUND: In 2017, the American Orthopaedic Association advocated for the increased use of telehealth as an assessment and treatment platform, and demand has significantly increased during the coronavirus disease 2019 pandemic. Diagnostic effectiveness (also called overall diagnostic accuracy) and reliability of a telehealth clinical examination vs. a traditional shoulder clinical examination (SCE) has not been established. Our objective is to compare the diagnostic effectiveness of a telehealth shoulder examination against an SCE for rotator cuff tear (RCT), using magnetic resonance imaging (MRI) as a reference standard; secondary objectives included assessing agreement between test platforms and validity of individualized tests. We hypothesize that tests provided in a telehealth platform would not have inferior diagnostic effectiveness to an SCE. METHODS: The study is a case-based, case-control design. Two clinicians selected movement, strength, and special tests for the SCE that are associated with the diagnosis of RCT and identified similar tests to replicate for a simulated telehealth-based examination (STE). Consecutive patients with no prior shoulder surgery or advanced imaging underwent both the SCE and STE in the same visit using 2 separate assessors. We randomized the order of the SCE or STE. A blinded reader assessed an MRI, to be used as a reference standard. We calculated diagnostic effectiveness, which provides values from 0% to 100% as well as agreement statistics (Kappa) between tests by an assessment platform, and sensitivity, specificity, and likelihood ratios for individual tests in both SCE and STE. We compared the diagnostic effectiveness (overall) of the SCE and STE with a Mann-Whitney U test. RESULTS: We included 62 consecutive patients with shoulder pain, aged 40 or older; 50 (81%) received an MRI as a reference standard. The diagnostic effectiveness of stand-alone tests was poor regardless of the group, with the exception of a few tests with high specificity. None had greater than 70% accuracy. There was no significant difference between the overall diagnostic effectiveness of the STE and SCE (P = .98). Overall agreement between the STE tests and the SCE tests ranged from poor to moderate (Kappa, 0.07-0.87). CONCLUSION: This study identified initial feasibility and noninferiority of the physician-guided, patient-performed STE when compared with an SCE in the detection of RCTs. Although these results are promising, larger studies are needed for further validation of an STE assessment platform.

Tranexamic acid or epsilon-aminocaproic acid in total joint arthroplasty? A randomized controlled trial.

AIMS: Antifibrinolytic agents, including tranexamic acid (TXA) and epsilon-aminocaproic acid (EACA), have been shown to be safe and effective for decreasing perioperative blood loss and transfusion following total hip arthroplasty (THA) and total knee arthroplasty (TKA). However, there are few prospective studies that directly compare these agents. The purpose of this study was to compare the benefits of intraoperative intravenous TXA with EACA. PATIENTS AND METHODS: A total of 235 patients (90 THA and 145 TKA) were enrolled in this prospective, randomized controlled trial at a single tertiary-care referral centre. In the THA cohort, 53.3% of the patients were female with a median age of 59.8 years (interquartile range (IQR) 53.3 to 68.1). In the TKA cohort, 63.4% of the patients were female with a median age of 65.1 years (IQR 59.4 to 69.5). Patients received either TXA (n = 119) or EACA (n = 116) in two doses intraoperatively. The primary outcome measures included change in haemoglobin level and blood volume, postoperative drainage, and rate of transfusion. Secondary outcome measures included postoperative complications, cost, and length of stay (LOS). RESULTS: TKA patients who received EACA had greater drainage (median 320 ml (IQR 185 to 420) vs 158 ml (IQR 110 to 238); p < 0.001), increased loss of blood volume (891 ml (IQR 612 to 1203) vs 661 ml (IQR 514 to 980); p = 0.014), and increased haemoglobin change from the preoperative level (2.1 ml (IQR 1.7 to 2.8) vs 1.9 ml (IQR 1.2 to 2.4); p = 0.016) compared with patients who received TXA. For the THA cohort, no statistically significant differences were observed in any haematological outcome measure. One patient in the EACA group required transfusion. No patient in the TXA group required transfusion. There were no statistically significant differences in number or type of postoperative complications or LOS for either THA or TKA patients regardless of whether they received TXA or EACA. CONCLUSION: For hip and knee arthroplasty procedures, EACA is associated with increased perioperative blood loss compared with TXA. However, there is no significant difference in transfusion rate. While further prospective studies are needed to compare the efficacy of each agent, we currently recommend orthopaedic surgeons to select their antifibrinolytic based on cost and regional availability. Cite this article: Bone Joint J 2019;101-B:1093-1099.

Early to Midterm Clinical and Radiographic Survivorship of the All-Polyethylene Versus Modular Metal-Backed Tibia Component in Primary Total Knee Replacement.

The purpose of this study was to compare the all-polyethylene tibial component with the modular metal-backed component in primary total knee arthroplasty. A retrospective review of 1064 patients recorded clinical failure, as determined by need for revision surgery, range of motion, and impending radiographic loosening, as evaluated by the presence of radiolucent lines. Mean follow-up was 1.2 and 3 years, respectively. Survival in the all-polyethylene group was 100%, with 95.5% (95% CI: 85.8-98.6) survival in the metal-backed component group at 4.3 years. Thin (<4 mm) radiolucent lines were present in one patient (0.7%) with an all-polyethylene implant and 24 (16.9%) patients with the metalbacked component (p < .001), while one (0.7%) and two (1.4%) patients had evidence of osteolysis, respectively (p = .621). While there were fewer radiolucent lines noted around the all-polyethylene implant on radiographs, the clinical implications of the finding are unknown. In this study population, the all-polyethylene tibial component appears appropriate. (Journal of Surgical Orthopaedic Advances 28(2):108-114, 2019).

Interposition Dermal Matrix Xenografts: A Successful Alternative to Traditional Treatment of Massive Rotator Cuff Tears.

BACKGROUND: Management of massive rotator cuff tears in shoulders without glenohumeral arthritis remains problematic for surgeons. Repairs of massive rotator cuff tears have failure rates of 20% to 94% at 1 to 2 years postoperatively as demonstrated with arthrography, ultrasound, and magnetic resonance imaging. Additionally, inconsistent outcomes have been reported with debridement alone of massive rotator cuff tears, and limitations have been seen with other current methods of operative intervention, including arthroplasty and tendon transfers. HYPOTHESIS: The use of interposition porcine acellular dermal matrix xenograft in patients with massive rotator cuff tears will result in improved subjective outcomes, postoperative pain, function, range of motion, and strength. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: Sixty patients (61 shoulders) were prospectively observed for a mean of 50.3 months (range, 24-63 months) after repair of massive rotator cuff tears with porcine acellular dermal matrix xenograft as an interposition graft. Subjective outcome data were obtained with visual analog scale for pain score (0-10, 0 = no pain) and Modified American Shoulder and Elbow Surgeons (MASES) score. Active range of motion in flexion, external rotation, and internal rotation were recorded. Strength in the supraspinatus and infraspinatus muscles was assessed manually on a 10-point scale and by handheld dynamometer. Ultrasound was used to assess the integrity of the repair during latest follow-up. RESULTS: Mean visual analog scale pain score decreased from 4.0 preoperatively to 1.0 postoperatively ( P < .001). Mean active forward flexion improved from 140.7° to 160.4° ( P < .001), external rotation at 0° of abduction from 55.6° to 70.1° ( P = .001), and internal rotation at 90° of abduction from 52.0° to 76.2° ( P < .001). Supraspinatus manual strength increased from 7.7 to 8.8 ( P < .001) and infraspinatus manual strength from 7.7 to 9.3 ( P < .001). Mean dynamometric strength in forward flexion was 77.7 N in nonoperative shoulders (shoulder that did not undergo surgery) and 67.8 N ( P < .001) in operative shoulders (shoulder that underwent rotator cuff repair with interposition porcine dermal matrix xenograft). Mean dynamometric strength in external rotation was 54.5 N in nonoperative shoulders and 50.1 N in operative shoulders ( P = .04). Average postoperative MASES score was 87.8. Musculoskeletal ultrasound showed that 91.8% (56 of 61) of repairs were fully intact; 3.3% (2 of 61), partially intact; and 4.9% (3 of 61), not intact. CONCLUSION: Patients who underwent repair of massive rotator cuff tears with interposition porcine acellular dermal matrix graft have good subjective function as assessed by the MASES score. Patients have significant improvement in pain, range of motion, and manual muscle strength. Postoperative ultrasound demonstrated that the repair was completely intact in 91.8% of patients, a vast improvement compared with results previously reported for primary repairs of massive rotator cuff tears.

A pilot study of orthopaedic resident self-assessment using a milestones' survey just prior to milestones implementation.

OBJECTIVE: To pilot test if Orthopaedic Surgery residents could self-assess their performance using newly created milestones, as defined by the Accreditation Council on Graduate Medical Education. METHODS: In June 2012, an email was sent to Program Directors and administrative coordinators of the 154 accredited Orthopaedic Surgery Programs, asking them to send their residents a link to an online survey. The survey was adapted from the Orthopaedic Surgery Milestone Project. Completed surveys were aggregated in an anonymous, confidential database. SAS 9.3 was used to perform the analyses. RESULTS: Responses from 71 residents were analyzed. First and second year residents indicated through self-assessment that they had substantially achieved Level 1 and Level 2 milestones. Third year residents reported they had substantially achieved 30/41, and fourth year residents, all Level 3 milestones. Fifth year, graduating residents, reported they had substantially achieved 17 Level 4 milestones, and were extremely close on another 15. No milestone was rated at Level 5, the maximum possible. Earlier in training, Patient Care and Medical Knowledge milestones were rated lower than the milestones reflecting the other four competencies of Practice Based Learning and Improvement, Systems Based Practice, Professionalism, and Interpersonal Communication. The gap was closed by the fourth year. CONCLUSIONS: Residents were able to successfully self-assess using the 41 Orthopaedic Surgery milestones. Respondents' rate improved proficiency over time. Graduating residents report they have substantially, or close to substantially, achieved all Level 4 milestones. Milestone self-assessment may be a useful tool as one component of a program's overall performance assessment strategy.

Staple fixation for akin proximal phalangeal osteotomy in the treatment of hallux valgus interphalangeus.

BACKGROUND: The Akin proximal phalangeal osteotomy is commonly used in conjunction with metatarsal osteotomies to treat hallux valgus. Multiple fixation methods including suture, wire, screw, and staple fixation have been described. The aims of this study were to assess the intraoperative and postoperative complications and to evaluate short-term postoperative outcomes in patients who underwent Akin osteotomy with staple fixation. METHODS: Forty-four patients (51 feet) with painful hallux valgus were retrospectively reviewed at an average of 40.4 ± 15.8 (range, 25.9 to 79.9) weeks following an Akin osteotomy with staple fixation. Patient reported preoperative and postoperative Visual Analog Score (VAS) (0 to 10, 0 = no pain) was recorded. Level of activity was reported postoperatively. Hallux valgus angles (HVAs), intermetatarsal angles (IMAs), and hallux valgus interphalangeus angles (IPAs) were evaluated on preoperative as well as final postoperative radiographs. Postoperative clinical and radiographic examinations were used to evaluate for complications. RESULTS: Mean VAS improved from 4.4 ± 2.6 to 1.0 ± 1.2 (P < .001). Activity level was classified as ability to bear weight as tolerated 3/51 (5.9%), ambulate 1 to 4 blocks 2/51 (3.9%), ambulate a minimum of 6 blocks 18/51 (35.3%), and ambulate an unlimited distance 28/51 (59.4%). Average HVA, IMA, and IPA improved from 25.6 ± 10.0 degrees to 14.1 ± 8.1 degrees (P < .001), 13.1 ± 4.6 degrees to 8.0 ± 3.0 degrees (P < .001), and 7.9 ± 3.4 degrees to -3.1 ± 6.4 degrees (P < .001), respectively. No major postoperative complications, including infections, nonunions, or recurrent deformities, were recorded. Two patients sustained breaches of the lateral cortex, but this was without appreciable complication. Three patients (5.9%) reported unilateral proximal-medial great phalanx tenderness. There was 1 revision for persistent deformity, specifically in the HVA and IPA angles. CONCLUSION: Akin osteotomy with staple fixation was a safe and effective procedure as part of a hallux valgus correction with improvement in pain and hallux valgus deformity with a low risk for complications. LEVEL OF EVIDENCE: Level IV, case series.

The value of diagnostic medical imaging.

Diagnostic medical imaging has clear clinical utility, but it also imposes significant costs on the health care system. This commentary reviews the factors that drive the cost of medical imaging, discusses current interventions, and suggests possible future courses of action.