Neonatal MRI

The neurological examination often falls short as a definitive test of central nervous system (CNS) integrity in newborn infants. In addition, neonatal brain injury often eludes diagnosis, especially in preterm infants, because obvious signs are not apparent or may be attributed to immaturity. However, the likelihood of CNS compromise increases dramatically with signs of perinatal distress such as low umbilical cord blood pH, low Apgar score, and seizures. The importance of early diagnosis becomes apparent in studies showing the efficacy of treating brain injury with pharmacologic and head- or body cooling therapies. These treatments may support the maturing brain in its early self-repair mechanisms and rescue neurons after the initial perinatal insult. The treatment’s success, however, hinges on early diagnosis. Magnetic resonance imaging (MRI) techniques are far superior to ultrasonography (US) or computed tomography (CT) in detecting early perinatal brain injury. MRI provides more specific anatomical localisation and more often reveals the underlying cause and timing of the initial insult. In addition, MRI is the only technique that can distinguish the presence or absence of myelin. Information such as the timing of the insult, its location, and myelination are crucial for assessing neurodevelopmental outcome. This paper reviews the basic principles of MRI as well as the benefits of imaging the neonatal brain. It also examines two pathological patterns of neonatal brain injury on MRI: intraventricular haemorrhage (IVH) and hypoxic-ischaemic encephalopathy (HIE).</p

Clinical Characteristics and Multisystem Imaging Findings of COVID-19: An Overview for Orthopedic Surgeons

The COVID-19 pandemic holds widespread implications for global public health, economies, societies, and the practice of orthopedic surgery. As our knowledge of the transmissibility of SARS-CoV-2 and the symptomatology and management of COVID-19 expands, orthopedic surgeons must remain up to date on the latest medical evidence and surgical perspectives. While COVID-19 primarily manifests with pulmonary symptoms, cardiovascular, neurologic, and other major organ systems may also be affected and present with hallmark imaging findings. This article reviews initial and emerging literature on clinical characteristics and imaging findings of COVID-19

Magnetic resonance imaging of the failed superior capsular reconstruction

Superior capsular reconstruction (SCR) of the shoulder is an increasingly common procedure in the treatment of patients with massive, irreparable rotator cuff tears lacking significant osteoarthritis. Post-operatively, the appearance of failed grafts has only been described in isolated case reports and review articles. From January 2016 through December 2017, surgical records at a single tertiary-care facility were queried to identify all patients undergoing SCR. Patient records were reviewed for patient demographic information, reason for post-operative MRI, and post-operative surgeon assessment. 74 patients underwent SCR, of whom 12 received a follow-up MRI post-operatively. One patient was excluded due to missing records; the remaining 11 patients comprise the study cohort. Post-operative MRIs were obtained at mean six months after surgery. On review of post-operative MRIs, three distinct locations of failure were identified. Four patients (40%) had midsubstance failure of the allograft with all glenoid and humeral head fixation remaining intact. One patient (10%) had complete detachment of the allograft from both glenoid and humeral head fixation. Five patients (50%) had detachment of the allograft from the glenoid. In this series of ten failed SCRs, the most common mode of failure was loss of fixation on the glenoid, followed closely by midsubstance rupture. We found no instances of isolated fixation failure on the humeral head. This series illustrates the need for careful imaging in patients whose post-operative course suggests clinical failure. These findings suggest that strengthening glenoid fixation may provide better clinical outcomes as this procedure becomes more common. Level of evidence: III - Retrospective study. •Failure of the SCR was evident on imaging in 10 of 11 of the symptomatic subjects.•There was an overall SCR graft failure rate of 14% over the study period.•Three distinct modes of failure were identified on MRI:(1)midsubstance rupture of the graft;(2)loss of both humeral and glenoid fixation; and(3)loss of glenoid fixation with intact graft

Systemic Complications and Radiographic Findings of Opioid Use and Misuse: An Overview for Orthopedic Surgeons

Amid growing concern about the misuse of prescribed opioids, the rising rates of opioid use disorder, and the use of illicit opioids, clinicians in ambulatory, inpatient, and operative environments are encountering opioid-related complications in their patients. These complications can affect multiple organ systems including cardiovascular, pulmonary, gastrointestinal, and neurologic and are related to excess opioid levels in the body or contamination from non-sterile injection. It is important for the orthopedic surgeon to have a general understanding of the pathologies associated with opioid use disorder and their appearance on diagnostic imaging. This article reviews image findings of several complications, organized in a systems-based approach, for the orthopedic surgeon

Chronic Lower Leg Pain in Athletes: Overview of Presentation and Management

Athletes with chronic lower leg pain present a diagnostic challenge for clinicians due to the differential diagnoses that must be considered. We aimed to review the literature for studies on the diagnosis and management of chronic lower leg pain in athletes. A literature review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA). The PubMed, Scopus, and Cochrane library databases were searched, and articles that examined chronic lower leg pain in athletes were considered for review. Two independent reviewers conducted the search utilizing pertinent Boolean operations. Following two independent database searches, 275 articles were considered for initial review. After the inclusion and exclusion criteria were applied, 88 were included in the final review. These studies show that the most common causes of lower leg pain in athletes include medial tibial stress syndrome, chronic exertional compartment syndrome, tibial stress fractures, nerve entrapments, lower leg tendinopathies, and popliteal artery entrapment syndrome. Less frequently encountered causes include saphenous nerve entrapment and tendinopathy of the popliteus. Conservative management is the mainstay of care for the majority of cases of chronic lower leg pain; however, surgical intervention may be necessary. Multiple conditions may result in lower leg pain in athletes. A focused clinical history and physical examination supplemented with appropriate imaging studies can guide clinicians in diagnosis and management. We provide a table to aid in the differential diagnosis of chronic leg pain in the athlete

Optimal detection of scapholunate ligament tears with MRI

Background Scapholunate interosseous ligament (SLIL) injuries can often be difficult to detect using magnetic resonance imaging (MRI), especially with older 1.0 and 1.5 Tesla magnets. Wrist arthroscopy is the gold standard for diagnosis of SLIL injuries, but is an invasive procedure with associated risks. Purpose To assess whether SLIL injuries can be more accurately detected using axial MRI sequences instead of coronal sequences. Material and Methods An institutional review board approved retrospective analysis of arthroscopic wrist surgeries performed at our institution. Patients that had a preoperative MRI performed at our university center using a 1.5 Tesla scanner with a dedicated wrist coil were included in the study. Three fellowship-trained musculoskeletal radiologists reviewed the axial sequences and coronal sequences independently. The accuracy of the coronal and axial sequences was compared with the arthroscopic/surgical findings. Result Twenty-six patients met the inclusion criteria. The sensitivity for SLIL tears was 79% and 65% for the axial and coronal sequences, respectively. The specificity was 82% for the axial and 69% for the coronal sequences, respectively. The positive and negative predictive values for the axial sequences were 76% and 84% respectively, compared to 68% and 71% for the coronal sequences, a statistically significant difference. Conclusion SLIL tears are more readily detectable on axial MRI sequences than coronal. Clinically, patients with radial-sided wrist pain and suspicion for SLIL tears should have the axial sequences scrutinized carefully. An otherwise normal study with the axial sequence being degraded by motion or other MRI artifacts might need repeat imaging

MRI findings of chronic distal tendon biceps reconstruction and associated post-operative findings

Rupture of the distal biceps tendon is becoming increasingly diagnosed due to an active aging population and an increase in diagnostic imaging opportunities. While physical exam may help in diagnosis, magnetic resonance imaging (MRI) is particularly useful in evaluating chronic rupture. Although partial tears can be managed conservatively, the gold standard treatment for a chronic distal biceps tear is anatomic reinsertion with additional use of an allograft or autograft. No study has highlighted the normal appearance and postsurgical complications seen on MRI associated with allograft or autograft usage. Clinicians and radiologists may be unaware of the normal and abnormal post-operative imaging findings and their clinical relevance. The purpose of this manuscript is to discuss the epidemiology, clinical presentation, and preoperative MRI findings of distal biceps ruptures necessitating reconstruction, to explain distal biceps tendon surgical reconstruction technique with allograft or autograft usage, to display the normal and abnormal post-operative MRI findings, and to review the clinical outcomes associated with the procedure

Cervical Ligament Insufficiency in Progressive Collapsing Foot Deformity: It May Be More Important Than We Know

Category: Hindfoot; Midfoot/Forefoot Introduction/ Purpose: Subluxation at the subtalar joint is one of the major radiographic features that characterize progressive collapsing foot deformity (PCFD). Although it is recognized that the cervical ligament plays an important function in maintaining the subtalar joint's stability, its role and involvement in PCFD is largely unknown. The purpose of this study was to assess the prevalence of cervical ligament insufficiency in patients with PCFD and to establish if its integrity of it changes with increasing axial plane deformity. We hypothesized that there will be a higher prevalence of cervical ligament insufficiency in a PCFD cohort compared to that of a control group. Additionally, we hypothesized that those with higher degrees of cervical ligament insufficiency will have a more severe abduction deformity and talocalcaneal subluxation. Methods: This study retrospectively reviewed magnetic resonance imaging (MRI) of 78 PCFD patients and age- and gender- matched controls. A radiologist specializing in musculoskeletal disorders evaluated the structural derangement of the cervical ligament into five grades (Grade 0 indicating normal and Grade 4 indicating a tear greater than 50% of the cross-sectional area), as previously described. To compare its involvement in PCFD, two commonly involved ligaments (spring and interosseous) in PCFD were also evaluated. Plain radiographic parameters, including the talonavicular coverage angle (TNC), lateral talo-1st metatarsal (Meary’s) angle, calcaneal pitch, and hindfoot moment arm, as well as axial plane orientation of the talus (TM-Tal) and calcaneus (TM-Calc) relative to the transmalleolar axis and talocalcaneal subluxation (Diff Calc-Tal), were correlated with the cervical ligament MRI grading system. Results: The overall distribution of the degree of cervical ligament involvement was significantly different between the PCFD and control groups (P < .001, Table 1). MRI evidence of a tear (Grades 3 or 4) in the cervical ligament was identified in 47 of 78 (60.3%) feet in the PCFD group, which was significantly higher than the control group (10.9%) and greater than that of superomedial spring (43.6%) and talocalcaneal interosseous (44.9%) ligaments. Univariate ordinal logistic regression modelling demonstrated a predictive ability of TM-Calc (Odds ratio [OR]: 1.17, 95% confidence interval [CI]: 1.06-1.30, p=.004), Diff Calc- Tal (OR: 1.15, 95% CI: 1.06-1.26, p=.002), TNC (OR: 1.08, 95% CI: 1.03-1.13, p=.003), and Meary’s angle (OR: 1.05, 95% CI: 1.02-1.10, p=.006) in determining higher cervical ligament grade on MRI (Figure 1). Conclusion: We found that cervical ligament insufficiency is a significant component of PCFD and is more common than anticipated in this study. Based on the radiographic findings in the current study, cervical ligament insufficiency appears to be primarily associated with axial plane midfoot and hindfoot deformity. If its biomechanical properties are established in the future studies, we think the reconstruction of the cervical ligament may be a potential adjunct surgical procedure for PCFD patients with significant axial plane deformity