External Fixator Usage and Delayed MRI Scans: A National Survey Study.

OBJECTIVE: To report the current state of institutional protocols regarding the use of MRI in patients with external fixation devices (EFDs) in the United States. DESIGN: National Survey Study. PARTICIPANTS: Practicing orthopaedic surgeons frequenting the Orthopaedic Trauma Association website were invited to participate in this study. RESULTS: Sixty-two eligible orthopaedic surgeons completed the survey. No respondents reported any known harmful complications of MRI use with an EFD. Eight respondents (13%) reported at least one early scan termination because of mild warmth or vibration without any lasting complications. Fifty-six respondents (90%) reported delays to care related to MRI-EFD compatibility labeling, and 27 respondents (48%) reported delayed MRI scans in every patient with an EFD who needed one. Twenty-six surgeons (42%) had modified their practice in some way in response to these barriers. Examples include delaying EFD placement until after MRI, relying on CT arthrograms over MRI for surgical planning, and taking patients to the operating room to remove EFDs temporarily and then replace them. Nineteen respondents (31%) had developed formal protocols to address this issue, but having a written protocol was not associated with any decrease in delays ( P = 0.119). Eighty-nine percent of respondents thought there was a need for a national consensus guideline on this issue. CONCLUSION: Despite no previous reports of harmful complications, MRI utilization is frequently delayed or prevented in patients with EFDs in place. This is a pervasive problem nationally, which persists despite the implementation of written institutional protocols. Additional research is needed, potentially at the national level, to address this common issue. LEVEL OF EVIDENCE: V.

Inter-reader variability when applying the 2013 Fleischner guidelines for potential solitary subsolid lung nodules.

BACKGROUND: In 2013, the Fleischner Society published recommendations for managing subsolid pulmonary nodules. Inter-reader variability has not yet been defined and has potential implications for the ease and reproducibility of applying the guidelines to clinical practice. PURPOSE: To evaluate inter-reader variability when applying the 2013 Fleischner guidelines for potential solitary subsolid lung nodules. MATERIAL AND METHODS: Potential nodules were identified through a systematic retrospective review of CT studies that reported a ground-glass lesion. Three radiologists decided whether these lesions fit criteria of a subsolid nodule and thus merit application of the Fleischner Society guidelines, determined if a solid component was present, and measured each component in two dimensions. Final management recommendations were based on these intermediate decisions. Inter-reader variability for management was calculated and Fleiss' kappa was used to determine significance. Logistic regression and Fisher's exact test determined whether management was contingent on each intermediate decision. RESULTS: Forty-four nodules with mean diameter of 9.4 mm were evaluated by three radiologists. Final management recommendations were in agreement for 93 out of 132 cases (70.4%, kappa = 0.56). Inter-reader variability in management recommendation was contingent on disagreement over whether a pulmonary lesion fit criteria of a subsolid nodule for 24 cases (P < 0.01), whether there was a solid component for 10 cases (P = 0.01), and whether the measurement met the threshold of 5 mm for five cases (P = 0.12). CONCLUSION: There is moderate inter-reader variability when applying the 2013 Fleischner Society management recommendations. Significant contributors of variability include whether the potential lesions fit subsolid nodule criteria and whether a solid component is present. Measurement variability does not significantly affect the final management decisions.