Role of Magnetic Resonance Imaging in the Diagnosis of Osteomyelitis in Diabetic Foot Infections.

PURPOSE: The role of magnetic resonance imaging (MRI) in the diagnosis of osteomyelitis in foot infections in diabetics was investigated. The accuracy, sensitivity, and specificity of MRI, plain radiography, and nuclear scanning were determined for diagnosing osteomyelitis, and a cost comparison was made. METHODS: Twenty-seven patients with diabetic foot infections were studied prospectively. All patients underwent MRI and plain radiography. Twenty-two patients had technetium bone scans, and 19 patients had Indium scans. Nineteen patients had all four tests performed. Patients with obvious gangrene or a fetid foot were excluded. RESULTS: The diagnosis of osteomyelitis was established by pathologic specimen (n = 18), bone culture (n = 3), or successful response to medical management (n = 6). Osteomyelitis was confirmed in nine of the pathologic specimens. The diagnostic sensitivity, specificity, and accuracy for MRI was 88%, 100%, and 95%, respectively, for plain radiography it was 22%, 94%, and 70%, respectively, for technetium bone scanning it was 50%, 50%, and 50%, respectively, and for Indium leukocyte scanning it was 33%, 69%, and 58%, respectively. The data were analyzed statistically with the two-tailed Fisher\u27s exact test. MRI was the only test that was statistically significant (p \u3c 0.01). CONCLUSIONS: MRI appeared to be the single best test for the diagnosis of osteomyelitis associated with diabetic foot infections. It had a better diagnostic accuracy than conventional modalities and appeared to be more cost-effective than the frequently used Indium scan

Obesity and pronated foot type may increase the risk of chronic plantar heel pain : a matched case-control study

Background : Chronic plantar heel pain (CPHP) is one of the most common musculoskeletal disorders of the foot, yet its aetiology is poorly understood. The purpose of this study was to examine the association between CPHP and a number of commonly hypothesised causative factors.Methods : Eighty participants with CPHP (33 males, 47 females, mean age 52.3 years, S.D. 11.7) were matched by age (&plusmn; 2 years) and sex to 80 control participants (33 males, 47 females, mean age 51.9 years, S.D. 11.8). The two groups were then compared on body mass index (BMI), foot posture as measured by the Foot Posture Index (FPI), ankle dorsiflexion range of motion (ROM) as measured by the Dorsiflexion Lunge Test, occupational lower limb stress using the Occupational Rating Scale and calf endurance using the Standing Heel Rise Test.Results : Univariate analysis demonstrated that the CPHP group had significantly greater BMI (29.8 &plusmn; 5.4 kg/m2 vs. 27.5 &plusmn; 4.9 kg/m2; P &lt; 0.01), a more pronated foot posture (FPI score 2.4 &plusmn; 3.3 vs. 1.1 &plusmn; 2.3; P &lt; 0.01) and greater ankle dorsiflexion ROM (45.1 &plusmn; 7.1&deg; vs. 40.5 &plusmn; 6.6&deg;; P &lt; 0.01) than the control group. No difference was identified between the groups for calf endurance or time spent sitting, standing, walking on uneven ground, squatting, climbing or lifting. Multivariate logistic regression revealed that those with CPHP were more likely to be obese (BMI &ge; 30 kg/m2) (OR 2.9, 95% CI 1.4 &ndash; 6.1, P &lt; 0.01) and to have a pronated foot posture (FPI &ge; 4) (OR 3.7, 95% CI 1.6 &ndash; 8.7, P &lt; 0.01).Conclusion : Obesity and pronated foot posture are associated with CPHP and may be risk factors for the development of the condition. Decreased ankle dorsiflexion, calf endurance and occupational lower limb stress may not play a role in CPHP.<br /

Intraperitoneal drain placement and outcomes after elective colorectal surgery: international matched, prospective, cohort study

Despite current guidelines, intraperitoneal drain placement after elective colorectal surgery remains widespread. Drains were not associated with earlier detection of intraperitoneal collections, but were associated with prolonged hospital stay and increased risk of surgical-site infections.Background Many surgeons routinely place intraperitoneal drains after elective colorectal surgery. However, enhanced recovery after surgery guidelines recommend against their routine use owing to a lack of clear clinical benefit. This study aimed to describe international variation in intraperitoneal drain placement and the safety of this practice. Methods COMPASS (COMPlicAted intra-abdominal collectionS after colorectal Surgery) was a prospective, international, cohort study which enrolled consecutive adults undergoing elective colorectal surgery (February to March 2020). The primary outcome was the rate of intraperitoneal drain placement. Secondary outcomes included: rate and time to diagnosis of postoperative intraperitoneal collections; rate of surgical site infections (SSIs); time to discharge; and 30-day major postoperative complications (Clavien-Dindo grade at least III). After propensity score matching, multivariable logistic regression and Cox proportional hazards regression were used to estimate the independent association of the secondary outcomes with drain placement. Results Overall, 1805 patients from 22 countries were included (798 women, 44.2 per cent; median age 67.0 years). The drain insertion rate was 51.9 per cent (937 patients). After matching, drains were not associated with reduced rates (odds ratio (OR) 1.33, 95 per cent c.i. 0.79 to 2.23; P = 0.287) or earlier detection (hazard ratio (HR) 0.87, 0.33 to 2.31; P = 0.780) of collections. Although not associated with worse major postoperative complications (OR 1.09, 0.68 to 1.75; P = 0.709), drains were associated with delayed hospital discharge (HR 0.58, 0.52 to 0.66; P &lt; 0.001) and an increased risk of SSIs (OR 2.47, 1.50 to 4.05; P &lt; 0.001). Conclusion Intraperitoneal drain placement after elective colorectal surgery is not associated with earlier detection of postoperative collections, but prolongs hospital stay and increases SSI risk

Nonoperative Estimation of the Soleus Musculotendinous Junction Using Magnetic Resonance Imaging.

Although it is recognized as the muscle flap of choice for middle-third defects of the lower limb, the capability for even more distal transposition of the soleus muscle remains controversial. Such reach depends directly on the site of insertion of the muscle and previously has not been assessed convincingly without surgical intervention. Magnetic resonance imaging (MRI) may be a noninvasive alternative for determining the distal extent of the musculotendinous junction of the soleus muscle. In our last four patients, preoperative MRI scans were obtained prior to an elective soleus muscle transfer. The distance from the ankle joint to the most distal site of the soleus insertion was measured on the MRI scan and compared with the actual intraoperative measurement, which had a significant correlation (r = 0.98, p = 0.019). A retrospective review of 42 other sagittal ankle MRI scans predicted the mean of this distance to be 1.92 +/- 1.23 cm (range -0.4 to 4.5 cm), compared with gross anatomic dissections in 30 unrelated fresh cadavers, where this was 4.06 +/- 3.11 cm (range -0.7 to 12.5 cm). These additional data are pertinent because they reinforce recognition of the great variation in soleus anatomy, which would limit clinical applications for the distal third of the leg only for those individuals with very distal insertions. The MRI scan can reliably identify the soleus muscle and provides a nonoperative method for evaluation of potential feasibility for its use as a local muscle flap for distal lower extremity defects

Magnetic Resonance Imaging in the Evaluation of Persistent Carpal Tunnel Syndrome.

Magnetic resonance imaging was used to assess nine median nerves in the wrists of seven patients who had signs and symptoms of persistent compressive median neuropathy despite previous carpal tunnel release. Intraoperative findings were then correlated in eight surgically treated cases with both MRI findings and postoperative results. Magnetic resonance imaging suggested a potential abnormality in each of eight operative cases. These findings correlated very well with both intraoperative observations and postoperative results, which indicated that some abnormality involving either the median nerve or the transverse carpal ligament had been present in all cases. Magnetic resonance imaging proved to be a sensitive and specific tool in the evaluation of persistent postoperative median nerve compression

Carotid Artery Stenosis: Preoperative Noninvasive Evaluation in a Community Hospital.

PURPOSE: The purpose of this study was to determine whether noninvasive evaluation with duplex ultrasonography and magnetic resonance angiography of patients with carotid artery stenosis can replace contrast angiography at our institution. METHODS: This study consisted of a retrospective chart review of 40 patients (74 carotid arteries) in combination with a blinded reanalysis of original data. Contrast angiography was compared with duplex ultrasonography and magnetic resonance angiography. The overall diagnostic accuracy of duplex ultrasonography and magnetic resonance angiography was determined individually and concordantly in patients being evaluated for carotid artery stenosis. RESULTS: The overall sensitivity of duplex ultrasonography was 88.5%, and the specificity was 91.7% (Spearman correlation coefficient = 0.8456; p \u3c 0.001). For magnetic resonance angiography the sensitivity was 92.3%, and the specificity was 97.9% (Spearman correlation coefficient = 0.9086; p \u3c 0.001). In the presence of concordance, the noninvasive studies exhibited a sensitivity of 100%, (correlation coefficient = 0.9661; kappa value = 0.9655). No occlusions or severe lesions were missed by both studies. In only one vessel (1.52%) was a false-positive concordance noted. CONCLUSIONS: Carotid endarterectomy may be undertaken with a high degree of confidence that the operation will be appropriate if the noninvasive evaluations are concordant. In the absence of concordance of the noninvasive studies, contrast angiography should be considered

CT prior to second-look operation in ovarian cancer.

Second-look surgery is used in restaging patients with ovarian cancer to define sites of recurrence, plan therapy, and perform tumor debulking. We evaluated the role of CT in detecting residual or recurrent tumor in 55 patients in whom 64 abdominopelvic CT scans were obtained. Forty-eight patients underwent a second-look operation, and eight of these patients had an additional third-look operation. CT correctly identified 17 (85%) of 20 cases with residual or recurrent pelvic disease and three (75%) of four cases with bulky abdominal disease. CT failed to detect tumor in any of the five cases with minimal abdominopelvic disease and was able to detect carcinomatosis in only two (8%) of 24 cases. In four cases, CT detected pelvic disease not identified on clinical pelvic examination. On the 56 scans in 48 patients with surgical proof (280 surgical findings), CT had a sensitivity of 40% (22/55) and a specificity of 99% (224/225). In seven additional patients, second-look laparotomy was canceled because of CT findings of extensive, unresectable tumor. We conclude that CT provided valuable information regarding residual or recurrent tumor prior to second- and third-look surgery. In selective cases, CT findings obviated unnecessary surgery. However, the CT\u27s lack of sensitivity in identifying minimal abdominopelvic disease and carcinomatosis precludes its use as a substitute for second-look surgery