Presence of subchondral fracture in cases diagnosed as transient osteoporosis of the hip: a retrospective independent reader-based study.

OBJECTIVE: Transient osteoporosis of the hip (TOH) is an uncommon, typically self-limited diagnosis of uncertain etiology. We hypothesize that TOH represents an underlying subchondral fracture, and a discrete fracture line can often be detected on high-resolution MRI. MATERIALS AND METHODS: A retrospective PACS query identified patients meeting imaging criteria for TOH with intense bone marrow edema (BME) in the femoral head on MRI. Those with poor quality studies, other underlying pathologies, or antecedent trauma were excluded. Three musculoskeletal radiologists independently reviewed each case for presence of a definite subchondral fracture line on small field of view (FOV) MR images of the affected hip. Extent of BME, reciprocal acetabular BME, and joint effusion size were also recorded. Binomial logistic regression was performed to determine statistically significant predictors of subchondral fracture. RESULTS: Fifty patients met inclusion criteria (29 females, 0 pregnant). Mean age was 62±12 years (range 35-84). Average duration of symptoms before MRI was 102±135 days. Ten patients had bone densitometry within 2 years of MRI, six demonstrating osteopenia or osteoporosis. Subchondral fractures were unanimously identified in 44/50 (88%). Interclass correlation coefficient with absolute agreement was 0.73, 95% CI (0.57-0.84), indicating near-excellent agreement. Most cases demonstrated a large joint effusion (23/50, 46%) and acetabular BME (31/50, 62%). Increasing size of joint effusion was a statistically significant predictor of subchondral fracture (p=0.05), with 6.9 higher odds. There was a strong correlation with osteopenia/osteoporosis and fracture (p<0.001). CONCLUSION: Discrete subchondral fractures were identified unanimously on small FOV imaging in the majority of TOH cases.

Effect of Preoperative MRI Coracoid Dimensions on Postoperative Outcomes of Latarjet Treatment for Anterior Shoulder Instability.

Background: Preoperative coracoid dimensions may affect the size of the bone graft transferred to the glenoid rim and thus the postoperative outcomes of Latarjet coracoid transfer. Purpose: To determine the effect of coracoid length and width as measured on preoperative magnetic resonance imaging (MRI) on outcomes after Latarjet treatment of anterior shoulder instability. Study Design: Cohort study; Level of evidence, 3. Methods: Included were patients who underwent primary Latarjet surgery between 2009 and 2019 and had preoperative MRI scans and minimum 2-year postoperative outcomes. Longitudinal coracoid length was measured on axial MRI sequences as the distance from the coracoclavicular ligament insertion to the distal tip. Comparisons were made between shorter and longer coracoids and between narrower and wider coracoids. The outcomes of interest were recurrent instability, reoperation, complications, return to sport (RTS), and American Shoulder and Elbow Surgeons (ASES) score. Independent-samples t test, Mann-Whitney test, chi-square test, and Fisher exact test were used to compare outcomes between groups, and univariate correlation coefficients were calculated to evaluate the relationships between demographics and coracoid dimensions. Results: Overall, 56 patients were included (mean age, 28.4 years). The mean ± SD coracoid length was 21.6 ± 2.4 mm and width 10.0 ± 1.0 mm. Relative to patients with a longer coracoid (≥22 mm; n = 26), patients with a shorter coracoid (<22 mm; n = 30) had similar rates of recurrent instability (shorter vs longer; 6.7% vs 3.8%), complications (10.0% vs 15.4%), reoperation (3.3% vs 7.7%), and RTS (76.5% vs 58.8%) and similar postoperative ASES scores (85.0 vs 81.6) (P ≥ .05 for all). Likewise, relative to patients with a wider coracoid (≥10 mm; n = 27), patients with a narrower coracoid (<10 mm; n = 29) had similar prevalences of recurrent instability (narrower vs wider; 6.9% vs 3.7%), complications (17.2% vs 7.4%), reoperation (3.5% vs 7.4%), and RTS (66.7% vs 68.4%) and similar postoperative ASES scores (87.1 vs 80.0) (P ≥ .05 for all). Conclusion: Patients undergoing Latarjet coracoid transfer had similar postoperative outcomes regardless of preoperative coracoid dimensions. These findings should be confirmed in a larger cohort before further clinical recommendations are made.

Potential clinical impact of reporting breast arterial calcifications on screening mammograms in women without known coronary artery disease.

Cardiovascular disease remains a leading cause of death in women. 10-year likelihood for a cardiovascular event is determined by the American College of Cardiology Atherosclerotic Cardiovascular disease risk score calculator (ASVCD); however, this does not encompass risk factors unique to women. Breast arterial calcifications (BAC) detected on screening mammography may serve as a proxy for coronary atherosclerosis (CAC) in women. Our purpose was to investigate the correlation between BAC and CAC on imaging in women without a diagnosis of atherosclerosis to determine the potential clinical impact. Retrospective review was performed on a cohort of females evaluated by internists at our institution in 2019. Study patients had a screening mammogram within 1 year of a noncardiac chest CT. Clinical data were collected to determine ASCVD risk score. Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of BAC in detecting CAC were determined. 222 women met inclusion criteria, ranging from 41 to 77 years of age, among which 25% (56/222) had BAC. 84% (47/56) of women with BAC had CAC on CT, yielding a sensitivity, specificity, PPV, and NPV of 51%, 93%, 84%, and 72%, respectively. Of the 47 patients who had both BAC and CAC, 66% had an unknown or low-to-borderline ASCVD score. Women with BACs have a high specificity for CAC. The reporting of BACs should prompt clinicians to risk stratify women for atherosclerotic disease. These women may otherwise be undetected by conventional risk calculators.

Prevalence of lateral patellofemoral maltracking and associated complications in patients with Osgood Schlatter disease.

OBJECTIVE: To evaluate adults with history of Osgood Schlatter disease (OSD) for imaging features of lateral patellofemoral maltracking. METHODS: In a span of four years, 10,181 unique non-contrast knee MRIs were performed on patients aged 20-50. Patients with acute trauma, prior surgery, and synovial pathologies were excluded. 171 exams had imaging findings of OSD, and an age-matched control group of 342 patients without OSD was randomly selected. Two radiologists retrospectively reviewed MRIs for features of lateral patellofemoral maltracking. Maltracking was defined as edema in superolateral Hoffa's fat or a tibial tuberosity-trochlear groove (TT-TG) distance ≥20 mm with either patellar tilt/translation. Binomial logistic regression identified predictors of maltracking in OSD. Optimal TT-TG distance to indicate maltracking was determined by receiver operating characteristic curve. RESULTS: 59% (101/171) of the knees with OSD showed findings of maltracking, with patella alta, trochlear dysplasia, and quadriceps tendinosis as significant predictors of maltracking (p < 0.001). Patellofemoral chondrosis was present in 63% (107/171), with maltracking contributing to higher grade chondrosis more so than increasing age (OR 8.4 versus 1.07). 13 mm was the optimal cut-off TT-TG distance to indicate maltracking (sensitivity 83%, specificity 80%). The prevalence of maltracking in the control group was 15% (p < 0.001 compared with the OSD group). CONCLUSION: Adults with sequelae of OSD are at high risk of maltracking and are likely to develop patellofemoral chondrosis. A lower threshold for identifying maltracking patients, including a lower cut-off TT-TG distance can help identify those at risk. Radiologists should maintain a high index of suspicion for maltracking in adults with OSD to guide clinical intervention.

Minimally Invasive Ultrasound-Guided Carpal Tunnel Release Improves Long-Term Clinical Outcomes in Carpal Tunnel Syndrome.

BACKGROUND. Ultrasound guidance allows performance of carpal tunnel release with smaller incisions and quicker recovery than traditional open or endoscopic surgery. OBJECTIVE. The purpose of this study was to evaluate the long-term effectiveness of ultrasound-guided carpal tunnel release in improving function and discomfort in patients with carpal tunnel syndrome. METHODS. Retrospective review was conducted of 61 ultrasound-guided carpal tunnel release procedures performed on 46 patients (15 bilateral procedures) with clinically diagnosed carpal tunnel syndrome. The procedures were performed with a single-use transection device and local anesthesia at an outpatient radiology office. Patients answered three questionnaires (Quick Disabilities of the Arm, Shoulder, and Hand [QDASH] and two parts of the Boston Carpal Tunnel Syndrome Questionnaire-the symptom severity [BCTSQ-SS] and functional status [BCTSQ-FS] scales) to assess the function of and discomfort in the affected wrist immediately before and 2 weeks and at least 1 year after the procedure. Higher scores indicated increasing disability. Patients also answered a global satisfaction question at follow-up. Preprocedure and postprocedure scores were compared by paired Wilcoxon signed rank tests. RESULTS. The 46 patients (25 women, 21 men; mean age, 60.6 years; range, 21-80 years) had median preprocedure scores of 45.4 for QDASH, 3.2 for BCTSQ-SS, and 2.5 for BCTSQ-FS. The median scores 2 weeks after the procedure were 22.5 for QDASH, 1.7 for BCTSQ-SS, and 1.9 for BCTSQ-FS. All scores decreased (p < .001) from preprocedure scores and surpassed reference standards for clinically important difference in scores. Follow-up questionnaires obtained for 90% (55/61) of wrists a median of 1.7 years (range, 1.0-2.8 years) after the procedure showed further declines (p < .001) in median scores: 2.3 for QDASH, 1.2 for BCTSQ-SS, and 1.1 for BCTSQ-FS. At long-term follow-up evaluation, 96% (52/54) of wrists had lower QDASH and 98% (53/54) had lower BCTSQ (average of BCTSQ-SS and BCTSQ-FS) scores compared with the preprocedure scores. Among the patients who participated in the survey, 93% (37/40) were satisfied or very satisfied with the long-term outcomes. No immediately postoperative complications occurred. Two patients needed surgical intervention 8 and 10 days after surgery, one for infection after injury and one for posttraumatic compartment syndrome. CONCLUSION. Ultrasound-guided carpal tunnel release quickly improves hand function and reduces hand discomfort; improvement persists beyond 1 year. CLINICAL IMPACT. Ultrasound-guided carpal tunnel release may be a safe, effective, and less invasive alternative to traditional surgery.

Painful type II os naviculare: introduction of a standardized, reproducible classification system.

OBJECTIVE: To provide a novel MRI classification system for the symptomatic type II os naviculare by creating a standardized grading of associated bone marrow edema (BME) and correlating with patient symptoms. METHODS: BME was classified on an ordinal scale: grade 1, faint signal immediately adjacent to the synchondrosis; grade 2, intermediate signal within the os and navicular tuberosity without extending to the navicular body; grade 3, intense signal extending to the navicular body. BME on 59 MRIs was independently graded by three radiologists. Inter- and intra-observer agreement was analyzed using intraclass correlation coefficient. Univariate and multivariate analyses assessed for patient and imaging characteristics predictive of subjective pain score. A cohort of 82 patients without BME represented a control group. RESULTS: Inter-observer agreement of BME grade was 0.95 (CI 0.93-0.97) and intra-observer was 0.92 (CI 0.87-0.96), indicating excellent agreement. In patients with BME, predictors of more severe pain were longer duration of pain (p = 0.02) and presence of soft tissue edema overlying the os naviculare (p < 0.001). One hundred percent of subjects with BME localized their pain to the medial midfoot (59/59) versus 25.6% (21/82) of controls (p < 0.001). CONCLUSIONS: This novel grading system provides reliable quantification of BME associated with os naviculare, which is a specific cause of medial foot/ankle pain. Early diagnosis is important as pain severity worsens with longer duration of symptoms. Pain severity is correlated with soft tissue edema overlying the os, which may be secondary to extrinsic compression, reactive to biomechanical stress, or reflect direct trauma.

Recent Trends in Medicare Reimbursements to Nonradiologist Physicians for In-Office MRI and CT.

PURPOSE: Previous studies demonstrated rapid growth in payments to nonradiologist providers (NRPs) for MRI and CT in their private offices. In this study, we re-examine the trends in these payments. METHODS: The nationwide Medicare Part B master files from 2004 to 2016 were accessed. They provide payment data for all Current Procedural Terminology codes. Codes for MRI and CT were selected. Global and technical component claims were counted. Medicare specialty codes identified payments made to NRPs and radiologists, and place-of-service codes identified payments directed to their private offices. RESULTS: Medicare MRI payments to NRPs peaked in 2006 at $247.7 million. As a result of the Deficit Reduction Act, there was a sharp drop to $189.5 million in 2007, eventually declining to $101.6 million by 2016 (-59% from peak in 2006). The NRP specialty groups with the highest payments for MRI ownership include orthopedists, neurologists, primary care physicians, and hospital-based specialists (pathology, physiatry, and hospitalists). Medicare CT payments to NRPs peaked in 2008 at $284.1 million and declined to $94.7 million in 2016 (-67% from peak). Cardiologists, primary care physicians, internal medicine specialists, urologists, and medical oncologists accounted for the most payments made to NRPs. Dollars paid to radiologists for private office MRI and CT dropped substantially since they peaked in 2006. CONCLUSIONS: NRP private offices (and radiology offices also) experienced massive decreases in Medicare payments for MRI and CT since peaking in 2006 and 2008, respectively. These trends suggest the financial viability of private office practice may be in jeopardy. However, certain recent policy changes could promote a resurgence.

Prostate Contrast Enhanced Transrectal Ultrasound Evaluation of the Prostate With Whole-Mount Prostatectomy Correlation.

OBJECTIVE: To investigate the diagnostic accuracy of contrast enhanced transrectal ultrasound (CE-TRUS) in comparison with whole-mount radical prostatectomy specimens. METHOD AND MATERIALS: Fifty-eight subjects who underwent CE-TRUS and subsequent radical prostatectomy with whole-mount pathology were included in the study. Each patient underwent evaluation with baseline TRUS and again during CE-TRUS with intravenous infusion of perflutren lipid microsphere (Definity, Lantheus Medical Imaging, N Billerica, MA). A subjective 5 point scale was used to rate each sextant of the prostate in 3 baseline imaging modes and in 5 contrast-enhanced imaging modes. Baseline TRUS and CE-TRUS findings were compared with digitized whole-mount findings. A clustered logistic regression model was computed to compare the area under the receiver operating characteristic curve (Az) for detection of prostate cancer by various modes of ultrasound imaging. RESULTS: Among the 58 whole-mount specimens, a maximum Gleason score of 6 was identified in 29 subjects, a score of 7 was identified in 24 and a score of 8 was identified in 5. The Az for baseline TRUS parameters was 0.55 for grayscale, 0.61 for color Doppler and 0.59 for power Doppler. CE-TRUS parameters demonstrated significant increases in Az with the highest Az for CE-power Doppler (0.66) and flash replenishment imaging (0.64) (P = .04 for comparison to baseline). The combination of CE-power Doppler and flash replenishment imaging resulted in improved Az compared with baseline imaging (0.70 vs 0.59, P= .006). CONCLUSION: Contrast-enhanced ultrasonography demonstrates greater diagnostic accuracy than baseline imaging. Diagnostic accuracy is further improved for "clinically significant" tumor volumes >1 cc.

The role of liver-directed surgery in patients with hepatic metastasis from a gynecologic primary carcinoma.

BACKGROUND: The management of patients with liver metastasis from a gynecologic carcinoma remains controversial, as there is currently little data available. We sought to determine the safety and efficacy of liver-directed surgery for hepatic metastasis from gynecologic primaries. METHODS: Between 1990 and 2010, 87 patients with biopsy-proven liver metastasis from a gynecologic carcinoma were identified from an institutional hepatobiliary database. Fifty-two (60%) patients who underwent hepatic surgery for their liver disease and 35 (40%) patients who underwent biopsy only were matched for age, primary tumor characteristics, and hepatic tumor burden. Clinicopathologic, operative, and outcome data were collected and analyzed. RESULTS: Of the 87 patients, 30 (34%) presented with synchronous metastasis. The majority of patients had multiple hepatic tumors (63%), with a median size of the largest lesion being 2.5 cm. Of those patients who underwent liver surgery (n=52), most underwent a minor hepatic resection (n=44; 85%), while 29 (56%) patients underwent concurrent lymphadenectomy and 45 (87%) patients underwent simultaneous peritoneal debulking. Postoperative morbidity and mortality were 37% and 0%, respectively. Median survival from time of diagnosis was 53 months for patients who underwent liver-directed surgery compared with 21 months for patients who underwent biopsy alone (n=35) (p=0.01). Among those patients who underwent liver-directed surgery, 5-year survival following hepatic resection was 41%. CONCLUSIONS: Hepatic surgery for liver metastasis from gynecologic cancer can be performed safely. Liver surgery may be associated with prolonged survival in a subset of patients with hepatic metastasis from gynecologic primaries and therefore should be considered in carefully selected patients.