Contrast flow in CT-guided lumbar interlaminar epidural steroid injections: does needle position effect the laterality of contrast flow?

PURPOSE: To evaluate the effect of needle position on the laterality of contrast flow in CT-guided lumbar interlaminar epidural steroid injections. MATERIALS AND METHODS: A retrospective review of consecutive CT-guided interlaminar lumbar epidural steroid injections was performed. The terminal needle tip position (midline or lateral) and the laterality of epidural contrast were evaluated by two readers. Contrast flow pattern was classified as ipsilateral to needle trajectory, bilateral, or contralateral. Bilateral flow was further divided into asymmetric, symmetrical, or asymmetric to the contralateral side. Inter-reader agreement was calculated with the kappa statistic. The relationship of needle position to contrast laterality was calculated with the chi statistic. Pain scores were compared for bilateral and unilateral flows with a two-tailed T test for independent means. RESULTS: A total of 250 injections were included in 204 patients, with an age range of 24 to 93 years. The most commonly injected level (145/250) was L4-L5. Agreement between the two readers was almost perfect and substantial (kappa 0.751-0.880). The majority of injections (154/250) demonstrated contrast flow ipsilateral to the needle trajectory, 90/250 demonstrated bilateral flow, and 6/250 had contralateral flow. Of the 90 cases with bilateral flow, 80% were performed with a midline terminal needle position (p < 0.001). There was no difference in immediate post-procedure pain scores between patients with ipsilateral or bilateral contrast flow. CONCLUSION: For interlaminar epidural steroid injections, a midline terminal needle tip position has a greater probability of producing bilateral contrast flow compared to a lateral terminal needle tip position.

Deep learning discrimination of rheumatoid arthritis from osteoarthritis on hand radiography.

PURPOSE: To develop a deep learning model to distinguish rheumatoid arthritis (RA) from osteoarthritis (OA) using hand radiographs and to evaluate the effects of changing pretraining and training parameters on model performance. MATERIALS AND METHODS: A convolutional neural network was retrospectively trained on 9714 hand radiograph exams from 8387 patients obtained from 2017 to 2021 at seven hospitals within an integrated healthcare network. Performance was assessed using an independent test set of 250 exams from 146 patients. Binary discriminatory capacity (no arthritis versus arthritis; RA versus not RA) and three-way classification (no arthritis versus OA versus RA) were evaluated. The effects of additional pretraining using musculoskeletal radiographs, using all views as opposed to only the posteroanterior view, and varying image resolution on model performance were also investigated. Area under the receiver operating characteristic curve (AUC) and Cohen's kappa coefficient were used to evaluate diagnostic performance. RESULTS: For no arthritis versus arthritis, the model achieved an AUC of 0.975 (95% CI: 0.957, 0.989). For RA versus not RA, the model achieved an AUC of 0.955 (95% CI: 0.919, 0.983). For three-way classification, the model achieved a kappa of 0.806 (95% CI: 0.742, 0.866) and accuracy of 87.2% (95% CI: 83.2%, 91.2%) on the test set. Increasing image resolution increased performance up to 1024 × 1024 pixels. Additional pretraining on musculoskeletal radiographs and using all views did not significantly affect performance. CONCLUSION: A deep learning model can be used to distinguish no arthritis, OA, and RA on hand radiographs with high performance.

Transcatheter arterial tendinopathy embolization as a treatment for painful and refractory tendinopathy: a systematic review and meta-analysis.

OBJECTIVE: Transcatheter arterial embolization (TAE) is a novel minimally invasive therapy for painful tendinopathy in patients with pain refractory to conservative management. The purpose of this study was to evaluate evidence on the efficacy of TAE for tendinopathy related pain. MATERIALS AND METHODS: Using Embase, PubMed, and Web of Science, a systematic review and meta-analysis was performed to identify studies evaluating TAE for painful tendinopathy. The primary outcome measure was change in pain scale score at 6 months. A Ratio of Means (ROM) was used to compare the effect size post treatment as compared to baseline. The Visual Analog Scale (VAS) was used as the metric for comparison. RESULTS: After screening titles, abstracts, and the full text, 5 studies met inclusion criteria. A total of 97 tendinopathy embolization procedures performed in 74 patients were included. Patients who underwent TAE demonstrated declines in VAS ROM at 1 day 0.53 [95% CI 0.31,0.88], 1 week (0.51 [95% CI 0.32,0.79]), 1 month (0.45 [95% CI 0.29, 0.71]), 3-4 months (0.33 [95% CI 0.22,0.48]), and 6 months following embolization (0.18[95% CI 0.13,0.26]), respectively. DISCUSSION: TAE provides substantial short-term reductions in pain scores for patients suffering with refractory tendinopathy related pain of the rotator cuff, elbow extensor and flexor, Achilles, and patellar tendons.

Radiation dose of fluoroscopy-guided versus ultralow-dose CT-fluoroscopy-guided lumbar spine epidural steroid injections.

OBJECTIVE: Compare radiation dose of lumbar spine epidural steroid injections (ESIs) performed under fluoroscopy guidance and ultralow-dose CT-fluoroscopy guidance. MATERIALS AND METHODS: Retrospective review of consecutive lumbar ESIs performed using fluoroscopy, between May 2017 and April 2019, and using ultralow-dose CT-fluoroscopy, between August 2019 and February 2021, was performed. Ultralow-dose CT-fluoroscopy technique omits a planning CT scan, utilizes CT-fluoroscopy, and minimizes radiation dose parameters. Patient characteristics (age, sex, height, weight, body mass index (BMI)), procedural characteristics (anatomic level, type of ESI, procedure time, pain reduction, complications, trainee participation), and radiation dose were compared. Chi-square tests and two-sample t-tests were performed for statistical analysis. RESULTS: One hundred and forty-seven patients (mean age 55.8 ± 16.7; 85 women) underwent ESIs using fluoroscopy. Sixty-six patients (mean age 60.9 ± 16.7; 33 women) underwent ESIs using ultralow-dose CT-fluoroscopy. The effective dose for the fluoroscopy group was 0.30 mSv ± 0.34, compared to 0.15 mSV ± 0.11 for ultralow-dose CT-fluoroscopy (p < 0.001). The average age in the CT-fluoroscopy group was older (p = 0.04), and there was more trainee participation in the fluoroscopy group (p < 0.001); otherwise there was no statistically significant difference in patient or procedural characteristics between the conventional fluoroscopy group and the ultralow-dose CT-fluoroscopy group. There was no statistically significant difference in immediate post-procedure pain reduction between the groups (p = 0.16). Four intrathecal injections occurred only in the fluoroscopy group, though this difference was not significant (p = 0.18). CONCLUSION: Ultralow-dose CT-fluoroscopy technique for image-guided lumbar spine ESIs can lower radiation dose compared to fluoroscopy-guided technique.

Diagnostic accuracy of pelvic radiographs for the detection of traumatic pelvic fractures in the elderly.

PURPOSE: Prompt identification of traumatic pelvic fractures in the elderly is critical to guide clinical management; however, the accuracy of pelvic radiographs is often compromised by multiple factors. The purpose of this study is to examine the diagnostic accuracy of radiographs for the detection of pelvic fractures, with CT as the standard of reference. METHODS: A retrospective review was performed of patients ≥ 65 years with traumatic pelvic fractures evaluated with both pelvic radiography and computed tomography (CT) from May 2016 to October 2019. Pelvic fractures were classified into fractures of the pubis, ilium, ischium, sacrum, and acetabulum. All pelvic radiographs were independently reviewed by two emergency radiologists. Original CT reports were utilized for the reference standard. RESULTS: 177 patients were included, with a total of 555 fractures. The mean age was 81 years and 68% were female. The most common mechanism of injury was fall (62%), followed by motor vehicle accidents (18%). The most fractured bone was the pubis (314/555 fractures). Global pooled sensitivity for pelvic radiographs in detecting pelvic fractures compared to CT was 48%, with a specificity of 93%. Sensitivity for the detection of pelvic fractures is classified by the following types: pubis 61%, acetabulum 60%, ilium 41%, sacrum 20%, and ischium 17%. Eighteen patients (10%) required surgical fixation. Mortality was 8%. CONCLUSION: Pelvic radiographs have low sensitivity in detecting traumatic pelvic fractures. These radiographically occult fractures may be clinically significant as a cause of long-term pain and may require orthopedic consultation and possible surgical management.

Simplified Universal Grading of Lumbar Spine MRI Degenerative Findings: Inter-Reader Agreement of Non-Radiologist Spine Experts.

OBJECTIVE: 1) To describe a simplified multidisciplinary grading system for the most clinically relevant lumbar spine degenerative changes. 2) To measure the inter-reader variability among non-radiologist spine experts in their use of the classification system for interpretation of a consecutive series of lumbar spine magnetic resonance imaging (MRI) examinations. METHODS: ATS multidisciplinary and collaborative standardized grading of spinal stenosis, foraminal stenosis, lateral recess stenosis, and facet arthropathy was developed. Our institution's picture archiving and communication system was searched for 50 consecutive patients who underwent non-contrast MRI of the lumbar spine for chronic back pain, radiculopathy, or symptoms of spinal stenosis. Three fellowship-trained spine subspecialists from neurosurgery, orthopedic surgery, and physiatry interpreted the 50 exams using the classification at the L4-L5 and L5-S1 levels. Inter-reader agreement was assessed with Cohen's kappa coefficient. RESULTS: For spinal stenosis, the readers demonstrated substantial agreement (κ = 0.702). For foraminal stenosis and facet arthropathy, the three readers demonstrated moderate agreement (κ = 0.544, and 0.557, respectively). For lateral recess stenosis, there was fair agreement (κ = 0.323). CONCLUSIONS: A simplified universal grading system of lumbar spine MRI degenerative findings is newly described. Use of this multidisciplinary grading system in the assessment of clinically relevant degenerative changes revealed moderate to substantial agreement among non-radiologist spine physicians. This standardized grading system could serve as a foundation for interdisciplinary communication.

Imaging of meniscal allograft transplantation: what the radiologist needs to know.

Meniscal allograft transplantation is an emerging surgical option for younger patients with symptomatic meniscal deficiency, which aims to restore anatomic biomechanics and load distribution in the knee joint, and by so doing to potentially delay accelerated osteoarthritis. In this review article, we summarize the structure and biomechanics of the native meniscus, describe indications and procedure technique for meniscal allograft transplantation, and demonstrate the spectrum of expected postoperative imaging and role of imaging to identify potential complications.

Do non-weight-bearing knee radiographs for chronic knee pain result in increased follow-up imaging?

OBJECTIVE: While weight-bearing radiographs are considered the optimal method for evaluation of joint spaces in osteoarthritis, non-weight-bearing radiographs are often performed. The purpose of this study is to evaluate the rate of follow-up radiographs in patients receiving non-weight-bearing radiographs for chronic knee pain in the outpatient setting, compared with patients receiving weight-bearing radiographs. MATERIALS AND METHODS: Consecutive patients who received non-weight-bearing knee radiographs for chronic knee pain between January 1, 2018, and June 15, 2019, were included. Exclusion criteria included trauma, concern for infection or tumor, and post-surgical radiographs. An age- and sex-matched control group of 100 patients who received weight-bearing knee radiographs was compiled. The proportion of follow-up radiographs within 1 year was compared between the study and control groups with chi-squared tests. RESULTS: Four hundred non-weight-bearing knee radiographic examinations were included. There were 74/400 (18.5%) follow-up radiographs within 12 months. All follow-up radiographs were weight-bearing. In the control group, 4/100 (4%) had follow-up weight-bearing radiographs within 1 year (p < 0.001). CONCLUSION: Outpatients who underwent non-weight-bearing knee radiographs for chronic pain had a higher frequency of repeat imaging than those who initially underwent weight-bearing knee radiographs. These results suggest that non-weight-bearing knee radiographs are of lower clinical utility compared with weight-bearing radiographs.

Clinical utility of a focused hip MRI for assessing suspected hip fracture in the emergency department.

PURPOSE: A focused hip MRI (FHMR) for the detection of radiographically occult hip fractures was implemented in our emergency department (ED) in 2013. The goal of this study was to assess the clinical utility of this protocol. METHODS: We retrospectively reviewed radiology reports of 262 unique patients who underwent 263 FHMR (coronal T1, coronal STIR, axial T2 fat saturated) for suspected hip fracture in the ED from October 2013 to March 2020. Electronic medical records were reviewed for the ED course, follow-up imaging, and clinical management within 90 days. RESULTS: Seventy-one patients had one or more fractures identified by FHMR: one-third had proximal femoral fractures; two-third had pelvic fractures. Of these 71 patients, 53 (74%) had radiographically occult fractures, including 14 (20%) with occult proximal femoral fractures; 4 patients had fractures occult on CT. Nineteen patients with a suspected fracture on radiography were found to have no fracture on FHMR. Four fractures not reported on FHMR were later seen on follow-up imaging: these included 1 isolated greater trochanter, 1 additional ischial tuberosity, 1 additional superior pubic ramus, and 1 additional sacrum. All four fractures were treated non-operatively. Muscle/tendon injury was the most common type of injury, seen in 50% (130/262) patients with the most commonly torn tendons being the hamstring (44%; 15/34) followed by gluteus medius tendon (18%; 6/34). A full-hip or pelvis MRI was done after FHMR in only 5 patients, primarily for the purpose of better characterizing findings already identified on FHMR (2 for fracture, 2 for tendon injury, 1 for soft tissue metastasis). Only one of these five studies provided new information: ruling out a previously questioned fracture. Clinical management of the vast majority of patients was based solely on findings from the FHMR. CONCLUSIONS: FHMR offers reliable identification of radiographically occult hip fractures and muscle/tendon injuries. The protocol is well trusted in guiding patient management in our ED.

Bone Marrow Edema at Dual-Energy CT: A Game Changer in the Emergency Department.

Dual-energy CT is increasingly being used in the emergency department to help diagnose acute conditions. Its applications include demonstrating bone marrow edema (BME) seen in the setting of occult fractures and other acute conditions. Dual-energy CT acquires data with two different x-ray energy spectra and is able to help differentiate materials on the basis of their differential energy-dependent x-ray absorption behaviors. Virtual noncalcium (VNCa) techniques can be used to suppress the high attenuation of trabecular bone, thus enabling visualization of subtle changes in the underlying attenuation of the bone marrow. Visualization of BME can be used to identify occult or mildly displaced fractures, pathologic fractures, metastases, and some less commonly visualized conditions such as ligamentous injuries or inflammatory arthritis. The authors' major focus is use of dual-energy CT as a diagnostic modality in the setting of trauma and to depict subtle or occult fractures. The authors also provide some scenarios in which dual-energy CT is used to help diagnose other acute conditions. The causes and pathophysiology of BME are reviewed. Dual-energy CT image acquisition and VNCa postprocessing techniques are also discussed, along with their applications in emergency settings. The authors present potential pitfalls and limitations of these techniques and their possible solutions.©RSNA, 2020.

Clinical utility of a postprocedural CT scan in CT-guided musculoskeletal biopsies.

OBJECTIVE: The purpose of this study is first to determine the clinical utility of the postprocedure scan in detecting postinterventional complications after CT-guided musculoskeletal biopsies, and second to evaluate the contribution to the radiation dose of the postprocedural CT scan. MATERIALS AND METHODS: Retrospective analysis of 500 consecutive CT-guided musculoskeletal biopsies over an 18-month period from 29 March 2017 to 28 September 2018, where spiral postprocedure scans were obtained in every case. To assess the clinical utility of postinterventional CT scans, it was determined whether immediate post-procedural complications were detected on the postprocedural scans only or were also seen on the procedural images. To evaluate the relative radiation exposure of postprocedural scans, a ratio was obtained of the dose-length product (DLP) of the postprocedural scan compared with the total DLP of each case. RESULTS: A total of 397 bone biopsies and 103 soft-tissue biopsies were performed in 471 patients. The immediate postprocedural complication rate was 0.4% (2 out of 500) in all procedures. Both complications were minor (small hematomas) and detected only on postinterventional CT scans. The average total DLP for the procedures was 383.5 mGy*cm. The average DLP of the postprocedural scan was 64.0 mGy*cm. The average radiation dose contribution of the postprocedural CT scans toward the total DLP was 17.4%. CONCLUSION: Immediate postprocedural complications in CT-guided musculoskeletal interventions are rare. When complications do occur, they are usually minor. To substantially reduce radiation dose, postinterventional CT scans should not be performed routinely.

Current applications and future directions of deep learning in musculoskeletal radiology.

Deep learning with convolutional neural networks (CNN) is a rapidly advancing subset of artificial intelligence that is ideally suited to solving image-based problems. There are an increasing number of musculoskeletal applications of deep learning, which can be conceptually divided into the categories of lesion detection, classification, segmentation, and non-interpretive tasks. Numerous examples of deep learning achieving expert-level performance in specific tasks in all four categories have been demonstrated in the past few years, although comprehensive interpretation of imaging examinations has not yet been achieved. It is important for the practicing musculoskeletal radiologist to understand the current scope of deep learning as it relates to musculoskeletal radiology. Interest in deep learning from researchers, radiology leadership, and industry continues to increase, and it is likely that these developments will impact the daily practice of musculoskeletal radiology in the near future.

Temporomandibular joint imaging: current clinical applications, biochemical comparison with the intervertebral disc and knee meniscus, and opportunities for advancement.

Temporomandibular disorders encompass multiple pathologies of the temporomandibular joint that manifest as middle/inner ear symptoms, headache, and/or localized TMJ symptoms. There is an important although somewhat limited role of imaging in the diagnostic evaluation of temporomandibular disorders. In this manuscript, we provide a comprehensive review of TMJ anatomy, outline potentially important features of TMJ disc ultrastructure and biochemistry in comparison with the intervertebral disc and knee meniscus, and provide imaging examples of the TMJ abnormalities currently evaluable with MRI and CT. In addition, we provide an overview of emerging and investigational TMJ imaging techniques in order to encourage further imaging research based on the biomechanical alterations of the TMJ disc.

Tibial bone stress injury: diagnostic performance and inter-reader agreement of an abbreviated 5-min magnetic resonance protocol.

OBJECTIVE: To compare the diagnostic performance and inter-reader agreement of an abbreviated (5 min) MR protocol compared to a complete (25 min) protocol, for evaluation of suspected tibial bone stress injury. MATERIALS AND METHODS: This IRB-approved retrospective study consisted of 95 consecutive MR examinations in 88 patients with suspected tibial bone stress injury. Three musculoskeletal radiologists independently classified all examinations utilizing both an abbreviated protocol consisting only of axial T2-weighted images with fat suppression, and after a washout period again classified the complete examinations. Accuracy was calculated as proportion of cases classified exactly, within 1 grade, within 2 grades, and also utilizing a simplified "clinically relevant" classification combining grades 2, 3, and 4A into a single group. Significance testing was performed with the chi-test, and a post-hoc power analysis was performed. Inter-reader agreement was calculated with Kendall's coefficient of concordance, with significance testing performed utilizing the z-test after bootstrapping to obtain the standard error. RESULTS AND CONCLUSIONS: There was no significant difference in accuracy of grading tibial bone stress injuries between complete and abbreviated examinations. For complete exams, pooled exact accuracy was 47.8%; accuracy within 1 grade was 82.8%; and accuracy within 2 grades was 96.1%. For the abbreviated protocol, corresponding accuracies were 50.2, 82.0, and 93.9%. With the "clinically relevant" simplified classification, accuracy was 58.6% for complete exams and 64.2% for abbreviated exams. There was no significant difference in inter-reader agreement, with substantial agreement demonstrated for both complete (Kendall coefficient of concordance 0.805) and abbreviated examinations (coefficient of 0.767).

Computed tomography window blending in maxillofacial imaging.

PURPOSE: The purpose of this study was to demonstrate the ability of a custom window blending algorithm to depict multicompartmental disease processes of the maxillofacial region in a single image, using routine computed tomography (CT) DICOM data. METHODS: Five cases were selected from case files demonstrating trauma, infection, and malignancy of the maxillofacial region on routine CT examinations. Images were processed with a modified Relative Attenuation-Dependent Image Overlay (RADIO) window-blending algorithm in Adobe Photoshop controlled by ExtendScript. RESULTS: The modified RADIO algorithm was able to demonstrate pertinent multicompartmental imaging findings in each of the examinations, allowing simultaneous visualization of clinically relevant bone and soft tissue findings in a single image, without needing to change window and level settings. CONCLUSION: A custom window blending algorithm can demonstrate a range of multicompartmental pathology in the maxillofacial region in a single image.

Diagnostic Performance of CT for Occult Proximal Femoral Fractures: A Systematic Review and Meta-Analysis.

OBJECTIVE. The purpose of this study was to assess the diagnostic performance of CT for detection of occult proximal femoral fracture. MATERIALS AND METHODS. A systematic search adhering to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines was performed for studies of the sensitivity and specificity of CT for detection of hip fracture. Two independent investigators extracted data and assessed the quality of each study using the revised Quality Assessment of Diagnostic Accuracy Studies (QUADAS-2). A qualitative systematic review and quantitative meta-analysis were performed. A Bayesian bivariate random effects meta-analysis model with integrated nested Laplace approximation was used to estimate sensitivity and specificity. RESULTS. Thirteen heterogeneously reported studies were assessed that included 1248 patients (496 with a hip fracture and 752 without) with MRI or clinical follow-up as the reference standard. There were 50 false-negative examinations. The summary estimate of sensitivity was 94% and of specificity was 100%. CONCLUSION. CT can be considered a reasonable choice when occult proximal femoral fracture is suspected clinically in patients for whom MRI is contraindicated or not readily available. However, for patients with ongoing clinical concern about hip fracture despite normal CT findings, MRI should be performed.

Radiology Report Template Optimization at an Academic Medical Center.

OBJECTIVE. Variability in reports of the same imaging study performed at the same institution may be confusing to referrers and patients, hindering results communication. The purpose of this study was to introduce a quality improvement initiative aimed at reducing variation in radiology report templates at a large academic center. MATERIALS AND METHODS. The quality improvement initiative was undertaken at a large multisite, multidivision academic radiology practice performing more than 820,000 radiologic examinations annually. A project charter defined the goals, scope, and personnel of the initiative and an escalation pathway for conflict resolution. Standard requirements for templates were initially developed. From September 2017 to May 2018, an oversight committee (24 organ system and modality-based work groups with representatives from nine subspecialty divisions) reviewed and harmonized all institutional radiology report templates across the enterprise irrespective of the imaging site or division that interpreted the study. The primary outcome measure was percentage reduction in report templates after harmonization. The secondary outcome measure was monthly adherence to harmonized templates for 9 months after implementation assessed by manual review of 40 randomly selected reports per month. The paired t test was used to assess template reduction, and the chi-square trend test was used to study trend in adherence to harmonized templates. RESULTS. Among 19,687 total templates at baseline, 597 harmonized templates remained after harmonization (p < 0.001). There was variation in template reduction by work group (multiple p < 0.05; reduction range, 79.2-99.3%). Radiologist adherence to harmonized templates ranged from 88.0% to 100%, unchanged in the 9 months after implementation (p = 0.23, chi-square trend). CONCLUSION. A radiology report harmonization initiative reduced 97.0% of report templates with a sustained high degree of adherence to harmonized templates after implementation at a large multisite multidivision academic radiology practice.

Thinking beyond pannus: a review of retro-odontoid pseudotumor due to rheumatoid and non-rheumatoid etiologies.

Retro-odontoid pseudotumor, or mass-like retro-odontoid soft tissue thickening, is an uncommon but important imaging finding that may be associated with rheumatoid arthritis, crystal deposition diseases, as well as non-inflammatory conditions such as cervical degenerative changes and mechanical alterations. Retro-odontoid pseudotumor is commonly associated with atlantoaxial microinstability or subluxation. MRI and CT have an important role in the detection and diagnosis of retro-odontoid pseudotumor. However, due to a wide range of imaging characteristics and ambiguous etiology, it is a frequently misunderstood entity. The purpose of this article is to review relevant anatomy of the craniocervical junction; describe various imaging appearances, pathophysiology and histology in both rheumatoid and non-rheumatoid etiologies; and discuss differential diagnosis of retro-odontoid pseudotumor in order to help guide clinical management.

Clinical applications of a computed tomography color "marrow mapping" algorithm to increase conspicuity of nondisplaced trabecular fractures.

PURPOSE: To explore clinical applications of a novel conventional computed tomography (CT) color post-processing algorithm to increase conspicuity of nondisplaced trabecular fractures. MATERIALS AND METHODS: The algorithm was created in Adobe Photoshop and Adobe Extendscript, utilizing DICOM images from conventional CT as source images. A total of six representative cases were selected and processed. No statistical analyses were performed. RESULTS: A total of six cases are demonstrated, five with MRI correlation demonstrating corresponding fractures and bone marrow edema, including a case of sacral insufficiency fracture, two cases of vertebral body fracture, two cases of nondisplaced hip fracture, and a knee bone marrow edema lesion (without MRI correlate). All cases were processed successfully without error. CONCLUSIONS: A conventional CT color post-processing algorithm may be clinically useful in increasing conspicuity of nondisplaced fractures and bone marrow edema. A potential pitfall is the presence of subchondral or marrow sclerosis, which may mimic edema. Future prospective studies will be necessary to evaluate diagnostic performance.

A simplified classification of proximal femoral fractures improves accuracy, confidence, and inter-reader agreement of hip fracture classification by radiology residents.

PURPOSE: To demonstrate the effect of teaching a simplified treatment-based classification of proximal femoral fractures on the accuracy, confidence, and inter-reader agreement of radiology residents. The authors hypothesize that these measures will improve after viewing an educational presentation. MATERIALS AND METHODS: Three radiology residents independently classified 100 operative proximal femoral fractures, both before and after viewing a 45-min educational video describing the simplified classification scheme, with a washout period of at least 12 weeks between sessions. Based on the gold standard established by consensus of two radiologists and an orthopedic trauma surgeon utilizing intraoperative fluoroscopic imaging, operative reports, and pre-procedural imaging, accuracy of classification was calculated for each reader before and after viewing the educational video. Reader confidence was recorded on a 0-10 scale, and inter-reader agreement was calculated with Fleiss's kappa. McNemar's test was used to compare accuracy, a paired t test was used to compare confidence, and the Z-test was used to compare kappa values after bootstrapping to determine the standard error of the mean. RESULTS: The study cohort included 60/100 females, with a mean age of 76.6 years. The pooled classification accuracy was initially 65%, which improved to 80% in the second reading session after viewing the educational video (p < 0.0001). Confidence improved from 6.9 initially to 8.6 (p < 0.0001). Inter-reader agreement improved from a kappa of 0.45 (moderate agreement) to 0.74 (substantial agreement) (p < 0.0001). CONCLUSIONS: A simplified treatment-based classification of proximal femoral fractures is easily taught to radiology residents and resulted in increased accuracy, increased inter-reader agreement, and increased reader confidence.