Hip joint space width in an asymptomatic population: Computed tomography analysis according to femoroacetabular impingement morphologies.

BACKGROUND: Although the association between femoroacetabular impingement (FAI) syndrome and hip osteoarthritis (OA) is well established, not all hips exhibiting cam or pincer morphologies (i.e. imaging findings of FAI syndrome) are symptomatic or arthritic. It is difficult to detect which subgroup will wear out, or how does the arthritic process start radiographically. Therefore, we measured in a retrospective study based on computed tomography (CT) analysis, the joint space width (JSW) according to a standard protocol and we investigated its variation according to the presence of a cam and/or pincer morphology. We hypothesized that the radiological presence of a cam and/or pincer hip morphologies, even in asymptomatic subjects, would affect JSW. METHODS: Two hundred pelvic CT scans performed for non-orthopedic etiologies in asymptomatic patients were analyzed using a 3D software. After excluding patients with hip OA or previous hip surgery, 194 pelvic CT scans (388 hips) were retained. We measured for each hip the presence of FAI syndrome imaging findings (cam and pincer morphologies) using the classical parameters of coxometry. In addition, we performed a measurement of articular joint space width according to a standard protocol. We then calculated the mean thickness of 3 defined regions along the femoroacetabular joint: anterior-superior, posterior-inferior, and posterior-superior. Lastly, we compared the JSW across 4 groups: hips with (1) no cam or pincer, (2) pincer, (3) cam, and (4) cam and pincer morphologies using a multivariate analysis. Additionally, a topographic heatmap of JSW was plotted allowing quantitative representation of JSW along the joint. RESULTS: Increased JSW with peak difference of 0.9 mm (25.7%) was found in hips with cam and pincer morphologies when compared to normal ones (p = 0.002) and to hips with pincer or cam morphologies only. CONCLUSION: Positive variations in JSW were associated to the presence of cam and pincer morphologies. This significant increase in JSW could be one of the earliest measurable changes preceding later classical alterations.

Omphalitis with Umbilical Abscess in an Adult with a Urachal Remnant.

Omphalitis is an inflammation of the umbilicus and is seldom diagnosed in adults. It is even rarer when it results from an infection of the urachus, an embryological remnant that connects the umbilicus to the dome of the bladder. Patients with omphalitis present with erythema, edema, tenderness, and purulent discharge form the umbilical stump. Workup includes ultrasonography and CT scan of the abdomen and pelvis. Management consists of antibiotics and incision and drainage of the umbilical abscess, followed by surgical resection of the urachal remnant. In this article, we report a case of omphalitis complicated by umbilical abscess in a 20-year-old female with a urachal remnant.

The Ischial Spine in Developmental Hip Dysplasia: Unraveling the Role of Acetabular Retroversion in Periacetabular Osteotomy.

PURPOSE: Radiological diagnosis of acetabular retroversion (AR) is based on the presence of the crossover sign (COS), the posterior wall sign (PWS), and the prominence of the ischial spine sign (PRISS). The primary purpose of the study is to analyze the clinical significance of the PRISS in a sample of dysplastic hips requiring periacetabular osteotomy (PAO) and evaluate retroversion in symptomatic hip dysplasia. METHODS: In a previous paper, we reported the classic coxometric measurements of 178 patients with symptomatic hip dysplasia undergoing PAO where retroversion was noted in 42% of the cases and was not found to be a major factor in the appearance of symptoms. In the current study, we have added the retroversion signs PRISS and PWS to our analysis. Among the retroverted dysplastic hips, we studied the association of the PRISS with the hips requiring PAO. We also defined the ischial spine index (ISI) and studied its relationship to the coxometric measurements and AR. RESULTS: In hips with AR, the operated hips were significantly associated with the PRISS compared to the nonoperated ones (χ 2 = 4.847). Additionally, the ISI was able to classify acetabular version (anteverted, neutral, and retroverted acetabula). A direct correlation between the ISI and the retroversion index (RI) was found, and the highest degree of retroversion was found when the 3 signs of acetabular retroversion were concomitantly present (RI = 33.6%). CONCLUSION: The PRISS, a radiographic sign reflecting AR, was found to be significantly associated with dysplastic hips requiring PAO where AR was previously not considered a factor in the manifestation of symptoms and subsequent requirement for surgery. Moreover, the PRISS can also serve as an adequate radiographic sign for estimating acetabular version on pelvic radiographs.

Management of patients with high-risk and advanced prostate cancer in the Middle East: resource-stratified consensus recommendations.

PURPOSE: Prostate cancer care in the Middle East is highly variable and access to specialist multidisciplinary management is limited. Academic tertiary referral centers offer cutting-edge diagnosis and treatment; however, in many parts of the region, patients are managed by non-specialists with limited resources. Due to many factors including lack of awareness and lack of prostate-specific antigen (PSA) screening, a high percentage of men present with locally advanced and metastatic prostate cancer at diagnosis. The aim of these recommendations is to assist clinicians in managing patients with different levels of access to diagnostic and treatment modalities. METHODS: The first Advanced Prostate Cancer Consensus Conference (APCCC) satellite meeting for the Middle East was held in Beirut, Lebanon, November 2017. During this meeting a consortium of urologists, medical oncologists, radiation oncologist and imaging specialists practicing in Lebanon, Syria, Iraq, Kuwait and Saudi Arabia voted on a selection of consensus questions. An additional workshop to formulate resource-stratified consensus recommendations was held in March 2019. RESULTS: Variations in practice based on available resources have been proposed to form resource-stratified recommendations for imaging at diagnosis, initial management of localized prostate cancer requiring therapy, treatment of castration-sensitive/naïve advanced prostate cancer and treatment of castration-resistant prostate cancer. CONCLUSION: This is the first regional consensus on prostate cancer management from the Middle East. The following recommendations will be useful to urologists and oncologists practicing in all areas with limited access to specialist multi-disciplinary teams, diagnostic modalities and treatment resources.

Gas-Forming Liver Abscess versus Emphysematous Hepatitis: A Radiologic Diagnostic Dilemma-A Case Report and Review of the Literature.

A 38-year-old diabetic woman, with history of cholecystectomy and ventral hernia repair, was hospitalized due to sudden-onset abdominal pain and fever. Computed tomography revealed a mixed collection containing necrotic debris and emphysematous change in the left lobe of the liver mainly in segments II and III. These radiological findings suggested emphysematous hepatitis (EH). The patient's condition deteriorated rapidly, and she was rushed to the operating room for urgent exploratory laparotomy where debridement was performed. Intraoperatively the patient was found to have an abscess with incomplete capsule concurrent with hepatic necrosis suggesting the co-occurrence of abscess and EH. The patient survived and was discharged after 13 days. Relevant literature was reviewed, and to the best of our knowledge, EH is an extremely rare entity with limited data regarding its pathogenesis, causative organisms, and management. EH is a rapidly invasive disease process that can be fatal if appropriate therapeutic intervention is delayed. Initial presentations are usually subtle, thus high clinical and radiological suspicion is required for early diagnosis and management to decrease associated mortality and morbidity. We hence report the first successfully treated case of EH with review of the literature.

A Dynamic Anatomical Description of the Parietal Pleura Setting Safety Limits for Intercostal Percutaneous Access.

PURPOSE: We came up with a dynamic anatomical study intended to validate the safety of intercostal approach used by our center to access the upper pole of the kidney during percutaneous surgery. MATERIALS AND METHODS: A total of 101 patients presenting randomly to the radiology department for CT evaluation of the abdomen and superior pelvis were involved in this study. Deep inspiration and expiration sequences in the prone position were evaluated to establish the location of the parietal pleura in relation to different anatomical landmarks. Three-dimensional reconstruction was performed to simulate the access needle course through the retroperitoneum. RESULTS: Our data show that the position of parietal pleura is invariably higher on the right side irrespective of anatomical relation or respiratory changes. Higher position of the parietal pleura was noted in all considered landmarks upon full expiratory sequences. Using the midclavicular line as a landmark, our data show that on the right side, the parietal pleura was higher than the 10th intercostal space (ICS) in 100% of patients. Going up to the level of the ninth and eighth ICS, the pleura is higher in 89.1% and 66.3% of patients, respectively. Moreover, on the left side, the level of the parietal pleura was higher than the 11th ICS in 100% of patients. Reaching the 10th ICS, the parietal pleura still is higher in 92.07% of cases. Going up to the ninth ICS reduces the margin to 64.35% and using the eighth ICS would convey a margin of 24.7%. CONCLUSIONS: Supracostal access for percutaneous nephrolithotomy carries a risk of pulmonary complications, limiting its use worldwide. We have shown in this study that using the differences in inspiration and expiration along with the right anatomical landmarks could substantially lower the risk of complications. However, regardless of the side or landmark used, supracostal access is safe in >90% of cases.

Metastatic prostate adenocarcinoma presenting with pulmonary symptoms: a case report and review of the literature.

INTRODUCTION: Prostate cancer has a high tendency to spread to bone. Pulmonary metastasis and generalized lymphadenopathy commonly develop after pelvic and bone involvement have already occurred. Few patients with prostate cancer present initially with symptomatic metastatic lung lesions and lymphadenopathy without any other concomitant distant dissemination. CASE PRESENTATION: We report a case of a 73-year-old white male who sought medical help for symptoms of cough, hemoptysis, and dyspnea. A chest X-ray was done revealing multiple "cannon ball" infiltrates involving all segments of the lung parenchyma. Fine-needle aspiration cytology under computed tomography guidance of a subpleural lesion revealed adenocarcinomatous cells. Despite the absence of any detectable osseous lesions and with the presence of multiple hilar, mediastinal, para-aortic, and pelvic lymphadenopathy, the patient had a complete work-up in search for the primary adenocarcinoma. His prostate specific antigen was 146 ng/ml and a prostatic biopsy done, revealing an acinar prostatic adenocarcinoma. A tru-cut biopsy of a lung lesion under computed tomography guidance showed a metastatic prostatic adenocarcinoma positive for prostate specific antigen stain. CONCLUSION: This case sheds light on an unusual metastatic pattern of prostatic adenocarcinoma. It also emphasizes the importance of including prostate cancer in the differential diagnosis of men with adenocarcinoma of unknown origin.