Costal Chondroid Tumors Mimicking Intraabdominal Masses: The Pivotal Role of Computed Tomography in Diagnosis.

Teaching Point: Costal chondroid tumors can mimic abdominal masses and, when located in the right hypochondrium, may suggest hepatic origin. Computed tomography is essential to determine their origin and nature and to guide appropriate treatment.

Talar metastasis of mucinous lung adenocarcinoma with fluid-fluid levels: a rare presentation mimicking a benign tumor.

The differential diagnosis of bone tumors in the talus is broad and includes both benign and malignant conditions. Metastases, although very rare, are one of these conditions. The typical nonspecific clinical and radiological presentations of metastases are a diagnostic challenge, and a high level of suspicion is needed in order to perform an adequate diagnostic approach. Moreover, they can present with features which have classically been associated with benign conditions such as fluid-fluid levels. We present a rare case of talar metastasis of a mucinous pulmonary adenocarcinoma that presented with fluid-fluid levels and was initially misdiagnosed as a giant-cell tumor with areas of secondary aneurysmal bone cyst transformation.

MRI findings prior to return to play as predictors of reinjury in professional athletes: a novel decision-making tool.

BACKGROUND: Because MRI has shown great accuracy in assessing acute muscle injuries, identification of risk factors for reinjury before return to play (RTP) in professional athletes during the healing process could be very relevant. We assessed the value of MRI findings prior to RTP as predictors of reinjury. METHODS: Retrospective observational study of 59 professional athletes, mean age 26 years, with first-time acute muscle injury and successful rehabilitation ready to RTP. They underwent MRI within 6 days of the injury and within 7 days prior to RTP. The primary outcome was reinjury. Risk of reinjury was assessed using radiological signs in control MRI scans before RTP. The risk was classified as low, medium or high when none, one or two radiological signs were observed, respectively. RESULTS: Reinjury occurred in 9 participants, with a rate of 15.2%. None of the baseline MRI-related variables was significantly associated with reinjury. In the control MRI scan performed within 7 days prior to RTP, three independent findings were significantly associated with reinjury. These included transversal and/or mixed connective tissue gap (p = 0.002), intermuscular oedema (p = 0.015) and callus gap (p = 0.046). In the predictive model of the risk of reinjury, the presence of two of these radiological signs, together with interstitial feathery oedema, was associated with a high risk of recurrence (OR 29.58, 95% CI 3.86-226.64; p = 0.001). CONCLUSIONS: In professional athletes with acute muscle injuries of the lower limbs successfully rehabilitated, some radiological signs on MRI performed shortly before RTP were associated with a high risk of reinjury.

Postoperative Hip MR Imaging.

Postoperative imaging of the hip used to be dominated by radiographs, computed tomography, and occasionally nuclear medicine studies, given that most surgeries were arthroplasties or, less commonly, core decompressions. The indications and procedures performed have expanded well beyond arthroplasties and now include labral procedures (resections, repairs, and reconstructions), osteochondroplasties, acetabuloplasties, and removal of loose bodies, among others. As a result, postoperative evaluation of the hip now often includes MR imaging and MR arthrography. This article discusses normal postoperative appearances and some of the more common complications associated with hip arthroscopy and hip arthroplasty with a focus on MR imaging.

Pseudo Green Hair.

Green hair is due to insoluble copper deposits in the hair of blonde people. Although it is most frequently due to an increase in the copper content of algaecides in swimming pools, other causes have been recognized. Herewith, we present a case of a blonde girl who had previously commercially highlighted her hair and the hair had turned green following a swim in a pool with excess copper content in the water. Lifeguard swimming pool commented another previously affected blonde female swimmer 2 days ago. To date, <10 cases involving swimming pools with clearly increased copper concentrations have been published, and to the best of our knowledge, no similar case without traces of copper in X-ray microanalysis has been reported in the literature.

Clinical indications for image-guided interventional procedures in the musculoskeletal system: a Delphi-based consensus paper from the European Society of Musculoskeletal Radiology (ESSR)-part VII, nerves of the lower limb.

OBJECTIVES: To perform a Delphi-based consensus on published evidence on image-guided interventional procedures for peripheral nerves of the lower limb (excluding Morton's neuroma) and provide clinical indications. METHODS: We report the results of a Delphi-based consensus of 53 experts from the European Society of Musculoskeletal Radiology who reviewed the published literature for evidence on image-guided interventional procedures offered around peripheral nerves in the lower limb (excluding Morton's neuroma) to derive their clinical indications. Experts drafted a list of statements and graded them according to the Oxford Centre for evidence-based medicine levels of evidence. Consensus was considered strong when > 95% of experts agreed with the statement or broad when > 80% but < 95% agreed. The results of the Delphi-based consensus were used to write the paper. RESULTS: Nine statements on image-guided interventional procedures for peripheral nerves of the lower limb have been drafted. All of them received strong consensus. Image-guided pudendal nerve block is safe, effective, and well tolerated with few complications. US-guided perisciatic injection of anesthetic provides good symptom relief in patients with piriformis syndrome; however, the addition of corticosteroids to local anesthetics still has an unclear role. US-guided lateral femoral cutaneous nerve block can be used to provide effective post-operative regional analgesia. CONCLUSION: Despite the promising results reported by published papers on image-guided interventional procedures for peripheral nerves of the lower limb, there is still a lack of evidence on the efficacy of most procedures. KEY POINTS: • Image-guided pudendal nerve block is safe, effective, and well tolerated with few complications. • US-guided perisciatic injection of anesthetic provides good symptom relief in patients with piriformis syndrome; however, the addition of corticosteroids to local anesthetics still has an unclear role. • US-guided lateral femoral cutaneous nerve block can be used to provide effective post-operative regional analgesia. The volume of local anesthetic affects the size of the blocked sensory area.

Clinical indications for image-guided interventional procedures in the musculoskeletal system: a Delphi-based consensus paper from the European Society of Musculoskeletal Radiology (ESSR)-part VI, foot and ankle.

OBJECTIVES: Clarity regarding accuracy and effectiveness for interventional procedures around the foot and ankle is lacking. Consequently, a board of 53 members of the Ultrasound and Interventional Subcommittees of the European Society of Musculoskeletal Radiology (ESSR) reviewed the published literature to evaluate the evidence on image-guided musculoskeletal interventional procedures around this anatomical region. METHODS: We report the results of a Delphi-based consensus of 53 experts from the European Society of Musculoskeletal Radiology who reviewed the published literature for evidence on image-guided interventional procedures offered around foot and ankle in order to derive their clinical indications. Experts drafted a list of statements and graded them according to the Oxford Centre for evidence-based medicine levels of evidence. Consensus was considered strong when > 95% of experts agreed with the statement or broad when > 80% but < 95% agreed. The results of the Delphi-based consensus were used to write the paper that was shared with all panel members for final approval. RESULTS: A list of 16 evidence-based statements on clinical indications for image-guided musculoskeletal interventional procedures in the foot and ankle were drafted after a literature review. The highest level of evidence was reported for four statements, all receiving 100% agreement. CONCLUSION: According to this consensus, image-guided interventions should not be considered a first-level approach for treating Achilles tendinopathy, while ultrasonography guidance is strongly recommended to improve the efficacy of interventional procedures for plantar fasciitis and Morton's neuroma, particularly using platelet-rich plasma and corticosteroids, respectively. KEY POINTS: • The expert panel of the ESSR listed 16 evidence-based statements on clinical indications of image-guided musculoskeletal interventional procedures in the foot and ankle. • Strong consensus was obtained for all statements. • The highest level of evidence was reached by four statements concerning the effectiveness of US-guided injections of corticosteroid for Morton's neuroma and PRP for plantar fasciitis.

Clinical indications for image-guided interventional procedures in the musculoskeletal system: a Delphi-based consensus paper from the European Society of Musculoskeletal Radiology (ESSR)-part V, knee.

OBJECTIVES: Interventional procedures around the knee are widely adopted for treating different musculoskeletal conditions. A panel of experts from the Ultrasound and Interventional Subcommittees of the European Society of Musculoskeletal Radiology (ESSR) reviewed the existing literature to assess the evidence on image-guided musculoskeletal interventional procedures around the knee, with the goal of highlighting some controversies associated with these procedures, specifically the role of imaging guidance, as well as the efficacy of the medications routinely injected. METHODS: We report the results of a Delphi-based consensus of 53 experts in musculoskeletal radiology, who reviewed the published literature for evidence on image-guided interventional procedures around the knee to derive a list of pertinent clinical indications. RESULTS: A list of 10 statements about clinical indications of image-guided procedures around the knee was created by a Delphi-based consensus. Only two of them had the highest level of evidence; all of them received 100% consensus. CONCLUSIONS: Ultrasonography guidance is strongly recommended for intra-articular and patellar tendinopathy procedures to ensure the precision and efficacy of these treatments. Prospective randomized studies remain warranted to better understand the role of imaging guidance and assess some of the medications used for interventional procedures around the knee. KEY POINTS: • A list of 10 evidence-based statements on clinical indications of image-guided interventional procedures around the knee was produced by an expert panel of the ESSR. • Strong consensus with 100% agreement was obtained for all statements. • Two statements reached the highest level of evidence, allowing us to strongly recommend the use of ultrasonography to guide intra-articular and patellar tendon procedures to ensure higher accuracy and efficacy of these treatments.

Clinical indications for image-guided interventional procedures in the musculoskeletal system: a Delphi-based consensus paper from the European Society of Musculoskeletal Radiology (ESSR)-part IV, hip.

OBJECTIVES: Image-guided musculoskeletal interventional procedures around the hip are widely used in daily clinical practice. The need for clarity concerning the actual added value of imaging guidance and types of medications to be offered led the Ultrasound and the Interventional Subcommittees of the European Society of Musculoskeletal Radiology (ESSR) to promote, with the support of its Research Committee, a collaborative project to review the published literature on image-guided musculoskeletal interventional procedures in the lower limb in order to derive a list of clinical indications. METHODS: In this article, we report the results of a Delphi-based consensus of 53 experts who reviewed the published literature for evidence on image-guided interventional procedures offered in the joint and soft tissues around the hip in order of their clinical indications. RESULTS: Ten statements concerning image-guided treatment procedures around the hip have been collected by the panel of ESSR experts. CONCLUSIONS: This work highlighted that there is still low evidence in the existing literature on some of these interventional procedures. Further large prospective randomized trials are essential to better confirm the benefits and objectively clarify the role of imaging to guide musculoskeletal interventional procedures around the hip. KEY POINTS: • Expert consensus produced a list of 10 evidence-based statements on clinical indications of image-guided interventional procedures around the hip. • The highest level of evidence was only reached for one statement. • Strong consensus was obtained for all statements.

Factors associated with short-term mortality after emergency department care of residents living in aged care homes: findings from the multicenter Caregency study. / Factores asociados con mortalidad a corto plazo en personas que viven en residencias atendidas en servicios de urgencias: resultados del estudio multicéntrico Caregency.

OBJECTIVES: To evaluate short-term mortality in people transferred from aged care homes for treatment in a hospital emergency department (ED) and to analyze factors associated with mortality. MATERIAL AND METHODS: Multicenter study of a random sample of retrospective data of patients treated in 5 EDs in Catalonia in 2017. The patients were over the age of 65 years and lived in residential care facilities. In addition to short-term mortality (in the ED or within 30 days of discharge), we analyzed sociodemographic characteristics, prior functional and cognitive status, multimorbidity, triage level on arrival, length of stay in the ED, and hospital admission. Odds ratios (ORs) for factors associated with short-term mortality were calculated by multivariate regression analysis. RESULTS: A total of 2444 ED admissions were analyzed. The patients' mean (SD) age was 85.9 (7.1) years, and 67.7% .were women. Short-term mortality (in 15.5%) was associated with age >90 years (OR, 1.50; 95% CI, 1.5-1.95 years), a Charlson index >2 (OR, 1.47; 95% CI, 1.14-1.90), and dependency assessed as moderate (OR, 1.50; 95% CI, 1.03- 2.20) or severe (OR, 2.56; 95% CI, 1.84-3.55). Other associated factors were a higher level of urgency on triage, duration of ED stay, and hospital admission. CONCLUSION: Aged residents with the characteristics associated with short-term mortality could benefit from interventions for potentially avoiding unnecessary transfers to an ED, and from the implementation of comprehensive geriatric care within the ED. This could be useful to support good quality of care at the end of life.

OBJETIVO: Evaluar la frecuencia y los factores asociados con la mortalidad a corto plazo de personas que viven en residencias tras ingreso en urgencias. METODO: Análisis retrospectivo multicéntrico de una muestra aleatoria de admisiones de personas $ 65 años que viven en residencias en cinco servicios de urgencias de Cataluña, a lo largo de 2017. Se analizaron características sociodemográficas, el estado funcional y cognitivo previo, multimorbilidad, nivel de triaje de las urgencias, duración de la estancia en urgencias, hospitalización y mortalidad a corto plazo (en urgencias o en los 30 días posteriores al alta). Se utilizó un análisis de regresión multivariante para investigar los factores asociados con la mortalidad a corto plazo. RESULTADOS: Se analizaron 2.444 admisiones en urgencias, con una edad media de 85,9 (DE 7,1) años, 67,7% mujeres. La mortalidad a corto plazo (15,5%) se asoció con una edad > 90 años (OR 1,50; IC 95%: 1,5-1,95), un índice de Charlson > 2 (OR 1,47; IC 95%: 1,14-1,90), y un grado de dependencia moderado (OR 1,50; IC 95%: 1,03-2,20) y grave (OR 2,56; IC 95%: 1,84-3,55). También se asoció con un mayor nivel de triaje de la urgencia, duración de la estancia en urgencias e ingreso en planta de hospitalización. CONCLUSIONES: Los ancianos residentes con las características descritas podrían beneficiarse especialmente de intervenciones dirigidas a la prevención de traslados potencialmente innecesarios a urgencias y a la implementación de una atención integral geriátrica dentro de los servicios de urgencias, a fin de garantizar una buena calidad de los cuidados en fases finales de la vida.

Comparison of the diagnostic accuracy of diffusion-weighted and dynamic contrast-enhanced MRI with 18F-FDG PET/CT to differentiate osteomyelitis from Charcot neuro-osteoarthropathy in diabetic foot.

PURPOSE: To compare the diagnostic accuracy of diffusion-weighted imaging (DWI) and dynamic contrast-enhanced-magnetic resonance imaging (DCE-MRI) involving two region of interest (ROI) sizes with 18-fluorodeoxyglucose positron emission tomography/computed tomography (18F-FDG PET/CT) to differentiate diabetic foot osteomyelitis (DFO) from Charcot neuro-osteoarthropathy (CN). METHOD: Thirty-one diabetic patients were included in this prospective study. Two readers independently evaluated DWI (apparent diffusion coefficient [ADC] and high-b-value signal pathological-to-normal bone ratio [DWIr]) and DCE-MRI parameters (Ktrans, Kep, Ve, internal area under the gadolinium curve at 60 s [iAUC60] and time intensity curve [TIC]) using two different ROI sizes, and 18F-FDG PET/CT parameters (visual assessment, SUVmax, delayed SUVmax, and percentage changes between SUVmax and delayed SUVmax). Techniques were compared by univariate analysis using the area under the receiver operating characteristic curve [AUC]. Reliability was analyzed with Kappa and Intraclass correlation [ICC]. RESULTS: DWIr, Ktrans and iAUC60 showed better diagnostic accuracy (AUC = 0.814-0.830) and reliability (ICC > 0.9) for large than for small ROIs (AUC = 0.736-0.750; ICC = 0.6 in Ktrans, 0.8 in DWIr and iAUC60). TIC showed moderate diagnostic performance (AUC = 0.739-0.761) and reliability (κ 0.7). Visual assessment of 18F-FDG PET/CT demonstrated a significantly higher accuracy (AUC = 0.924) than MRI parameters. Semi-quantitative 18F-FDG PET/CT parameters did not provide significant improvement over visual analysis (AUC = 0.848-0.903). CONCLUSION: DWIr, Ktrans and iAUC60 allowed reliable differentiation of DFO and CN, particularly for large ROIs. Visual assessment of 18F-FDG PET/CT was the most accurate technique for differentiation.

Value of multidetector computed tomography for the differentiation of delayed aseptic and septic complications after total hip arthroplasty.

OBJECTIVE: The differentiation between delayed aseptic and septic complications of total hip arthroplasty is crucial to allow appropriate surgical planning and timely antimicrobial treatment. The aim of this study was to investigate the utility of multidetector computed tomography (CT) findings to diagnose aseptic mechanical loosening, granulomatous reaction, and periprosthetic joint infection in patients who underwent total hip arthroplasty before revision surgery. MATERIALS AND METHODS: Ninety-six consecutive patients with a clinical suspicion of periprosthetic complications underwent revision surgery over an 8-year period. All patients had been evaluated preoperatively using multidetector CT without contrast media. Two blinded musculoskeletal radiologists reviewed multidetector CT images, including periprosthetic soft-tissue accumulation, prosthetic acetabular malposition, periprosthetic osteolysis, enlarged iliac lymph nodes, and heterotopic ossification. Risk factors for aseptic and septic loosening were identified using multivariate analysis. RESULTS: Multidetector CT-related variables independently associated with periprosthetic joint infection were high periprosthetic soft-tissue accumulation, periprosthetic osteolysis without expansile periosteal reaction and enlarged iliac lymph nodes. On the other hand, the absence of the following radiological signs: low or high periprosthetic soft-tissue accumulation, mild or severe periprosthetic osteolysis, and enlarged iliac lymph nodes, were predictors of aseptic mechanical loosening. Low periprosthetic soft-tissue accumulation, severe periprosthetic osteolysis with expansile periosteal reaction, and mild acetabular malposition were significant variables associated with granulomatosis. CONCLUSION: Multidetector CT findings are useful to differentiate between aseptic and septic complications before revision surgery. The presence of osteolysis with expansile periosteal reaction appeared to be a time-dependent variable.

Update on Whole-body MRI in Musculoskeletal Applications.

Whole-body magnetic resonance imaging (WB-MRI) is a powerful tool increasingly used to assess oncologic and nononcologic diseases. WB-MRI provides information about diffuse multifocal pathologies with excellent anatomical definition through high soft tissue contrast and spatial resolution as well as valuable functional information from diffusion-weighted images. In addition to its roles in establishing the diagnosis and assessing the extent and severity of disease, WB-MRI is also useful for monitoring the response to treatment for malignant and benign systemic diseases affecting the musculoskeletal system. This article reviews and updates the applications of WB-MRI in current practice, discussing the role of this helpful tool in various conditions involving the musculoskeletal system including bone metastases, hematologic cancers, inflammatory processes, infections, and multisystemic-multifocal bone, nerve, vascular, and muscle/soft tissue disorders, as well as other idiopathic conditions.

Accuracy of Computed Tomography-Guided Joint Aspiration and Computed Tomography Findings for Prediction of Infected Hip Prosthesis.

BACKGROUND: Infection after total hip arthroplasty remains a diagnostic challenge. We assessed the accuracy of computed tomography (CT)-guided joint aspiration combined with CT findings for prediction of septic hip prosthesis before revision surgery. METHODS: A total of 96 patients (64.6% men; mean age, 68 years) scheduled for elective revision surgery due to suspicion of infection after total hip arthroplasty underwent CT-guided joint aspiration. Volume and microbiological cultures of aspirated fluid and salient findings on CT scans, including periprosthetic soft-tissue mass, malpositioning of the prosthesis, periprosthetic osteolysis, reactive enlarged lymph nodes, and heterotopic ossification, were assessed by a blinded radiologist. RESULTS: Septic hip prosthesis was shown on revision surgery in 35 patients (36.4%), with Staphylococcus epidermidis isolated in 54.3% of cases. Culture of the aspirated fluid yielded the same microorganism in 24 patients (68.6%). The accuracy of preoperative CT-guided joint aspiration was 86.5%. High volume (>1 mL) of aspirated fluid was recorded in 32 patients (33.3%). In the multivariate analysis, high volume on CT aspiration, accumulation of soft tissue exceeding the joint margin, osteolysis without bone insufflation, and enlarged iliac lymph nodes were significant predictors of infected hip prosthesis. Similar results were obtained after adjustment of the model by the presence of aggressive granulomatosis. CONCLUSION: Preoperative CT-guided joint aspiration is accurate to diagnose septic hip prosthesis based on CT imaging findings and volume and bacterial culture of the aspirated fluid. Enlarged iliac lymph nodes emerged as a strong predictor of infection.