Use of Preoperative Magnetic Resonance Imaging to Predict Clinical Outcomes After Core Muscle Injury Repair.

BACKGROUND: Core muscle injury (CMI), often referred to as a sports hernia or athletic pubalgia, is a common cause of groin pain in athletes. Imaging modalities used to assist in the diagnosis of CMI include ultrasound (US) and magnetic resonance imaging (MRI). PURPOSE: To determine if preoperative MRI findings predict clinical outcomes after surgery for CMI. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: A retrospective cohort study was performed on a consecutive series of patients who were operatively treated for CMI by a single surgeon. CMI was diagnosed based on history, physical examination, and a positive US. In addition, all patients underwent a preoperative MRI. Patients were divided into 2 groups based on whether the MRI was interpreted as positive or negative for CMI. All patients underwent mini-open CMI repair. Patient-reported outcomes (PROs) were collected both pre- and postoperatively and included a visual analog scale (VAS) for pain, the University of California, Los Angeles (UCLA) activity score, and the modified Harris Hip Score. RESULTS: A total of 39 hips were included in this study, of which 17 had a positive MRI interpretation for CMI (44%) and 22 had a negative MRI interpretation (56%). Mean age at the time of surgery was 35 years (range, 17-56 years), and mean follow-up was 21 months (range, 12-35 months). No significant difference was found between groups in mean age or time to follow-up. Patients in both groups demonstrated significant improvement from preoperative to most recent follow-up in terms of the UCLA activity score (P < .05). VAS scores significantly improved for patients with a positive MRI interpretation (P = .001) but not for those with a negative MRI interpretation (P = .094). No significant difference on any PROs was found between groups at the most recent follow-up. CONCLUSION: Successful clinical outcomes can be expected in patients undergoing surgery for CMI diagnosed based on history, physical examination, and US. Patients with a preoperative MRI consistent with CMI may experience greater improvement in pain postoperatively, although MRI does not predict postoperative activity level in these patients.

A proposed algorithm for the treatment of core muscle injuries.

In recent years, there has been increased awareness and treatment of groin injuries in athletes. These injuries have been associated with various terminologies including sports hernia, core muscle injury (CMI), athletic pubalgia and inguinal disruption, among others. Treatment of these injuries has been performed by both orthopaedic and general surgeons and may include a variety of procedures such as rectus abdominis repair, adductor lengthening, abdominal wall repair with or without mesh, and hip arthroscopy for the treatment of concomitant femoroacetabular impingement. Despite our increased knowledge of these injuries, there is still no universal terminology, diagnostic methodology or treatment for a CMI. The purpose of this review is to present a detailed treatment algorithm for physicians treating patients with signs and symptoms of a CMI. In doing so, we aim to clarify the various pathologies involved in CMI, eliminate vague terminology, and present a clear, stepwise approach for both diagnosis and treatment of these injuries.

Acute Appendicitis Masquerading Distal Intestinal Obstruction Syndrome in Adult Cystic Fibrosis.

Overshadowed by Sino-pulmonary infections, Cystic Fibrosis (CF) commonly affects gastrointestinal organs because of secretory and motility dysfunction. Infrequently, these changes result in Distal Intestinal Obstruction Syndrome (DIOS), an increasingly diagnosed gastrointestinal entity in adult Cystic Fibrosis patients. We present a case 22-year-old male who presented to our hospital with right lower quadrant abdominal pain with suspicion of acute appendicitis and was subsequently diagnosed as DIOS. Our case highlights the importance of DIOS as one of the differential diagnosis of right lower quadrant abdominal pain in a patient with a CF, especially for physicians working at community hospitals which may not have a Cystic Fibrosis care program available.

Ultrasound-Guided Calcium Debridement of the Shoulder Joint: A Case Series.

OBJECTIVE: Our purpose was to assess the outcomes of those who underwent an ultrasound-guided debridement of the deposits. Specifically, we analyzed: (1) function; (2) pain; (3) activity level; (4) patient satisfaction; and (5) complications. MATERIALS AND METHODS: A review of patients who underwent an ultrasound-guided debridement of calcific deposits about their shoulder joint between 2005 and 2015 was performed. Our final cohort consisted of 38 patients with a mean age of 53 years (range, 35 to 62 years)-11 men and 27 women-and a mean follow up of 32 months (range, 12 to 53 months). Functional outcomes, activity level, and pain level were assessed using the Disabilities of Arm, Shoulder, and Hand (DASH) scale, the University of Southern California (UCLA) activity scale, and the Visual Analog Scale (VAS). Additionally, patients were asked if they were satisfied with the outcomes of their procedure. All medical records were assessed for potential complications from this procedure. RESULTS: Excellent outcomes were achieved. The mean DASH score improved from 21 to 10 points (p=0.0001). Additionally, mean UCLA score increased from 2 to 7 points (p=0.0001). Furthermore, the mean reported VAS improved from 8 to 1.6 (p=0.0001). Ninety-seven percent of patients reported being satisfied. There were no reported complications in our cohort. CONCLUSION: We found that this procedure can result in effective pain relief and prevent or delay the need for more invasive procedures. Future studies should evaluate the role of calcium deposit size in the outcomes of those who undergo debridement.

Accuracy and Safety of Percutaneous Lumbosacral Pedicle Screw Placement Using Dual-Planar Intraoperative Fluoroscopy.

STUDY DESIGN: Retrospective case series with prospective arm. PURPOSE: To assess the safety and accuracy of percutaneous lumbosacral pedicle screw placement (PLPSP) in the lumbosacral spine using intraoperative dual-planar fluoroscopy (DPF). OVERVIEW OF LITERATURE: There are several techniques available for achieving consistent, safe, and accurate results with PLPSP. There is a paucity of literature describing the beneficial operative, economic, and clinical outcomes of DPF, the most readily accessible image guidance system. METHODS: From 2004 to 2014, 451 consecutive patients underwent PLPSP using DPF, for a total of 2,345 screw placement. The results of prospectively obtained postoperative computed tomography (CT) examinations of an additional 41 consecutive patients were compared with the results of 104 CT examinations obtained postoperatively due to clinical symptomatology; these results were interpreted by three reviewers. The rates of revision indicated by misplaced screws with consistent clinical symptomatology were compared between groups. Pedicle screw placement was graded according to 2-mm increments in medial pedicle wall breach and measurement of screw axis placement. RESULTS: Seven of the 2,345 pedicle screws placed percutaneously with the use of the dual-planar fluoroscopic technique required revision because of a symptomatic misplaced screw, for a screw revision rate of 0.3%. There were no statistically significant demographic differences between patients who had screws revised and those who did not. All screws registered greater than 10 mA on electromyographic stimulation. In the 41 prospectively obtained CT examinations, one out of 141 screws (0.7%) was revised due to pedicle wall breach; whereas among the 104 patients with 352 screws, three screws were revised (0.9%). CONCLUSIONS: DPF is an extremely accurate, safe, and reproducible technique for placement of percutaneous pedicle screws and is a readily available and cost-effective alternative to CT-guided pedicle screw placement techniques. Postoperative CT evaluation is not necessary with PLPSP unless the patient is symptomatic. Acceptable electromyographic thresholds may need to be reevaluated.

Accuracy of in vivo palpation-guided acromioclavicular joint injection assessed with contrast material and fluoroscopic evaluations.

OBJECTIVE: The purpose of this study was to evaluate the accuracy of in vivo acromioclavicular (AC) joint injections without fluoroscopic guidance and assess whether patient demographics affected the accuracy of injections. MATERIALS AND METHODS: A consecutive cohort of patients who presented with painful acromioclavicular joints was prospectively evaluated. All patients had clinical and radiographic evidence of AC arthritis, had failed conservative measures, and thus had received intraarticular corticosteroid injections. All injections were performed by experienced fellowship-trained musculoskeletal radiologists and by blinded digital palpation technique. Accuracy of injections was assessed with biplanar fluoroscopic views. RESULTS: Forty-one AC injections in 22 males and 16 females with a mean age of 51 years (range 18 to 78) were identified. Twenty-three injections were in the right shoulder and 18 in the left. Only 15 injections were confirmed to be in the intraarticular AC joint, yielding an accuracy of 36.5%. There were no significant differences in the mean age (54 vs. 52 years; p = 0.58), male-to-female ratio (p = 0.73), and side of the injection between the accurate and inaccurate injections, respectively. CONCLUSION: Based on the findings of the present study, the authors encourage the use of image guidance for corticosteroid treatment of the AC joint. LEVEL OF EVIDENCE: Level IV Therapeutic Case Series.

Diagnosis and triage of a patient with an extra-osseous fat fluid level.

Extra-osseous fat fluid level is rarely seen in osteomyelitis, with only three magnetic resonance imaging (MRI) cases previously reported in the literature. The rarity of this finding is probably secondary to the extensive necrosis of bone marrow that needs to occur at a rapid phase for the fat to accumulate. However, an extra-osseous fat fluid level is a specific diagnostic sign of osteomyelitis in cases with otherwise equivocal imaging findings and should be reported as such, especially when associated with medullary bone destruction and in the absence of trauma.

Primary osteomyelitis of the acetabulum resulting in septic arthritis of the hip and obturator internus abscess diagnosed as acute appendicitis.

The misdiagnosis of acute appendicitis is not uncommon. Rarely does infection of the triradiate cartilage imitate this entity. This case highlights an uncommon presentation of acetabular osteomyelitis as acute appendicitis and the severity of its sequelae. Like septic arthritis of the hip, acute appendicitis overtreatment is acceptable in part because of the complications resulting from delayed diagnosis and treatment. However, this case demonstrates the need to consider pelvic osteomyelitis and peripelvic infection in the differential diagnosis of appendicitis.

Periostitis secondary to interleukin-11 (Oprelvekin, Neumega). Treatment for thrombocytopenia in pediatric patients.

Interleukin-11 (Oprelvekin, Neumega) is a newly introduced thrombopoietic growth factor that stimulates production, differentiation, and maturation of megakaryocytes and platelets. Reversible periostitis has been reported as the side effect of the drug in primates and in the phase I/II trials. We report our experience with 5 cases of periostitis, occurring in thrombocytopenic children with three non-malignant and two malignant conditions, out of 24 pediatric patients treated with IL-11 at 75 micro g/kg per day for a median of 17 days. The findings were noted in the clavicle or the proximal humerus. Two patients also had forearm and lower-extremity long-bone involvement. All patients had normal bones before IL-11 was given, changes occurred in both non-malignant and malignant diseases, and periostitis disappeared after use of the drug was discontinued. The distribution and appearance of the changes are similar to prostaglandin E1 and hypervitaminosis A. The changes are reversible after termination of treatment and are most noted in younger patients. The exact mechanism is not clear. The detection of periostitis makes it essential for the radiologists to inquire as to what medications patients are receiving. The pediatric doses (75 g/kg/d) are above those recommended for adult patients (50 g/kg/d) and this may account for the pediatric bone changes of periostitis.