Osteoporotic Vertebral Fractures are Common in Hip Fracture Patients and are Under-recognized.

INTRODUCTION: The vertebrae are the most common site for osteoporotic fracture. While they can result in disability and increased mortality, only one-third present clinically. People with multiple fractures are at greater risk of future fractures. Most hip fracture patients are neither diagnosed nor treated for their underlying osteoporosis. Computed tomography (CT) studies are often performed on hospitalised patients, can be used to diagnose osteoporosis and are gaining popularity for opportunistic osteoporosis screening by measuring BMD and other bone strength indices. The aim of this study was to assess the prevalence of vertebral fractures on CT pulmonary angiograms (CTPA) in a cohort of hip fracture patients and whether this increased their diagnosis and treatment rates. METHODS: We retrospectively identified all hip fractures admitted to our institution between 2010 and 2017 to identify those who underwent CTPA scans. An independent, blinded consultant musculoskeletal radiologist reviewed the images for vertebral fractures and quantified severity using Genant criteria. Results were compared to the original radiology report, discharge diagnoses and treatment rates for osteoporosis. RESULTS: Eleven percent (225/2122) of patients had CTPA images available. Seventy percent (158) were female with a mean age of 78 years (SD: 11). The median length of stay for all patients was 16 days (1-301). Forty percent (90) of patients had at least one vertebral fracture present and 20% (46) had more than one fracture. Only one in 5 radiology reports noted the fractures. 24% of subjects had osteoporosis treatment recorded at hospital discharge and there was no difference between those with vertebral fractures to those without. CONCLUSION: Many hip fracture patients have undiagnosed spine fractures. A screening strategy which evaluates CT scans for fractures has potential to increase diagnosis and treatment rates of osteoporosis. However, more work is needed to increase awareness.

Aiming for the Bottom Corner: How to Score a Field Goal When Landing Venous Stents in May-Thurner Syndrome.

PURPOSE: To report an iliac venous stent landing technique using only fluoroscopy in patients with May-Thurner syndrome (MTS). MATERIAL AND METHODS: Sixty-five patients (69% female) who had self-expanding nitinol stents deployed for symptomatic MTS were retrospectively analyzed. Mean age was 50 years (range 18-80). The cephalic stent right lower corner was deployed to the right of the lumbar vertebra spinous process (SP), but not as far to the right as the right pedicle lateral border. Mode stent diameter and length were 14 mm (range 12-18) and 120 cm (range 60-180), determined by venography, respectively. The anatomical positions of the right common iliac artery, inferior vena cava (IVC), and stent were assessed relative to these bony landmarks on computed tomography venography. RESULTS: Position of the proximal right common iliac artery right lateral border lay a mean distance of 12 mm (±8 to the right of the SP and 13 mm (±7) left of the right pedicle lateral border. Mean position of the IVC right lateral wall lay 1 mm (±6) to the right of the right pedicle lateral border. Mean position of the cephalic stent right lower corner was 6 mm (±6) to the left of the right pedicle lateral border and 19 mm (±7) to the right of the SP. The mean space left between the cephalic stent right lower corner and the IVC right lateral wall was 5 mm (±5). Primary patency rate at 1 year was 88%. CONCLUSIONS: Important vascular structures lie in predictable locations relative to bony landmarks, facilitating accurate venous stent placement using fluoroscopy only.

Peroneus Tertius Tendon Tear Causing Lateral Ankle Pain in a Child.

The peroneus tertius muscle arises in the anterior compartment of the leg and demonstrates significant morphologic variation. Its function is not yet clearly delineated. We present the case of a 12-year-old patient with an isolated tear of the peroneus tertius tendon that resulted in lateral based ankle pain. After surgical reconstruction, the patient's pain resolved, and he was able to return to his normal activities.

The prevalence of vertebral fracture on vertebral fracture assessment imaging in a large cohort of patients with rheumatoid arthritis.

OBJECTIVE: RA accelerates bone loss, increasing the risk of osteoporosis (OP) and fracture. DXA imaging has been validated for identifying RA patients at risk of fracture. The objective of this study was to assess the presence of asymptomatic vertebral fractures (VFs) in a cohort of patients with established RA referred for DXA using VF assessment (VFA) technology. METHODS: We determined the prevalence of VFs in a cohort of RA patients age ≥ 40 years fulfilling the 1987 ACR classification criteria. Two blinded radiologists independently reviewed all VFA scans to determine the presence and severity of VFs using Genant criteria. We compared the prevalence and severity of VFs between RA patients and determined the independent associations of different variables with VFs using multivariable logistic regression. RESULTS: Six hundred and three subjects fulfilled study inclusion criteria. Thirteen per cent of the entire cohort (77/603) had one or more vertebral deformities identified on VFA imaging: 58% were female with mean age 56 years. The prevalence of OP and osteopenia was 59% and 40%, respectively. The prevalence and severity of VFs showed significant correlation with spine T-scores (r = -0.37, P < 0.001) and femoral T-scores (r = -0.31, P < 0.001). In multivariable analyses VFs were significantly and independently associated with a longer duration of RA, markers of disease activity and severity. CONCLUSION: VFs were detected on VFA images in 13% of women and men with well-established RA referred for DXA testing. Longer duration and severity of RA disease were independent risk factors for fractures in our study.

The prevalence of aortic calcification on vertebral fracture assessment imaging among patients with rheumatoid arthritis.

Patients with rheumatoid arthritis (RA) are at increased risk of osteoporosis (OP) and cardiovascular disease (CVD). Dual-energy X-ray absorptiometry scans have been validated for identifying patients with RA at risk for fracture. Reliable CVD risk stratification remains an unmet need in this population. Vertebral fracture assessment (VFA)-detected abdominal aortic calcification (AAC) has been validated as a marker of CVD in other populations, but the prevalence among patients with RA is unknown. In this study, we determined the prevalence and severity of AAC on VFA scans in a cohort of patients with RA. AAC was detected in 211 of the 603 (35%) eligible subjects; 24% were graded as severe. In multivariable analyses, the presence of AAC was significantly associated with longer disease duration and higher disease activity (p<0.05). Further studies are needed on the relationship between AAC and CVD in patients with RA.

Establishing Baseline Radiological Metrics of the Talus and Calcaneus: A Retrospective Analysis of Computed Tomography Imaging in an Irish Cohort.

Introduction The subtalar joint anatomy is complex and heterogeneity in its morphology creates unique challenges for foot and ankle surgeons. Anatomical metrics used for prosthesis design are well established. However, there is a paucity of literature quantifying foot and ankle measurement techniques and metrics used for prosthesis design. The aim of this study was to document reproducible measurement techniques and quantify talar and calcaneal metrics in a sample of Irish patients on computed tomography imaging to aid in the design of a novel hindfoot plate. Methods A retrospective analysis of consecutive foot and ankle computed tomography images performed at our institution was undertaken. Five measurements were performed on each foot and ankle image. Statistical analysis was performed to identify if a correlation existed between measurements. Results Sixty-four CTs met the inclusion criteria. Talar body height 27.1 mm (SD 2.17 mm), talar neck width 32.7 mm (3.16 mm), talar head height 25.41 (SD 2.16 mm), lateral process to posterior talus 23.6 (2.64 mm), calcaneal height 43.8 mm (SD 3.9 mm). A positive correlation was identified between all measurements. Conclusion This study identified that there was a low degree of heterogeneity in talar and calcaneal measurements in an Irish cohort. Furthermore, the metrics used in this study will provide valuable information for the preliminary design of a novel hindfoot plate.

Talonavicular synostosis with lateral ankle instability--A case report and review of the literature.

Talonavicular coalition is a rare autosomal recessive congenital anomaly that is usually asymptomatic and detected incidentally on radiographs. It is associated with symphalangism, clinodactyly, a great toe that is shorter than the second toe, clubfoot, calcaneonavicular coalition, talocalcaneal coalition and a ball-and-socket ankle joint. The authors present a review of the literature and case report of a patient with complete osseous talonavicular coalition, talocalcaneal coalition and lateral ankle instability which was successfully treated with subtalar fusion and lateral ligament reconstruction.

Risk assessment tools for osteoporosis and fractures in 2022.

Osteoporosis is one of the frequently encountered non-communicable diseases in the world today. Several hundred million people have osteoporosis, with many more at risk. The clinical feature is a fragility fracture (FF), which results in major reductions in the quality and quantity of life, coupled with a huge financial burden. In recognition of the growing importance, the World Health Organisation established a working group 30 years ago tasked with providing a comprehensive report to understand and assess the risk of osteoporosis in postmenopausal women. Dual-energy X-ray absorptiometry (DXA) is the most widely endorsed technology for assessing the risk of fracture or diagnosing osteoporosis before a fracture occurs, but others are available. In clinical practice, important distinctions are essential to optimise the use of risk assessments. Traditional tools lack specificity and were designed for populations to identify groups at higher risk using a 'one-size-fits-all' approach. Much has changed, though the purpose of risk assessment tools remains the same. In 2022, many tools are available to aid the identification of those most at risk, either likely to have osteoporosis or suffer the clinical consequence. Modern technology, enhanced imaging, proteomics, machine learning, artificial intelligence, and big data science will greatly advance a more personalised risk assessment into the future. Clinicians today need to understand not only which tool is most effective and efficient for use in their practice, but also which tool to use for which patient and for what purpose. A greater understanding of the process of risk assessment, deciding who should be screened, and how to assess fracture risk and prognosis in older men and women more comprehensively will greatly reduce the burden of osteoporosis for patients, society, and healthcare systems worldwide. In this paper, we review the current status of risk assessment, screening and best practice for osteoporosis, summarise areas of uncertainty, and make some suggestions for future developments, including a more personalised approach for individuals.

Ligament and bone pathologic abnormalities more frequent in neuropathic joint disease in comparison with degenerative arthritis of the foot and ankle: implications for understanding rapidly progressive joint degeneration.

OBJECTIVE: The variable disease progression of osteoarthritis (OA) and the basis for rapid joint deterioration in some subgroups of patients are poorly understood. To explore an anatomic basis for rapidly progressive OA, this observational study compared the magnetic resonance imaging (MRI) patterns of disease between patients with neuropathic joint disease (NJD) and patients with degenerative arthritis of the ankle and foot. METHODS: MR images of the foot and ankle of patients with early NJD (n = 7) and patients with OA (n = 15) were assessed. The anonomized MR images were dichotomously scored by a musculoskeletal radiologist for the presence of the following abnormalities per bone (of a total of 14 bones): cartilage defects, bone cysts, bone marrow edema, fractures, joint debris, joint effusions, tendinopathy, tendinitis, and ligament tears. RESULTS: Although the degree of cartilage damage and joint cyst formation was comparable between the groups, the degree of ligament tears, or change in MRI signal intensity in the ligaments, was significantly greater in patients with NJD compared with patients with OA (median of 3 tears versus 0, of 14 total bones; P < 0.01). Moreover, in patients with early NJD compared with patients with OA, there was a significantly greater degree of diffuse bone marrow edema (median of 6.5 tarsal bones versus 2 adjacent bones, of 14 total bones; P < 0.01), a greater number of bone fractures (median 4 versus 0; P < 0.01), and more frequent bone debris (median 4.5 versus 0; P = 0.013). CONCLUSION: This analysis of NJD in the foot and ankle shows the predominance of bone and ligament abnormalities in NJD compared with the pattern of involvement in OA. These findings highlight the importance of structures other than articular cartilage in OA of the ankle and foot, and suggest that rapid joint degeneration in NJD may be more ligamentogenic or osteogenic in nature.

Postoperative imaging of the ankle and foot.

To evaluate the ankle and foot after surgery it is important to understand the primary clinical diagnosis, the surgical procedure performed, the interval since surgery, and patients' current clinical symptoms. Standard radiography is the most common imaging modality for evaluating the postoperative ankle and foot. This article also discusses when computed tomography (CT) and magnetic resonance (MR) imaging maybe used for evaluating the foot and ankle after surgery.

Opportunistic diagnosis of osteoporotic vertebral fractures on standard imaging performed for alternative indications.

Osteoporotic vertebral fractures (VFs) are the most common type of osteoporotic fracture. Patients with VF are at increased risk of hip fractures or additional VFs, both of which contribute to patient morbidity and mortality. Early diagnosis of VFs is essential so patients can be prescribed appropriate medical therapy. Most patients with clinical suspicion for VF have an X-ray of the spine. Many VFs are invisible on X-ray and require further imaging. CT can provide excellent bony detail but uses high doses of ionising radiation. MRI provides excellent soft tissue detail and can distinguish old from new fractures in addition to differentiating osteoporotic VFs from other causes of back pain. Bone scans have a limited role due to poor specificity. The literature suggests that radiologists frequently miss or do not report VFs when imaging is requested for an alternative clinical indication and when there is no clinical suspicion of VF. Common examples include failure to identify VFs on lateral chest X-rays, sagittal reformats of CT thorax and abdomen, lateral localizers on MRI and scout views on CT. Failure to diagnose a VF is a missed opportunity to improve management of osteoporosis and reduce risk of further fractures. This article discusses the role of radiographs, CT, MRI and bone scintigraphy in the assessment and recognition of osteoporotic fractures. This article focuses on opportunistic diagnosis of VFs on imaging studies that are performed for other clinical indications. It does not discuss use of dual energy X-ray absorptiometry which is a specific imaging modality for osteoporosis.

Inferior vena cava encirclement by caudate lobe hypertrophy: evaluation by MRI and CT and its impact on caval preservation during orthotopic liver transplantation.

BACKGROUND: Presence of a dorsal sector of liver that completely encircles the IVC may increase difficulty of IVC preservation for orthotopic liver transplantation (OLT). We sought to evaluate the incidence of IVC encirclement by hepatic parenchyma using preoperative MRI and CT and its effect on surgical technique and complications. METHODS: CT or MRI examinations less than 12 months before OLT were reviewed independently and blindly by two radiologists in 95 patients, with patient consent waived by IRB. IVC preservation was attempted for all patients without regard to imaging findings. Surgical records were reviewed regarding choice of technique or operative difficulties, and their relationship to complete IVC encirclement was calculated using ROC analysis and Fischer exact test. RESULTS: Complete encirclement was found by both readers in 16 of 95 patients (17%). Resection of the recipient IVC was required in three of 95 patients, two of whom had complete IVC encirclement. Association of complete IVC encirclement with surgical IVC resection had an area under the ROC curve of 0.752. CONCLUSION: Routine pretransplant assessment of IVC encirclement by dorsal sector hepatic tissue using MRI and CT may help identifying patients in whom IVC preservation will be difficult.

Spectrum of imaging findings on MRI and CT after uterine artery embolization.

Uterine artery embolization (UAE) is an effective treatment for symptomatic uterine fibroids. Magnetic resonance (MR) imaging is typically employed to evaluate the uterus following UAE for fibroid infarction, size, location change, persistent enhancement, changes in adenomyosis, and uterine necrosis. Variable pattern of calcification on computed tomography (CT) can differentiate embolic particles and fibroid involution. CT following UAE may be requested because of acute pelvic pain or chest discomfort or pyrexia and/or for complications that may require treatment in acute phase. Visualization of gas in uterus and uterine vessels following UAE is an expected finding that should not be misinterpreted as a sign of infection. The MRI and CT appearances vary depending upon the time interval after UAE and success of the procedure. Radiologists should be familiar with the range of post-UAE appearances on MRI and CT to better aid clinicians in correct diagnosis and treatment. The main purpose of this pictorial review is to identify the spectrum of findings on MRI and CT performed after UAE, to illustrate UAE-associated common and uncommon MRI and CT appearances and discuss post-UAE complications that require urgent medical or surgical intervention.

A systematic review of the Irish osteoporotic vertebral fracture literature.

INTRODUCTION: Vertebral fractures (VF) are the most common osteoporotic fracture. They are associated with significant morbidity and mortality and are an important predictor of future fractures. The epidemiology of VF in Ireland is limited and a greater understanding of their scale and impact is needed. Therefore, we conducted a systematic review of publications on osteoporotic VF in Ireland. METHODS: Systematic searches were conducted using PubMed, Medline, Embase, Scopus and Cochrane electronic databases to identify eligible publications from Ireland addressing osteoporotic VF. RESULTS: Twenty studies met the inclusion criteria out of 1558 citations. All studies were published since 2000. Data was obtained on 182,771 patients with fractures. Nine studies included more than 100 subjects and three included more than 1000. Females accounted for 70% with an overall mean age of 65.2 years (30-94). There was significant heterogeneity in study design, methods and outcome measures including the following: use of administrative claims data on public hospital admissions, surgical and medical interventions, the impact of a fracture liaison service and the osteoporosis economic burden. The prevalence of VF was difficult to ascertain due to definitions used and differences in the study populations. Only two studies systematically reviewed spine imaging using blinded assessors and validated diagnostic criteria to assess the prevalence of fractures in patient cohorts. CONCLUSIONS: Several studies show that VF are common when addressed systematically and the prevalence may be rising. However, there is a deficit of large studies systematically addressing the epidemiology and their importance in Ireland.

Adenomyosis: sonohysterography with MRI correlation.

OBJECTIVE: The purpose of this study was to describe the sonohysterographic features of adenomyosis with MRI correlation. CONCLUSION: In this study, when the sonohysterographic findings suggested adenomyosis, MRI findings confirmed the diagnosis in 96% of cases. Myometrial cracks are, to our knowledge, a previously undescribed sonohysterographic sign of adenomyosis.

Extrapancreatic neural plexus invasion by pancreatic carcinoma: characteristics on magnetic resonance imaging.

BACKGROUND: Our objective is to study the characteristics of extrapancreatic neural plexus invasion by pancreatic carcinoma on MR imaging. METHODS: 20 patients with both pancreatic carcinoma and extrapancreatic neural plexus invasion confirmed by pathology were recruited in this study. MR imaging was performed within 1 month before surgery. On MR images, signal intensity at the site of potential extrapancreatic neural plexus invasion, lymph nodes and tumor size were noted. The relationship of extrapancreatic neural plexus invasion to these findings was analyzed. RESULTS: Signs of extrapancreatic neural plexus invasion were depicted on MR imaging in 80% of patients, which included streaky and strand-like signal intensity structure in fat tissue in 50% of patients and irregular masses adjacent to tumor in 30%. Signal intensity at invasion site was similar to that of pancreatic carcinoma. The frequencies of patients with vascular invasion and with lymph nodes larger than 5 mm were, respectively, 50% and 55%. Tumor diameter was 24 +/- 7 mm on MR imaging. Extrapancreatic neural plexus invasion was correlated with vascular invasion (r = 0.58, P < 0.005), slightly related with lymphadenopathy (r = 0.35, 0.1 > P > 0.05), but not related with tumor size. CONCLUSION: MR imaging is useful to depict extrapancreatic neural plexus invasion by pancreatic carcinoma.

Gallbladder abnormalities in carcinoma of pancreatic head: findings on MR imaging.

BACKGROUND: Our objective is to study the gallbladder abnormalities on MR images associated with carcinoma of the pancreatic head. METHODS: Thirty-six patients who had surgical resection of pancreatic head carcinoma were retrospectively analyzed regarding the appearance of the tumor and gallbladder on MR imaging performed within one month before surgery. The changes of the gallbladder wall, and the dimension of the gallbladder, cystic duct, pericholecystic region, and common bile duct (CBD) on MR imaging were noted. RESULTS: About 92% (33/36) of patients had at least one gallbladder abnormality on MR imaging, including thickened gallbladder wall (58%), gallbladder wall striation (19%), gallbladder wall severe enhancement (44%), enlarged gallbladder (33%), gallbladder stone (19%), dilatation of cystic duct (67%), focally increased liver parenchymal enhancement adjacent to the gallbladder (19%), and pericholecystic fluid (11%). 64% of patients had dilated CBD. The diameter of the cystic duct was correlated with those of the CBD (r = 0.45, P < 0.01) and gallbladder (r = 0.56, P < 0.0001). Enlarged gallbladder, dilatation of the cystic duct, and CBD were correlated with chronic cholecystitis. CONCLUSION: Most patients with pancreatic head carcinoma show gallbladder abnormalities on MR imaging. Cystic duct dilatation follows CBD dilatation and is the primary cause for dilated gallbladder and chronic cholecystitis in carcinoma of pancreatic head.

Dilated cisternae chyli: a sign of uncompensated cirrhosis at MR imaging.

BACKGROUND: In order to retrospectively determine the frequency of dilated cisterna chyli (CC) on MR images in patients with cirrhosis, and to assess its value as a simple diagnostic imaging sign of uncompensated cirrhosis. METHODS: Study population included 257 patients (149 with pathologically proved cirrhosis and 108 control subjects without the history of chronic liver diseases) who had 1.5 T MR imaging. Cirrhosis patients were divided into compensated and uncompensated groups. Three independent observers qualitatively evaluated the visibility of CC 2 mm or greater in transverse diameter, identified as a tubular structure with fluid signal intensity. CC diameters greater than 6 mm were defined as dilated. Statistical analysis was performed by Student t-test and interobserver agreement via intraclass correlation coefficient. RESULTS: CCs with diameter 2 mm or more were recorded in 113 of 149 (76%) cirrhotic patients and 15 of 108 (14%) control subjects (P < 0.001). Dilated CCs were significantly more frequent in uncompensated than compensated cirrhotic patients (54% vs 5%, P < 0.001). The sensitivity, specificity, accuracy, and positive predictive value of dilated CC for uncompensated cirrhosis were 54%, 98%, 80%, and 96%, respectively. CONCLUSIONS: Dilated CC can be used as a simple and specific sign complimentary to other findings of uncompensated cirrhosis.

Pneumocephalus and Meningitis as Complications of Mastoiditis.

Pneumocephalus in the absence of trauma, tumour, or surgery is a rare entity. We report a case of a 73-year-old lady who presented with sepsis leading to confusion and unresponsiveness. A CT of brain revealed mastoiditis, sinusitis, and associated pneumocephalus. Further investigations led to an eventual diagnosis of pneumococcal meningitis. The combination of pneumocephalus and meningitis as complications of mastoiditis is rare with very few cases published in the literature. We describe one such case.

Submucosal fibroids becoming endocavitary following uterine artery embolization: risk assessment by MRI.

OBJECTIVE: The purpose of our study was to assess the relationship between the endometrium and submucosal fibroids before and after uterine artery embolization (UAE). MATERIALS AND METHODS: Contrast-enhanced pelvic 1.5-T MRI was performed in 49 women before and after UAE over a 2-year period. Dominant (largest diameter) fibroids in intramural, submucosal, subserosal, pedunculated subserosal, and endocavitary locations were assessed on pre- (baseline) and postembolization MRI. Size, locations of dominant fibroids relative to endometrium and serosa before and after embolization were compared. The ratio between the largest endometrial interface and the maximum dimension of the dominant submucosal fibroid (interface-dimension ratio) was determined on baseline MRI. The infarction rate for dominant fibroids was estimated after UAE. RESULTS: One hundred forty dominant fibroids were identified on baseline MRI. Forty-nine (35%) were intramural, 39 (28%) were submucosal, 34 (24%) were subserosal, eight (6%) were pedunculated subserosal, and 10 (6%) were endocavitary in location on preembolization MRI. After UAE, of 39 dominant submucosal fibroids, 13 (33%) became endocavitary: complete (n = 4), partial (n = 9) on the basis of European Society of Gynaecological Endoscopy (ESGE) classification. The preembolization mean interface-dimension ratio and mean diameters for dominant fibroids that became endocavitary were significantly greater than for those that did not become endocavitary after embolization (0.65 vs 0.32, p < 0.005; 8 vs 5.4 cm, p < 0.05, respectively). All dominant submucosal fibroids showed 100% infarction after UAE. CONCLUSION: Submucosal fibroids with an interface-dimension ratio of greater than 0.55 are more likely to migrate into the endometrial cavity after UAE. The majority of these are expelled spontaneously without significant symptoms. Rarely, submucosal fibroids greater than 6 cm in size that become endocavitary may cause postprocedural complications requiring further intervention and medical treatment.