The Diagnostic Accuracy of Radiographs and Magnetic Resonance Imaging in Predicting Deltoid Ligament Ruptures in Ankle Fractures.

BACKGROUND: Operative indications for supination-external rotation (SER) ankle fractures depend on the integrity of the medial structures. Despite the importance of assessing deep deltoid ligament injuries, the accuracy of common diagnostic tests has not been established. QUESTIONS/PURPOSES: The objective of this study was to compare the ability of injury (non-stress) and stress radiographs and magnetic resonance imaging (MRI) to diagnose deep deltoid ligament ruptures in operative SER ankle fractures. METHODS: Patients were included who underwent surgical fixation of SER ankle fractures and had appropriate injury and manual stress test radiographs, pre-operative ankle MRI, and intra-operative assessment of deep deltoid integrity by direct visualization. The medial clear space (MCS) was considered positive for all values over 5 mm on the injury or stress mortise radiographs. MRI analysis of the deep deltoid ligament injury was performed by blinded fellowship-trained musculoskeletal radiologists. Intra-operative direct visualization and assessment of the deltoid was performed using a direct medial ankle approach at the time of operative fracture fixation. RESULTS: Using intra-operative visualization as the gold standard, MCS measurements and MRI had differing abilities to diagnose a deep deltoid rupture. In cases where the MCS was less than 5 mm on injury radiographs and stress tests were performed, MCS measurements were much less accurate than MRI in predicting deltoid ruptures (46% versus 79%, respectively) with a high false positive rate (80%). In contrast, an MCS measurement of greater than 5 mm on injury radiographs was a strong predictor of deep deltoid rupture (accuracy of 95%). CONCLUSION: Compared with direct visualization of the deltoid ligament intra-operatively, these data support proceeding with surgery when the MCS on injury radiographs is greater than 5 mm without any additional stress tests or advanced imaging. When the MCS is less than 5 mm, we recommend MRI analysis because of its increased accuracy and decreased false positive rate. Improving our ability to diagnose deltoid ruptures will contribute to more effective management of patients with SER ankle fractures.

Reducing indwelling urinary catheter use through staged introduction of electronic clinical decision support in a multicenter hospital system.

OBJECTIVE: To integrate electronic clinical decision support tools into clinical practice and to evaluate the impact on indwelling urinary catheter (IUC) use and catheter-associated urinary tract infections (CAUTIs).Design, Setting, and ParticipantsThis 4-phase observational study included all inpatients at a multicampus, academic medical center between 2011 and 2015.InterventionsPhase 1 comprised best practices training and standardization of electronic documentation. Phase 2 comprised real-time electronic tracking of IUC duration. In phase 3, a triggered alert reminded clinicians of IUC duration. In phase 4, a new IUC order (1) introduced automated order expiration and (2) required consideration of alternatives and selection of an appropriate indication. RESULTS: Overall, 2,121 CAUTIs, 179,070 new catheters, 643,055 catheter days, and 2,186 reinsertions occurred in 3·85 million hospitalized patient days during the study period. The CAUTI rate per 10,000 patient days decreased incrementally in each phase from 9·06 in phase 1 to 1·65 in phase 4 (relative risk [RR], 0·182; 95% confidence interval [CI], 0·153-0·216; P<·001). New catheters per 1,000 patient days declined from 53·4 in phase 1 to 39·5 in phase 4 (RR, 0·740; 95% CI, 0·730; P<·001), and catheter days per 1,000 patient days decreased from 194·5 in phase 1 to 140·7 in phase 4 (RR, 0·723; 95% CI, 0·719-0·728; P<·001). The reinsertion rate declined from 3·66% in phase 1 to 3·25% in phase 4 (RR, 0·894; 95% CI, 0·834-0·959; P=·0017). CONCLUSIONS: The phased introduction of decision support tools was associated with progressive declines in new catheters, total catheter days, and CAUTIs. Clinical decision support tools offer a viable and scalable intervention to target hospital-wide IUC use and hold promise for other quality improvement initiatives.

The Effect of Soft Tissue Injuries on Clinical Outcomes After Tibial Plateau Fracture Fixation.

OBJECTIVE: To determine if ligamentous and meniscal injuries as determined by initial magnetic resonance imaging altered clinical outcomes after the fixation of tibial plateau fractures. DESIGN: Comparative cohort study. SETTING: Academic level I trauma center. PATIENTS/PARTICIPANTS: Eighty-two patients from a prospective database of operatively treated tibial plateau fractures met the inclusion criteria, which consisted of injury radiographs, preoperative knee magnetic resonance imaging (MRI), and a minimum of 12 months of clinical outcomes. INTERVENTION: In addition to radiographs and computed tomography scans for fracture assessment, an MRI was performed to detect tears in the medial and lateral menisci and complete ruptures of the cruciate ligaments (anterior cruciate ligament and posterior cruciate ligament) and collateral ligaments [lateral collateral ligament and medial collateral ligament (MCL)]. Surgical fixation of tibial plateau fractures was performed by a single surgeon based on injury patterns. MAIN OUTCOME MEASUREMENTS: Clinical outcomes included the Knee Outcome Survey Activities of Daily Living Scale, the Lower Extremity Functional Scale, the Short-Form 36, and knee range of motion. Secondary soft tissue surgeries and conversion to arthroplasty were also noted. RESULTS: On injury MRI, 60 patients (73%) had injuries to at least one soft tissue structure. At final follow-up, 2 patients (2%) had a secondary soft tissue surgery and 1 patient (1%) underwent total knee arthroplasty. Patient-reported outcomes and range of motion assessments were not significantly different in patients with and without medial meniscal tears, lateral meniscal tears, and complete MCL ruptures. CONCLUSIONS: In this cohort of patients with operative tibial plateau fractures, sutured lateral meniscal tears, untreated medial meniscus tears, and complete MCL ruptures did not significantly affect clinical outcomes. In addition, these data suggest that obtaining a preoperative MRI in patients with tibial plateau fractures to diagnose soft tissue injuries may not alter the surgical treatment or alter patient prognosis for midterm outcomes. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

OPPE, FPPE, QPS, and why the alphabet soup of physician assessment is essential for safer patient care.

Creating a successful quality and patient safety program requires a multifaceted approach that systematically reviews overall systems and processes, but also creates a standardized framework for evaluating individual practitioner performance on a routine basis. There are two required elements of competency assessment that are typically tied to the hospital credentialing process: ongoing professional practice evaluation (OPPE) and focused professional practice evaluation (FPPE). Each of these processes are mandated by the Joint Commission, and form an important cornerstone for ensuring adequate physician performance and knowledge base.

Posterior reversible encephalopathy syndrome: temporary visual loss after spinal deformity surgery.

Posterior reversible encephalopathy syndrome (PRES) is a rare cause of temporary postoperative visual loss (POVL) after spinal deformity surgery. We report on 2 patients diagnosed with PRES after spinal deformity surgery, who were closely examined postoperatively. A 78-year-old woman with severe disability due to degenerative lumbar spondylosis after laminectomy was treated with transpsoas lumbar interbody fusion from L1 to L4 and posterior spinal fusion from T10 to pelvis. She developed confusion and bilateral visual loss on postoperative day 7. A second patient, a 51-year-old woman with progressive pain and decompensation caused by adult scoliosis, was treated with posterior spinal fusion from T3 to pelvis and interbody fusion from L4 to S1 via a presacral interbody fusion approach. She developed bilateral visual loss on postoperative day 15. Both patients achieved a complete recovery of their vision after medical management of PRES. Timely diagnosis of PRES and prompt intervention allow for a good patient prognosis and complete recovery of eyesight.

MRI safety: a report of current practice and advancements in patient preparation and screening.

MRI offers detailed diagnostic images without ionizing radiation; however, there are considerable safety concerns associated with high electromagnetic field strength. With increasing use of high and ultra high (7T) magnetic field strength, adequate patient preparation and screening for ferrous material is increasingly important. We review current safety standards for patient screening and preparation and how they are implemented at our institution. In addition, we describe a novel supplemental screening technique wherein the lights are dimmed in response to detected ferrous metal at the threshold of Zone IV.

Dose length products for the 10 most commonly ordered CT examinations in adults: analysis of three years of the ACR Dose Index Registry.

As CT use steadily rises, concern over potential risks of radiation exposure from medical imaging has received increasing attention. Since May 2011, the ACR Dose Index Registry (DIR) has been open for general participation and has been collecting CT radiation dose data from an increasing number of facilities of various types. In this introductory review, we analyze the first three years of ACR DIR data, categorize the 10 most commonly performed CT examinations nationwide, review the variability of the recorded radiation dose indices for each, and take preliminary steps toward identifying possible factors associated with variability in dose indices. We believe that disseminating such information will help prompt informed improvements in standardization of CT protocols with respect to radiation dose.

Analysis of PITFL injuries in rotationally unstable ankle fractures.

BACKGROUND: Reduction and stabilization of the syndesmosis in unstable ankle fractures is important for ankle mortise congruity and restoration of normal tibiotalar contact forces. Of the syndesmotic ligaments, the posterior inferior tibiofibular ligament (PITFL) provides the most strength for maintaining syndesmotic stability, and previous work has demonstrated the significance of restoring PITFL function when it remains attached to a posterior malleolus fracture fragment. However, little is known regarding the nature of a PITFL injury in the absence of a posterior malleolus fracture. The goal of this study was to describe the PITFL injury pattern based on magnetic resonance imaging (MRI) and intraoperative observation. METHODS: A prospective database of all operatively treated ankle fractures by a single surgeon was used to identify all supination-external rotation (SER) types III and IV ankle fracture patients with complete preoperative orthogonal ankle radiographs and MRI. All patients with a posterior malleolus fracture were excluded. Using a combination of preoperative imaging and intraoperative findings, we analyzed the nature of injuries to the PITFL. In total, 185 SER III and IV operatively treated ankle fractures with complete imaging were initially identified. RESULTS: Analysis of the preoperative imaging and operative reports revealed 34% (63/185) had a posterior malleolus fracture and were excluded. From the remaining 122 ankle fractures, the PITFL was delaminated from the posterior malleolus in 97% (119/122) of cases. A smaller proportion (3%; 3/122) had an intrasubstance PITFL rupture. CONCLUSIONS: Accurate and stable syndesmotic reduction is a significant component of restoring the ankle mortise after unstable ankle fractures. In our large cohort of rotationally unstable ankle fractures without posterior malleolus fractures, we found that most PITFL injuries occur as a delamination off the posterior malleolus. This predictable PITFL injury pattern may be used to guide new methods for stabilizing the syndesmosis in these patients. LEVEL OF EVIDENCE: Level IV, case series.

Benign osseous and articular abnormalities of the pelvis: a review of CT imaging findings.

Computed tomography (CT) has become the standard of care for evaluation and follow-up for a wide range of abdominal and pelvic pathology. Many incidental osseous and articular abnormalities of the pelvis are detected on these studies, most of which have a benign etiology. However, most of these studies are interpreted by nonmusculoskeletal radiologists, who may not be familiar with the CT appearances of these benign musculoskeletal abnormalities. Uncertainty often leads to mischaracterization or unnecessary follow-up, resulting in increased health care costs and patient anxiety. This article reviews the CT appearance of the benign musculoskeletal entities that occur in pelvis.

Ankle fracture spur sign is pathognomonic for a variant ankle fracture.

BACKGROUND: The hyperplantarflexion variant ankle fracture is composed of a posterior tibial lip fracture with posterolateral and posteromedial fracture fragments separated by a vertical fracture line. This infrequently reported injury pattern often includes an associated "spur sign" or double cortical density at the inferomedial tibial metaphysis. The objective of this study was to quantitatively establish the association of the ankle fracture spur sign with the hyperplantarflexion variant ankle fracture. METHODS: Our clinical database of operative ankle fractures was retrospectively reviewed for the incidence of hyperplantarflexion variant and nonvariant ankle fractures as determined by assessment of injury radiographs, preoperative advanced imaging, and intraoperative observation. Injury radiographs were then evaluated for the presence of the spur sign, and association between the spur sign and variant fractures was analyzed. RESULTS: The incidence of the hyperplantarflexion variant fracture among all ankle fractures was 6.7% (43/640). The spur sign was present in 79% (34/43) of variant fractures and absent in all nonvariant fractures, conferring a specificity of 100% in identifying variant fractures. Positive predictive value and negative predictive value were 100% and 99%, respectively. CONCLUSION: The ankle fracture spur sign was pathognomonic for the hyperplantarflexion variant ankle fracture. It is important to identify variant fractures preoperatively as patient positioning, operative approach, and fixation construct of variant fractures often differ from those employed for osteosynthesis of nonvariant fractures. Identification of the spur sign should prompt acquisition of advanced imaging to formulate an appropriate operative plan to address the variant fracture pattern. LEVEL OF EVIDENCE: Level III, retrospective comparative study.

Retrospective analysis of postinjection ultrasound imaging after platelet-rich plasma or autologous blood: observational review of anatomic distribution of injected material.

OBJECTIVE: Characterization of the distribution and imaging characteristics of platelet-rich plasma (PRP) and autologous blood after injection is currently limited despite the growing use. We sought to improve understanding of the distribution of PRP or autologous blood after it has been injected into a tendon to evaluate whether injected materials truly stayed within the local region of injection. MATERIALS AND METHODS: Fifty ultrasound-guided PRP or autologous blood injections performed for tendinopathy were retrospectively reviewed. Consensus review of the imaging data was performed by two radiologists to characterize the distribution of the injectate (i.e., within the tendon, along the tendon sheath, along the paratenon, or leakage into the adjacent joint or surrounding soft tissues). The presence of fluid and microbubbles from the injectate served as an indicator of material distribution. RESULTS: Image review verified the injectate within the tendon in 100% of cases. In 98% of reviewed cases, injected PRP or autologous blood dissected beyond the local injection site (defined as >2 cm from the site of injection) and was identified in adjacent soft tissues in 51% of cases. Visualization of injectate along a paratenon or tendon sheath (when applicable) was seen in 86% and 100% of cases respectively; however, intraarticular extension was uncommon (8%). CONCLUSION: Our study showed that postinjection imaging may be of value in assessing the anatomic distribution of injectate after intratendinous therapy. Furthermore, our initial review found that in the majority of cases injected blood products tended to distribute beyond the local area of injection.

Utilization guidelines for reducing radiation exposure in the evaluation of aneurysmal subarachnoid hemorrhage: A practice quality improvement project.

OBJECTIVE: The purpose of this study was to reduce the cumulative radiation exposure from CT of patients with aneurysmal subarachnoid hemorrhage. MATERIALS AND METHODS: Baseline data on 30 patients with aneurysmal subarachnoid hemorrhage were collected retrospectively for all CT examinations of the head performed throughout the hospital course. Radiation exposure estimates were obtained by recording dose-length products for each examination. As a departmental practice quality improvement project, an imaging protocol was implemented that included utilization guidelines to reduce radiation exposure in CTA and CT perfusion examinations performed to detect vasospasm in patients with aneurysmal subarachnoid hemorrhage. Ten months after implementation of this protocol, data on 30 additional patients were analyzed. Means, medians, and SD estimates were compared for cumulative radiation exposure and absolute numbers of each examination. RESULTS: Sixty patients were included in the study: 30 patients at baseline and 30 patients after implementation of the quality improvement plan. These patients underwent 435 CT examinations: 248 examinations at baseline and 187 examinations with the new protocol. With the new algorithm, the mean number of CT examinations per patient was 5.8 compared with 7.8 at baseline, representing a decrease of 25.6%. The number of CT perfusion examinations per patient decreased 32.1%. Overall, there was a 12.1% decrease in cumulative radiation exposure (p > 0.05). CONCLUSION: With the structured imaging algorithm, the cumulative radiation exposure and number of CT examinations of the head decreased among patients with aneurysmal subarachnoid hemorrhage because utilization guidelines defined the appropriate imaging time points for detection of vasospasm. Application of these methods to other patient populations with high use of CT may reduce cumulative radiation exposure while the clinical benefits of imaging are maintained.