Comparison of "Human" and Artificial Intelligence Hand-and-Wrist Skeletal Age Estimation in an Epiphysiodesis Cohort.

BACKGROUND: We previously demonstrated that the White-Menelaus arithmetic formula combined with skeletal age as estimated with the Greulich and Pyle (GP) atlas was the most accurate method for predicting leg lengths and residual leg-length discrepancy (LLD) at maturity in a cohort of patients treated with epiphysiodesis. We sought to determine if an online artificial intelligence (AI)-based hand-and-wrist skeletal age system provided consistent readings and to evaluate how these readings influenced the prediction of the outcome of epiphysiodesis in this cohort. METHODS: JPEG images of perioperative hand radiographs for 76 subjects were independently submitted by 2 authors to an AI skeletal age web site (http://physis.16bit.ai/). We compared the accuracy of the predicted long-leg length (after epiphysiodesis), short-leg length, and residual LLD with use of the White-Menelaus formula and either human-estimated GP or AI-estimated skeletal age. RESULTS: The AI skeletal age readings had an intraclass correlation coefficient (ICC) of 0.99. AI-estimated skeletal age was generally greater than human-estimated GP skeletal age (average, 0.5 year greater in boys and 0.1 year greater in girls). Overall, the prediction accuracy was improved with AI readings; these differences reached significance for the short-leg and residual LLD prediction errors. Residual LLD was underestimated by ≥1.0 cm in 26 of 76 subjects when human-estimated GP skeletal age was used (range of underestimation, 1.0 to 3.2 cm), compared with only 10 of 76 subjects when AI skeletal age was used (range of underestimation, 1.1 cm to 2.2 cm) (p < 0.01). Residual LLD was overestimated by ≥1.0 cm in 3 of 76 subjects by both methods (range of overestimation, 1.0 to 1.3 cm for the human-estimated GP method and 1.0 to 1.6 cm for the AI method). CONCLUSIONS: The AI method of determining hand-and-wrist skeletal age was highly reproducible in this cohort and improved the accuracy of prediction of leg length and residual discrepancy when compared with traditional human interpretation of the GP atlas. This improvement could be explained by more accurate estimation of skeletal age via a machine-learning AI system calibrated with a large database. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

The Efficacy of Intra-articular Subtalar Steroid Injection for Symptomatic Talocalcaneal Coalitions: A 30-Year Single Institution Experience.

PURPOSE: While intra-articular steroid injection has been used anecdotally in patients with symptomatic talocalcaneal coalitions recalcitrant to traditional conservative modalities, the ability of this treatment to provide symptomatic relief and obviate or delay surgical intervention remains unknown. The purpose of this study is, therefore, to assess the treatment efficacy of intra-articular subtalar steroid injection in children with symptomatic talocalcaneal coalitions. METHODS: A retrospective study of all patients with isolated subtalar coalitions was performed at a single pediatric orthopaedic institution over a 30-year period. Radiographs were analyzed to identify the type of coalition (osseous or nonosseous), presence of any posterior facet involvement, and presence of a planovalgus foot deformity. Patients who underwent a subtalar joint steroid injection after failing other conservative treatments were identified and compared with those who did not receive an injection as part of their nonoperative management with regard to the need for ultimate surgical intervention and the time from presentation to surgery when applicable. RESULTS: A total of 83 patients (125 feet) met inclusion criteria, of whom 25 patients (34 feet) received a subtalar steroid injection. When compared with the 58 patients (91 feet) treated with standard nonoperative modalities, there were no differences with regard to sex, age at presentation (12.4 and 12.3 y, respectively), facet involvement, type of coalition, or the presence of a planovalgus deformity. In all, 12/34 (35%) feet in the injection group eventually elected surgical intervention compared with 36/91 (39%) feet that did not receive an injection (P=0.72). For those patients ultimately selecting surgical intervention, the average time from initial presentation to surgery was 878 days in the injection group versus 211 days in the noninjection group (P<0.001). CONCLUSIONS: While subtalar steroid injection can alleviate symptoms in some patients with a talocalcaneal coalition, this intervention does not appear to decrease the need for surgery when compared with traditional nonoperative therapies. In patients failing other forms of conservative treatment, subtalar steroid injections can delay surgical intervention by an average of nearly 2 years. LEVEL OF EVIDENCE: Level-III-therapeutic study.

Lateral Cuneiform Ossification and Tibialis Anterior Tendon Width in Children Ages 3 to 6: Implications for Interference Screw Fixation of Tibialis Anterior Tendon Transfers in Children.

BACKGROUND: While the transfer of the tibialis anterior tendon (TAT) to the lateral cuneiform (LC) following serial casting has been used for nearly 60 years to treat relapsed clubfoot deformity, modern methods of tendon fixation remain largely unstudied. Interference screw fixation represents an alternative strategy that obviates concerns of plantar foot skin pressure-induced necrosis and proper tendon tensioning associated with button suspensory fixation. A better understanding of LC morphology in young children is a necessary first step in assessing the viability of this fixation technique. Therefore, the purpose of this investigation is to define LC morphology and TAT width in children aged 3 to 6 years. METHODS: A retrospective radiographic review of 40 healthy pediatric feet aged 3 to 6 years who had either magnetic resonance imaging or computed tomography scans was performed at a single pediatric hospital. The length, width, and height of only the ossified portion of the LC were measured digitally using sagittal, coronal, and axial imaging. In addition, the maximal cross-sectional diameter of the TAT was measured at the level of the tibiotalar joint. RESULTS: The average ossified LC width ranged from 8.5 mm in the 3-year-old cohort to 10.3 mm in 6-year-old children. Analysis of variance testing revealed no statistically significant difference in width between age groups. Average ossified LC length ranged from 13.5 mm in the 3-year-old cohort to 18.3 mm in 6-year-old children with statistically significant increases in age groups separated by 2 or more years. Significant differences in LC height, volume, and TAT diameter were demonstrated after analysis of variance testing. The TAT to ossified LC width ratio ranged from 44% to 53% across age groups. CONCLUSIONS: The dimensions of the LC ossification center are large enough to allow interference screw fixation in children 3 to 6 years of age. Further studies are needed to investigate interference screw fixation performance in the pediatric clubfoot population. LEVEL OF EVIDENCE: Level IV.

Do We Really Need to Worry About Calcaneocuboid Subluxation During Lateral Column Lengthening for Planovalgus Foot Deformity?

BACKGROUND: Although lengthening of the lateral column through an osteotomy of the anterior calcaneus is an integral component of flatfoot reconstruction in younger patients with flexible planovalgus deformities, the procedure has been implicated in iatrogenic calcaneocuboid (CC) subluxation and subsequent degenerative changes at the CC articulation. The purpose of this study is to characterize alterations at the CC joint after lateral column lengthening (LCL) and determine if Steinmann pin stabilization of the CC joint before distraction maintains a normal relationship. METHODS: Seven matched pairs of fresh-frozen cadaveric feet underwent preprocedure plain radiography and cross-sectional computed tomography (CT) imaging. LCL by osteotomy through the anterior calcaneus was then performed. One foot of each matched pair had a single smooth Steinmann pin placed centrally across the CC joint before osteotomy distraction. Distraction across each osteotomy was then performed and maintained with a 12-mm porous titanium wedge. Repeat imaging was obtained and compared with preprocedure studies to quantify sagittal and rotational differences at the CC articulation. RESULTS: Following LCL, plain radiography demonstrated statistically significant increases in the percentage of the calcaneal articular surface dorsal to the superior aspect of the cuboid in both the pinned (8.2% vs. 17.6%, P=0.02) and unpinned (12.5% vs. 16.3%, P=0.04) specimens. No difference in the percentage of subluxation was found between the 2 groups after LCL. CT imaging demonstrated statistically significant increases in rotation between the calcaneus and cuboid after LCL in both the pinned (7.6±5.6 degrees, P=0.01) and unpinned (17±12.3 degrees, P=0.01) specimens. The degree of rotation was greater in unpinned specimens after LCL (P=0.043). CONCLUSIONS: Both sagittal and rotatory subluxation seem to occur at the CC joint after LCL regardless of pin stabilization. As a single pin would be expected to limit pure translation while having little effect on rotation, it is possible that the rotational changes identified on 3-dimensional imaging are interpreted as dorsal translation when viewed 2 dimensionally using plain radiography. Consideration should therefore be given to CC stabilization with 2 pins during LCL to prevent this rotatory subluxation. LEVEL OF EVIDENCE: Level V-cadaver study.

Accessory Cuboid Facet Associated With Calcaneonavicular Coalitions.

BACKGROUND: Calcaneonavicular (CN) coalitions are the most commonly encountered tarsal coalition. No study has assessed anatomic variations of the adjacent joints in the presence of a CN coalition. This study sought to identify differences in the anatomy of the calcaneocuboid (CC) articulation in feet with and without CN coalitions. METHODS: An institutional review board approved retrospective analysis of patients with symptomatic CN coalitions presenting to a single tertiary care pediatric orthopaedic hospital was performed. Patients without computed tomographic or magnetic resonance imaging were excluded. The morphology and dimensions of the cuboid portion of the CC joint were documented. When contralateral imaging was available in patients with a unilateral coalition, the morphology of the uninvolved side was evaluated to provide a cohort of controls for comparison. RESULTS: Imaging was available for 55 patients who had a mean age of 11.7 years. There were 80 CN coalitions and 18 normal feet. An accessory cuboid facet was identified articulating with the calcaneal portion of the coalition in 60/80 (75%) feet in the coalition group. In feet with a coalition and an accessory facet, the mean total length of the cuboid articular surface measured 25.3 mm (range, 17.7 to 33.3 mm). The average length of the accessory facet was 10.7 mm (range, 5.4 to 15.5 mm), while the length of the primary vertical cuboid articulation with the calcaneus was 14.6 mm (range, 6.4 to 21 mm). The accessory facet comprised 42.3% of the cuboid articular surface in these patients. Feet without a coalition as well as feet with a coalition and no accessory facet had primary vertical cuboid articulations that were significantly larger than feet with a coalition and an accessory facet (P<0.0001). An accessory cuboid facet was identified in only a single control foot (5.6%). CONCLUSIONS: This study reports the frequent presence of an accessory cuboid facet in patients with CN coalitions. This facet was present in 75% of patients with CN coalitions and comprised just over 40% of the cuboid articular length. This anatomic variation represents a significant difference in CC joint morphology between feet with and without CN coalitions. This information may be useful when planning surgical resections. LEVEL OF EVIDENCE: Level III-retrospective cohort study.

Effect of Lateral Column Lengthening on Subtalar Motion in a Cadaveric Model.

BACKGROUND: Although lengthening of the lateral column through a calcaneal neck osteotomy is an integral component of flatfoot reconstruction in younger patients with flexible planovalgus deformities, concern exists as to the effect of this intra-articular osteotomy on subtalar motion. The purpose of this study was to quantify the alterations in subtalar motion following lateral column lengthening (LCL). METHODS: The subtalar motion of 14 fresh-frozen cadaveric feet was assessed using a 3-dimensional motion capture system and materials testing system (MTS). Following potting of the tibia and calcaneus, optic markers were placed into the tibia, calcaneus, and talus. The MTS was used to apply a rotational force across the subtalar joint to a torque of 5 Nm. Abduction/adduction, supination/pronation, and plantarflexion/dorsiflexion about the talus were recorded. Specimens then underwent LCL via a calcaneal neck osteotomy, which was maintained with a 12-mm porous titanium wedge. Repeat subtalar motion analysis was performed and compared to pre-LCL motion using a paired t test. RESULTS: No statistically significant differences in subtalar abduction/adduction (10.9 vs 11.8 degrees, P = .48), supination/pronation (3.5 vs 2.7 degrees, P = .31), or plantarflexion/dorsiflexion (1.6 vs 1.0 degrees, P = .10) were identified following LCL. CONCLUSION: No significant changes in subtalar motion were observed following lateral column lengthening in this biomechanical cadaveric study. CLINICAL RELEVANCE: Although these findings do not obviate concerns of clinical subtalar stiffness following lateral column lengthening for planovalgus deformity correction, they suggest that diminished postoperative subtalar motion, when it occurs, may be due to soft tissue scarring rather than alterations of joint anatomy.

Imaging of the Pediatric Temporomandibular Joint.

Imaging of the temporomandibular joint in pediatric patients is a critical component in the evaluation and treatment of children with temporomandibular joint symptoms. MRI can provide detailed joint anatomy and identify inflammation, sometimes before symptom onset. Ultrasound scan is a convenient emerging modality to evaluate the joint and guide therapeutic injections. Radiography and computed tomography offer osseous detail to recognize early morphologic changes of the mandibular condyle and provide operative planning. Imaging promises to direct treatment to prevent future joint destruction and maintain function.

The influence of education on appropriateness rates for CT pulmonary angiography in emergency department patients.

RATIONALE AND OBJECTIVES: To evaluate appropriate utilization rates for computed tomography (CT) pulmonary angiography (CTPA) in a tertiary center emergency department (ED), before and after a health care provider educational intervention. MATERIALS AND METHODS: Institutional Review Board-approved retrospective study. Records for 100 consecutive CTPA studies ordered by the ED were retrieved from a radiology database. Appropriateness rates for the studies were determined using information from existing literature (clinical decision rules and society guidelines). Where pretest probability was not performed, it was calculated by the authors. After ED health care provider education regarding appropriateness guidelines through a dedicated lecture and question-and-answer session, appropriateness rates for another 100 consecutive CTPA ordered by the ED were calculated. RESULTS: In the preeducational intervention, 1% of patients had Wells scores performed, 65% were women, and 29% were age <40 years. Before CTPA, 40% patients had d-dimer testing, 15% of patients had a "negative" d-dimer, 17% had alternative explanations for chest pain, and 76% had low or intermediate pretest probability. Appropriateness rates for CTPA was 7%, and 8% of studies were positive. Postintervention, no Wells scores were performed, 59% were women, and 34% <40 years. Before CTPA, 32% of patients had d-dimer, 16% had a "negative" d-dimer, 22% had alternative explanations for chest pain, and 84% had low or intermediate pretest probability. The appropriateness rate for CTPA was 6% and 10% of studies were positive. CONCLUSION: A single educational intervention had no effect on appropriate utilization rates for CTPA. Repeated and sustained educational interventions may help improve imaging ordering pathways through the ED and other departments.

Sonographically guided patellar tendon fenestration: prognostic value of preprocedure sonographic findings.

OBJECTIVES: The purpose of this study was to determine whether any sonographic features of jumper's knee can predict the outcome after sonographically guided percutaneous patellar tendon fenestration. METHODS: Patients were identified between July 2001 and March 2009 who had clinical and sonographic findings of jumper's knee, who had failed conservative treatment, and who had sonographically guided percutaneous fenestration of the patellar tendon. Pain levels were assessed before and 4 weeks after fenestration. Sonograms were retrospectively characterized with regard to echogenicity, size, definition, location, calcification, and hyperemia of the abnormal patellar tendon region. Sonographic findings before fenestration were correlated with clinical outcomes. RESULTS: A total of 45 patellar tendons (32 consecutive patients) were included in the study. The average prefenestration functional pain score was 3.6 (range, 2-5), and the average postprocedure functional pain score after 4 weeks was 1.4 (range, 0-5). The preprocedure sonographic finding that correlated with an improved clinical outcome after tendon fenestration was the presence of a well-defined tendon abnormality. No other sonographic findings were associated with the clinical outcome. After fenestration, 76% (34 of 45) showed clinical improvement; 24% (11 of 45) showed no change; and 0% (0 of 45) had worse symptoms at 4 weeks. CONCLUSIONS: The presence of a well-defined area of tendinosis on sonography was associated with clinical improvement after percutaneous sonographically guided fenestration of the patellar tendon. All tendons either improved (76%) or showed no change (24%) in the functional pain score at 4 weeks after fenestration.

Embolization of intracranial aneurysms with second-generation Matrix-2 detachable coils: mid-term and long-term results.

BACKGROUND: Bioactive polyglycolic/polylactic acid (PGLA)-coated Matrix detachable coils were reported to incite intra-aneurysmal inflammation and fibrosis. Multiple large case series with Matrix-1 coils have shown no advantage with respect to aneurysm recurrence. Second-generation Matrix-2 coils were designed with improved platinum support and reduced copolymer friction. We assessed the safety and efficacy of Matrix-2 coil embolization. METHODS: 84 aneurysms were embolized primarily with Matrix-2 coils. Anatomic results were evaluated using a modified Raymond scale with progressive occlusion or recanalization/recurrence strictly defined as any interval change in intra-aneurysmal opacification. RESULTS: Mid-term (8.9 ± 3.4 months) and long-term (23.0 ± 7.4 months) follow-up was available for 65 aneurysms. At mid-term, 55 (85%) aneurysms remained stable (or progressed to occlusion) versus 10 (15%) recurrent aneurysms, 7 (11%) requiring retreatment. At long term, 49 (75%) aneurysms remained stable versus 16 (25%) recurrent aneurysms, 12 (18%) requiring retreatment. Statistically significant factors affecting recanalization included ruptured aneurysms 9/20 (45%), large aneurysms 5/8 (71%), post-procedure residual aneurysms 6/12 (50%) and differential coil packing density of recurrent (21%) versus stable (28%) aneurysms. Patient morbidity (5%) was limited to thromboembolic complications (n=4) or aneurysm rerupture (n=1). Patient mortality (5%) was secondary to subarachnoid hemorrhage complications (n=4) with no procedure-related deaths (0%). CONCLUSION: Coil embolization with Matrix-2 coils is safe and effective, preventing recanalization in small aneurysms at mid-term. Although these aneurysm recurrence rates initially appeared lower than previous reports with Matrix-1 or platinum coils, significant late recanalization was observed on long-term follow-up. We postulate that any derived benefit from Matrix-2 coils is directly dependent on post-procedure outcomes and coil packing density.

Magnetic resonance characterization of pheochromocytomas in the abdomen and pelvis: imaging findings in 18 surgically proven cases.

PURPOSE: To study the magnetic resonance imaging characteristics of adrenal and extra-adrenal pheochromocytomas in the abdomen and pelvis. METHODS: We retrospectively reviewed 18 cases of pathologically proven cases of pheochromocytomas in the abdomen and pelvis. These patients have undergone magnetic resonance imaging evaluation before surgery. The study population included 10 men and 7 women (age range, 19-68 years; mean, 38 years). A consensus review of the magnetic resonance images was performed by 2 blinded expert observers. A qualitative evaluation was completed, and the tumors were classified by anatomical location, shape, T2 signal, contrast enhancement, and signal dropout on chemical shift pulse sequences. RESULTS: On T2-weighted images, most lesions demonstrated mild to moderate increased signal intensity (SI) (n = 12), 5 lesions demonstrated a markedly increased SI, and only 1 lesion demonstrated an isointense SI on T2-weighted images.Five lesions demonstrated marked postcontrast enhancement. Three lesions demonstrated moderate enhancement, and 5 lesions demonstrated mild postcontrast enhancement.The pattern of enhancement was variable: 4 salt and pepper, 4 homogeneous, 3 heterogeneous, and 2 target with central necrosis and hemorrhage. None of the lesions contained significant amount of intracellular lipid, as no lesions demonstrated greater than 16.5% signal dropout on out-of-phase compared with in-phase pulse sequences.

Treatment of ruptured intracranial aneurysms since the International Subarachnoid Aneurysm Trial: practice utilizing clip ligation and coil embolization as individual or complementary therapies.

OBJECT: The aim of this study was to analyze the therapeutic decision-making process and outcome in 100 consecutive patients with aneurysmal subarachnoid hemorrhage (SAH) treated since the completion of the International Subarachnoid Aneurysm Trial (ISAT). All patients were evaluated and treated by a neurosurgeon with subspecialty training in both cerebrovascular and neuroendovascular surgery. METHODS: One hundred consecutive patients with aneurysmal SAH who had been admitted within 1 week posthemorrhage and who had been treated using either surgical clip application or endovascular coil embolization were included in this analysis. All patients underwent a uniform perioperative protocol. All surviving patients were given a questionnaire to assess their modified Rankin Scale score (mRS) and to grade themselves at 6 months and 1 year postintervention. The cohort consisted of 73 women and 27 men with a mean age of 57.27 years (range 27-87 years). Twenty-nine percent of the patients had a World Federation of Neurosurgical Societies (WFNS) Grade IV or V SAH. Forty-seven patients underwent direct surgical clip application, 41 endovascular embolization, and 12 a combination of the two procedures. Good functional outcome--indicated by mRS scores of 0 to 2 after at least 6 months--was achieved in 71% of patients. CONCLUSIONS: Data from the ISAT demonstrated a better functional outcome following endovascular embolization in a selected group of patients with aneurysmal SAH. In routine clinical practice, however, a significant number of patients still benefit from direct surgical clip ligation. Excellent functional results can be realized in a complementary clip ligation and coil occlusion practice in which each patient and aneurysm is evaluated and the two treatment modalities are used individually or, when needed, in combination.

Emerging concepts in the treatment of intracranial aneurysms: stents, coated coils, and liquid embolic agents.

Endovascular techniques for the treatment of intracranial aneurysms are rapidly evolving. Modifications of more traditional coils have been introduced. Such modifications include newer coils coated with various polymers to increase both coil thrombogenicity and degree of aneurysm packing. In addition, newer coil designs aimed at improving the conformability of the coil to the aneurysm have been used with promising preliminary results. The availability of a newer generation of stents specifically designed for intracranial navigation allows for more effective treatment of aneurysms with wide necks, which usually have been considered unsuitable for optimal endovascular treatment. Endovascular alternatives to coil embolization, such as liquid embolic materials, also have been explored for the treatment of intracranial aneurysms, with varying results. We summarize the rationale for use of these newer devices and early clinical experiences. Areas of current research and future directions of endovascular aneurysm treatment also are discussed.

Evolution of endovascular therapy for aneurysm treatment. Historical overview.

The endovascular treatment of intracranial aneurysms has recently become an established therapeutic option. The foundation of this treatment modality was laid by the work done in ground-breaking cases, combined with technological advances since the first half of the 19th century. In this historical overview the authors describe the steps taken by the early pioneers and the results of their work, which was often done under challenging circumstances. The work of these predecessors established the stepping-stones for constant development and refinement for those who have come after them, eventually evolving into the procedures used today. Endovascular treatment of intracranial aneurysms is only possible because of the work of these innovators.