A History and Modern Framework for Quality Improvement in Interventional Radiology.

Quality improvement (QI) initiatives have benefited patients as well as the broader practice of medicine. Large-scale QI has been facilitated by multi-institutional data registries, many of which were formed out of national or international medical society initiatives. With broad participation, QI registries have provided benefits that include but are not limited to establishing treatment guidelines, facilitating research related to uncommon procedures and conditions, and demonstrating the fiscal and clinical value of procedures for both medical providers and health systems. Because of the benefits offered by these databases, Society of Interventional Radiology (SIR) and SIR Foundation have committed to the development of an interventional radiology (IR) clinical data registry known as VIRTEX. A large IR database with participation from a multitude of practice environments has the potential to have a significant positive impact on the specialty through data-driven advances in patient safety and outcomes, clinical research, and reimbursement. This article reviews the current landscape of societal QI programs, presents a vision for a large-scale IR clinical data registry supported by SIR, and discusses the anticipated results that such a framework can produce.

A rare case of Levofloxacin-related Iliopsoas and Achilles tendon rupture.

Achilles tendon rupture is a well-documented adverse effect of Fluoroquinolones; however, herein we present a case of complete iliopsoas and Achilles, and partial semimembranosus tendon rupture secondary to Levofloxacin.

The value of coronal DWI in brainstem stroke diagnosis.

Acute brainstem strokes can present a diagnostic challenge due to its variable clinical presentation. MRI with diffusion-weighted (axial) imaging is highly sensitive for diagnosing ischemic lesions however even that can fail to identify early lesions in the brainstem. Combining coronal section to standard axial MRI-DWI can facilitate early diagnosis in these cases.

Flexion Posteroanterior Radiographs Affect Both Enrollment for and Outcomes After Injection Therapy for Knee Osteoarthritis.

BACKGROUND: Knee injection therapy is less effective for severe osteoarthritis (OA), specifically Kellgren-Lawrence (KL) grade 4. Patient selection for knee injection trials has historically been based on extension anteroposterior (AP) radiographic evaluation; however, emerging evidence suggests that KL grading using a flexion posteroanterior (PA) radiograph more accurately and reproducibly predicts disease severity. The impact of radiographic view on patient selection and outcome after knee injection therapy remains unknown. HYPOTHESIS: A 45° flexion PA radiograph will reveal more advanced knee OA in certain patients. These patients will report worse pre- and postinjection outcomes. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: Four raters independently graded extension AP and flexion PA radiographs from 91 patients previously enrolled in a knee injection trial. Patients determined to have KL grade 4 OA by any rater on extension AP radiographs were excluded. Among included patients, those upgraded to KL grade 4 on flexion PA radiographs by at least 2 raters constituted group 2, while all remaining patients constituted group 1. Demographic data and patient-reported outcome scores before injection and at 6 weeks, 3 months, 6 months, and 12 months postinjection were compared between groups. RESULTS: Overall, 64 patients met the inclusion criteria, of which 19 patients (30%) constituted group 2. Compared with group 1, patients in group 2 were older (58.7 vs 52.3 years, P = .02), had worse visual analog scale pain scores before (6.6 vs 5.3, P = .03) and 6 months after injection (5.3 vs 3.5, P = .01), had less improvement in both Lysholm (8.5 vs 20.5, P = .02) and Short Form-12 physical component (-2.2 vs 1.7, P = .03) scores from preinjection to 6 months postinjection, and had less improvement in both Lysholm (1.6 vs 13.1, P = .03) and Knee injury and Osteoarthritis Outcome Score sport subscale (-2.1 vs 16, P = .01) scores from preinjection to 12 months postinjection. CONCLUSION: One in 3 patients considered to have mild to moderate knee OA on extension AP radiography is upgraded to severe knee OA (KL grade 4) on flexion PA radiography. These patients report worse preinjection outcomes, worse pain scores at short-term follow-up, and decreased improvement in knee function scores between 6 months and 1 year postinjection.

Imaging for Nonarthritic Hip Pathology.

Diagnostic imaging is an essential aspect of the work-up for nonarthritic hip pain. This review, a comprehensive summary of orthopedic diagnostic imaging for nonarthritic hip pathology, includes the modalities of radiographs, computed tomography, and magnetic resonance imaging. The use of each modality in the work-up for nonarthritic hip pain is discussed.

Does the Hip Capsule Remain Closed After Hip Arthroscopy With Routine Capsular Closure for Femoroacetabular Impingement? A Magnetic Resonance Imaging Analysis in Symptomatic Postoperative Patients.

PURPOSE: The purpose of this study was to examine the hip capsule in a subset of symptomatic patients who underwent capsular closure during hip arthroscopy. METHODS: All patients undergoing primary hip arthroscopy for femoroacetabular impingement (FAI) with routine capsular closure between January 1, 2012, and December 31, 2015, were eligible. Only patients with unilateral surgery and a postoperative magnetic resonance imaging (MRI; ordered for persistent symptoms) were included. Four independent reviewers evaluated each hip capsule for thickness and the absence or presence of defects. RESULTS: During the study, 1,463 patients had hip arthroscopy for FAI with routine capsular closure, and 53 (3.6%) underwent a postoperative MRI. Fourteen of the 53 were excluded owing to revision status or additional procedures. The final study population included 39 patients (23 female patients and 16 male patients), with an average patient age of 31.7 ± 11.4 years and an average body mass index of 23.3 ± 2.9. There were 3 (7.5%) capsular defects, and the intraclass correlation coefficient (ICC) was 0.82. The operative hip capsule was significantly thicker in the zone of capsulotomy, and subsequent repair as compared with the unaffected, contralateral hip capsule (5.0 ± 1.2 mm vs 4.6 ± 1.4 mm; P = .02), ICC 0.83. Additionally, males had thicker hip capsules as compared with their female counterparts, on the operative side (5.4 ± 1.1 mm vs 4.5 ± 1.2 mm; P = .02) and the nonoperative side (4.8 ± 1.6 mm vs 4.1 ± 0.9 mm; P = .08). CONCLUSIONS: In a subset of symptomatic patients after hip arthroscopy for FAI, the majority (92.5%) of the repaired hip capsules remained closed at greater than 1 year of follow-up. The hip capsule adjacent to the capsulotomy and subsequent repair is thickened compared with the same location on the contralateral, nonoperative hip. Aside from gender, patient-related and FAI-related factors do not correlate with capsular thickness nor do they seem to correlate with the propensity to develop a capsular defect. LEVEL OF EVIDENCE: Level IV, prognostic case series.

Computed Tomographic Characterization of Traumastem-A New Oxidized Cellulose Hemostatic Agent.

Oxidized regenerated cellulose (ORC) is a commonly used surgical hemostatic agent. When retained at the surgical site, it is frequently misdiagnosed on postoperative computed tomography (CT) images as an abscess or a recurrent tumor. Oxidized nonregenerated cellulose (ONC) is a new, more effective version of ORC. It is more effective because of its unorganized fiber structure and greater material density, which may also alter its appearance on CT images relative to ORC. This image report compares the CT characteristics of ONC and ORC. A rabbit's bilateral femoral arteries were punctured to model peripheral vascular surgery. ORC was used to treat 1 of the femoral artery punctures and ONC to treat the contralateral puncture. Noncontrast CT imaging was performed immediately following surgery (day 0) and on postoperative day 14. On day 0, both ORC and ONC were isoattenuating relative to muscle and hyperattenuating to fat, although ONC appears more homogenous. On day 14, neither ORC nor ONC was clearly identifiable. Thus, postoperative retention of ONC can obscure immediate postoperative CT interpretation and, similar to ORC, lead to an erroneous diagnosis of an abscess. By day 14, ONC retention may not obscure CT interpretation. In noncontrast CT imaging, ONC appears more homogeneous than ORC, but is otherwise indistinguishable. The greater homogeneity of ONC may be caused by the unorganized fiber structure or greater material density. Intraoperative use of ONC should be clinically investigated before radiographically diagnosing a postoperative abscess or recurrent tumor.

Muscle soreness and delayed-onset muscle soreness.

Immediate and delayed-onset muscle soreness differ mainly in chronology of presentation. Both conditions share the same quality of pain, eliciting and relieving activities and a varying degree of functional deficits. There is no single mechanism for muscle soreness; instead, it is a culmination of 6 different mechanisms. The developing pathway of DOMS begins with microtrauma to muscles and then surrounding connective tissues. Microtrauma is then followed by an inflammatory process and subsequent shifts of fluid and electrolytes. Throughout the progression of these events, muscle spasms may be present, exacerbating the overall condition. There are a multitude of modalities to manage the associated symptoms of immediate soreness and DOMS. Outcomes of each modality seem to be as diverse as the modalities themselves. The judicious use of NSAIDs and continued exercise are suggested to be the most reliable methods and recommended. This review article and each study cited, however, represent just one part of the clinician's decisionmaking process. Careful affirmation of temporary deficits from muscle soreness is not to be taken lightly, nor is the advisement and medical management of muscle soreness prescribed by the clinician.

Biceps tenotomy versus tenodesis: a review of clinical outcomes and biomechanical results.

HYPOTHESIS: There are significant differences in incidence of cosmetic deformity and load to tendon failure between biceps tenotomy versus tenodesis for the treatment of long head of the biceps brachii (LHB) tendon lesions which are supported by the evidence-based strengths and weaknesses of each procedure in the literature. MATERIALS AND METHODS: PubMed, Embase, and Cochrane databases were searched for eligible clinical and biomechanical articles relating to biceps tenotomy or tenodesis from 1966 to 2010. Keywords were biceps tenotomy, biceps tenodesis, long head of the biceps brachii, and Popeye sign. All relevant studies were included based on study objectives, and excluded studies consisted of abstracts, case reports, letters to the editor, and articles without outcome measures. RESULTS: All articles reviewed were of level IV evidence. Combined results from reviewed papers on the differences between LHB tenotomy vs tenodesis demonstrated a higher incidence of cosmetic deformity in patients treated with biceps tenotomy. Complications were similar for each treatment, with a higher likelihood of bicipital pain associated with tenodesis. Lack of high levels of evidence from prospective randomized trials limits our ability to recommend one technique over another. DISCUSSION: This review demonstrated a higher incidence of cosmetic deformity in patients treated with biceps tenotomy compared with tenodesis, with an associated lower load to tendon failure. However, there was no consensus in the literature regarding the use of tenotomy vs. tenodesis for LHB tendon lesions due to variable results and methodology of published studies. Individual patient factors and needs should guide surgeons on whether to use tenotomy or tenodesis. CONCLUSIONS: There is a great need for future studies with high levels of evidence, control, randomization, and power, with well-defined study variables, to compare biceps tenotomy and tenodesis for the treatment of LHB tendon lesions.

Superior versus anteroinferior plating of the clavicle revisited: a mechanical study.

OBJECTIVES: This study was designed to compare bone-implant stiffness of two fixation techniques on a sawbone model of a clavicle fracture. METHODS: Twenty-four preosteotomized synthetic left clavicles (Sawbones Worldwide, Vashon, WA) were divided into four groups based on type of fixation: standard 3.5-mm pelvic reconstruction plate in the superior position; standard 3.5-mm pelvic reconstruction plate in an anteroinferior position; 3.5-mm locking pelvic reconstruction plate in a superior position; and a 3.5-mm locking pelvic reconstruction plate in an anteroinferior position. Three nondestructive cyclic mechanical tests were performed in random order: axial, torsion, and four-point bend. RESULTS: No significant difference was found in axial (P = 0.61) or torsional stiffness (internal rotation, P = 0.46 or external rotation, P = 0.49) among all groups. No significant difference occurred in bending rigidity (four-point bending test) with type of plate (P = 0.41), but when the plate was placed anteroinferiorly, bending rigidity was significantly higher (P < 0.001) than in the superior position. CONCLUSION: Placing the plate anteroinferiorly on the clavicle provides a more stable construct in terms of bending rigidity with no detriment in axial and torsional stiffness compared with placing the plate superiorly. We believe that anteroinferior plating is preferred as a result of the increase in bending rigidity together with other advantages, including avoidance of neurovascular compromise, the use of longer screws, and decreased hardware prominence.

MRI analysis of tibial position of the anterior cruciate ligament.

This study aimed to establish normal values for the position of the native anterior cruciate ligament (ACL) insertion on the tibia to assist in the evaluation of tunnel placement after primary ACL reconstruction or prior to revision surgery. One hundred consecutive MRI studies performed on patients with a mean age of 29 years (range 20-35) from a single MRI facility were reviewed. Patients with prior surgery, significant osteoarthritis, acute ACL injury, or evidence of ACL reconstruction were excluded. Using digital image software, measurements were taken of anterior-most and posterior-most portions of the ACL insertion on the tibia. Depth of the tibia was also measured from the anterior edge of the tibial plateau to the posterior edge at the origin of the posterior cruciate ligament. The anterior insertion of the native ACL was located at a mean of 14 ± 3 mm (28 ± 5%) from the anterior tibial articular margin; the posterior portion of the ACL was located at a mean of 31 ± 4 mm (63 ± 6%). The tibial insertion of the ACL is located between 28 and 63% of the total anterior-posterior depth of the tibia. The results from this study are clinically relevant as they provide the clinician with baseline data to describe the position of the tibial footprint of the native ACL on sagittal MR imaging. Further, this data can be used as a guide to evaluate tibial tunnel position prior to primary ACL reconstruction, revision ACL surgery, or in ACL-reconstructed patients who continue to experience pain, instability, or dysfunction postoperatively.

Painless, atraumatic, isolated lateral compartment syndrome of the leg: an unusual triad of atypical findings.

Compartment syndrome can be a devastating complication with significant morbidity when not recognized or treated expediently. Among the classic pentad of signs and symptoms associated with compartment syndrome, pain that is out of proportion to the injury is often cited as the earliest and most sensitive. We present a case report of an atypical presentation of compartment syndrome of the leg in which a patient taking lithium for bipolar disorder did not report pain out of proportion to the injury mechanism. Lithium has been implicated in altering pain perception and increasing the tolerance and threshold for pain, but this has not been widely reported in the orthopedic literature. In addition to compartment syndrome that was painless, the patient presented with 2 additional atypical findings. She presented with compartment syndrome that was atraumatic and isolated to only 1 out of the 4 compartments of the leg. A compartment syndrome that is painless, atraumatic, and isolated to a single compartment represents an unusual triad of atypical findings that has not been previously reported. With unusual presentations of compartment syndrome, there is an increased risk of late or unrecognized diagnosis, consequently increasing the likelihood of significant nerve damage or muscle necrosis. Clinicians have historically applied a higher level of scrutiny to patients who were deemed "obtunded," that is, those in whom an assessment of pain cannot be reliably determined. In the past, obtunded patients have included intubated or comatose patients, infants and children, mentally disabled patients, and patients with altered mental status, nerve injury, or distracting injuries. Based on evidence from the psychiatry and anesthesia literatures, we propose that patients taking lithium should be added to this list of "obtunded" patients in whom a reliable assessment of pain may not be possible.

Fixation of tissue-engineered human neocartilage constructs with human fibrin in a caprine model.

The primary objective of this study was to determine the retention rate of neocartilage constructs in caprine full-thickness cartilage defects by fibrin sealant alone. Two defects, one each on the trochlea and the medial femoral condyle, were created in the stifle joint in 12 goats. Eight goats (16 defects) were treated with neocartilage constructs and 4 goats (8 defects) with fibrin glue alone. Postoperative activity was protected weight bearing for 6 weeks and then unrestricted for 18 weeks. At 24-week procurement, 4 neocartilage constructs were retained in 8 medial femoral defects and 4 in 8 trochlear defects. In gross comparison, the defects that retained the construct had a mean grade significantly higher than defects treated with fibrin glue alone. The mean histological score of defects with retained constructs was also higher than those treated with fibrin sealant alone. There was no appreciable immunologic reaction to the human neocartilage xenograft or human fibrin sealant.

A randomized, prospective, double-blind study to investigate the effectiveness of adding DepoMedrol to a local anesthetic injection in postmeniscectomy patients with osteoarthritis of the knee.

BACKGROUND: Patients with osteoarthritis of the knee are at risk for poorer outcomes after arthroscopic meniscectomy. Intra-articular corticosteroid injections have been shown to be efficacious both in patients with osteoarthritis and postarthroscopy patients. HYPOTHESIS: A postoperative, intra-articular methylprednisolone and lidocaine injection in patients with chondromalacia undergoing meniscectomy will improve patient-rated pain and function compared with control patients. STUDY DESIGN: Randomized, controlled trial; Level of evidence, 1. METHODS: A total of 58 patients (59 knees) were randomized in a double-blinded fashion to receive either saline plus lidocaine (saline) or methylprednisolone plus lidocaine (steroid) after arthroscopic meniscectomy in which chondromalacia (modified Outerbridge grade 2 or higher) was confirmed. Preoperatively and at follow-up-6 weeks and 6, 9, and 12 months-patients underwent an examination and completed a subjective functioning survey. Scores were calculated using several validated scoring systems including the Lysholm, International Knee Documentation Committee (IKDC), and Short Form-12 (SF-12). RESULTS: No statistically significant differences were observed between the saline (n = 30) and steroid (n = 29) groups in their demographics and preoperative scores. At 6 weeks, the steroid group had higher scores than the saline group on multiple scales, including the IKDC. No differences in outcome scores existed at later time points. At 12 months, 86% of the steroid and 69% of the saline group were completely or mostly satisfied with the procedure (P = .01). In the saline group, 4 patients required reinjection and 2 underwent joint replacements within 12 months, while the steroid group had 3 reinjections and 2 meniscus transplants. CONCLUSION: The addition of a postoperative corticosteroid injection resulted in improved pain and function at an early time point; however, it provided no lasting difference compared with only local anesthetic injection.

Biceps tendinitis in chronic rotator cuff tears: a histologic perspective.

Patients with chronic rotator cuff tears frequently have anterior shoulder pain attributed to the long head of the biceps brachii (LHBB) tendon. In this study, tenodesis or tenotomy samples and cadaveric controls were assessed by use of immunohistochemical and histologic methods to quantify inflammation, vascularity, and neuronal plasticity. Patients had moderate pain and positive results on at least 1 clinical test of shoulder function. The number of axons in the distal LHBB was significantly less in patients with biceps tendinitis. Calcitonin gene-related peptide and substance P immunostaining was predominantly within nerve roots and blood vessels. A moderate correlation (R = 0.5) was identified between LHBB vascularity and pain scores. On the basis of these results, we conclude that, in the context of rotator cuff disease, the etiology of anterior shoulder pain with macroscopic changes in the biceps tendon is related to the complex interaction of the tendon and surrounding soft tissues, rather than a single entity.

Systematic review of single-bundle anterior cruciate ligament reconstruction outcomes: a baseline assessment for consideration of double-bundle techniques.

BACKGROUND: There is increasing interest in comparing the efficacy of single-bundle versus double-bundle anterior cruciate ligament reconstruction. Challenging this comparison, however, has been the lack of an established consensus on the success of single-bundle reconstruction. HYPOTHESIS: The current outcomes of single-bundle reconstruction can be clarified from a large unbiased body of evidence for future comparisons with double-bundle reconstructions. STUDY DESIGN: Systematic review. METHODS: A systematic review of 11 randomized, controlled trials comparing patellar tendon and hamstring tendon grafting is reported. The respective outcomes of each group were combined to assist the orthopaedic surgeon in assessing the current success of single-bundle reconstruction. The primary factors assessed were tibial subluxation and side-to-side differences in laxity. Secondary outcomes included concomitant injuries and treatments, complications, graft failure, range of motion, and radiographic evidence of degenerative changes. RESULTS: In this review of 1024 single-bundle anterior cruciate ligament reconstructions, 495 concomitant meniscal tears, 95 chondral injuries, and 2 posterior cruciate ligament tears were noted. The complication rate was 6%, and graft failure 4%. Reported pivot-shift test results were negative in 81% of cases; reported Lachman tests were negative in 59% cases; and KT-1000 arthrometer side-to-side differences were

Femoral and tibial tunnel position using a transtibial drilled anterior cruciate ligament reconstruction technique.

This study evaluates the position of the femoral tunnel, which is achieved using a transtibial, single-bundle anterior cruciate ligament (ACL) reconstruction technique. The radiographs of 50 consecutive, primary single-bundle ACL reconstructed knees using this technique were reviewed. The angle between the femoral tunnel and the apex of the intercondylar notch was recorded. The average angle from the 12-o'clock vertical position to the femoral tunnel was 49 degrees (range, 39 degrees-59.2 degrees; SD = 3.9), corresponding to the 10:20 position on a clock face for a right knee. These results demonstrate that it is technically possible to create an obliquely oriented single-bundle femoral tunnel at approximately the 10:20 position through a tibial tunnel angled approximately 60 degrees from the proximal tibial joint surface. This correlates to a femoral tunnel approximately midway between the anteromedial and posterolateral bundle origins of the ACL.