Imran M. Omar

Athletic pubalgia and the "sports hernia": MR imaging findings

PURPOSE To retrospectively determine the sensitivity and specificity of magnetic resonance (MR) imaging findings in patients with clinical athletic pubalgia, with either surgical or physical examination findings as the reference standard. MATERIALS AND METHODS Institutional review board approval was granted for this HIPAA-compliant study, and informed consent was waived. MR imaging studies in 141 patients (134 male patients, seven female patients; mean age, 30.1 years; range, 17-71 years) who had been referred to a subspecialist because of groin pain were reviewed for findings including hernia, pubic bone marrow edema, secondary cleft sign, and rectus abdominis and adductor tendon injury. MR imaging findings were compared with surgical findings for 102 patients, physical examination findings for all 141 patients, and MR imaging findings in an asymptomatic control group of 25 men (mean age, 29.8 years; range, 18-39 years). Sensitivity and specificity of MR imaging for rectus abdominis and adductor tendon injury were determined by using a chi(2) analysis, and significance of the findings was analyzed with an unpaired Student t test. Disease patterns seen at MR imaging were compared with those reported in the surgical and sports medicine literature. RESULTS One hundred thirty-eight (98%) of 141 patients had findings at MR imaging that could cause groin pain. Compared with surgery, MR imaging had a sensitivity and specificity, respectively, of 68% and 100% for rectus abdominis tendon injury and 86% and 89% for adductor tendon injury. Injury in each of these structures was significantly more common in the patient group than in the control group (P < .001). Only two patients had hernias at surgery. At MR imaging, injury or disease could be fit into distinct groups, including osteitis pubis, adductor compartment injury, rectus abdominis tendon injury, and injury or disease remote from the pubic symphysis. Patients with injury involving the rectus abdominis insertion were most likely to go on to surgical pelvic floor repair. CONCLUSION MR imaging depicts patterns of findings in patients with athletic pubalgia, including rectus abdominis insertional injury, thigh adductor injury, and articular diseases at the pubic symphysis (osteitis pubis).

Fresh osteochondral allograft for the treatment of cartilage defects of the talus: a retrospective review.

BACKGROUND Osteochondral lesions of the talar dome can cause substantial functional impairment and present a difficult treatment dilemma. Interest has recently focused on fresh osteochondral allografts as a promising treatment alternative. The purpose of this study was to evaluate the clinical outcome of osteochondral lesions of the talus treated with a fresh osteochondral allograft. METHODS We performed a transfer of fresh osteochondral allograft in forty-two patients with a symptomatic, refractory osteochondral lesion of the talus. Complete postoperative follow-up was achieved for thirty-eight patients with an average age of 44.2 years. Clinical evaluation was performed with use of the American Orthopaedic Foot & Ankle Society ankle-hindfoot score and a visual analog pain scale. All scores were obtained from either a retrospective chart review or a direct patient interview. All patients were also asked about their subjective satisfaction with the procedure. Magnetic resonance images were acquired for fifteen patients, to assess graft incorporation, subsidence, articular cartilage congruity, osteoarthritis, and stability with use of the De Smet criteria. RESULTS The average duration of follow-up after osteochondral allograft transplantation was 37.7 months. Graft failure occurred in four patients. With the inclusion of scores before revision for those with graft failure, the mean visual analog pain scale score improved from 8.2 to 3.3 points, and the mean American Orthopaedic Foot & Ankle Society ankle-hindfoot score improved from 52 to 79 points. Patient satisfaction with the outcome was rated as excellent, very good, or good by twenty-eight of the thirty-eight patients and as fair or poor by ten patients. Of the fifteen magnetic resonance imaging scans, most showed minimal graft subsidence, reasonable graft stability, and persistent articular congruence. CONCLUSIONS In our experience, transplantation of fresh osteochondral allograft is a viable and effective method for the treatment of osteochondral lesions of the talus as evidenced by improvements in pain and function.

Bisphosphonates and nonhealing femoral fractures: analysis of the FDA Adverse Event Reporting System (FAERS) and international safety efforts: a systematic review from the Research on Adverse Drug Events And Reports (RADAR) project.

BACKGROUND In the United States, hip fracture rates have declined by 30% coincident with bisphosphonate use. However, bisphosphonates are associated with sporadic cases of atypical femoral fracture. Atypical femoral fractures are usually atraumatic, may be bilateral, are occasionally preceded by prodromal thigh pain, and may have delayed fracture-healing. This study assessed the occurrence of bisphosphonate-associated nonhealing femoral fractures through a review of data from the U.S. FDA (Food and Drug Administration) Adverse Event Reporting System (FAERS) (1996 to 2011), published case reports, and international safety efforts. METHODS We analyzed the FAERS database with use of the proportional reporting ratio (PRR) and empiric Bayesian geometric mean (EBGM) techniques to assess whether a safety signal existed. Additionally, we conducted a systematic literature review (1990 to February 2012). RESULTS The analysis of the FAERS database indicated a PRR of 4.51 (95% confidence interval [CI], 3.44 to 5.92) for bisphosphonate use and nonhealing femoral fractures. Most cases (n = 317) were attributed to use of alendronate (PRR = 3.32; 95% CI, 2.71 to 4.17). In 2008, international safety agencies issued warnings and required label changes. In 2010, the FDA issued a safety notification, and the American Society for Bone and Mineral Research (ASBMR) issued recommendations about bisphosphonate-associated atypical femoral fractures. CONCLUSIONS Nonhealing femoral fractures are unusual adverse drug reactions associated with bisphosphonate use, as up to 26% of published cases of atypical femoral fractures exhibited delayed healing or nonhealing.

MRI findings in bipartite patella

PurposeBipartite patella is a known cause of anterior knee pain. Our purpose was to detail the magnetic resonance imaging (MRI) features of bipartite patella in a retrospective cohort of patients imaged at our institution.Materials and methodsMRI exams from 53 patients with findings of bipartite patella were evaluated to assess for the presence of bone marrow edema within the bipartite fragment and for the presence of abnormal signal across the synchondrosis or pseudarthrosis. Any other significant knee pathology seen at MRI was also recorded. We also reviewed 400 consecutive knee MRI studies to determine the MRI prevalence of bipartite patella.ResultsOf the 53 patients with bipartite patella 40 (75%) were male; 35 (66%) had edema within the bipartite fragment. Of the 18 with no edema an alternative explanation for knee pain was found in 13 (72%). Edema within the bipartite fragment was the sole finding in 26 of 53 (49%) patients. Bipartite patella was seen in 3 (0.7%) of 400 patients.ConclusionIn patients with bipartite patella at knee MRI, bone marrow edema within the bipartite fragment was the sole finding on knee MRI in almost half of the patients in our series.

Surgical treatment for chronic disease and disorders of the achilles tendon

&NA; Chronic Achilles tendon disorders range from overuse syndromes to frank ruptures. Numerous forms of treatment have been used, depending on the nature of the disorder or injury. Ultrasonography and magnetic resonance imaging are commonly used for evaluation. The spectrum of disease comprises paratenonitis, tendinosis, paratenonitis with tendinosis, retrocalcaneal bursitis, insertional tendinosis, and chronic rupture. However, there is no clear consensus on what defines a chronic Achilles disorder. Nonsurgical therapy is the mainstay of treatment for most patients with overuse syndromes. Surgical techniques for overuse syndromes or chronic rupture include débridement, local tissue transfer, augmentation, and synthetic grafts. Local tissue transfer most commonly employs either the flexor hallucis longus or flexor digitorum longus tendon to treat a chronic rupture. Reports on long‐term outcomes are needed before useful generalizations can be made regarding treatment.

Spectrum of MRI findings in clinical athletic pubalgia.

Athletic pubalgia is a frequently encountered syndrome for clinicians who treat active patients participating in a wide variety of athletic endeavors worldwide. Pathologies associated with this clinical scenario span anatomically from the pubic symphysis to the hip and include a myriad of poorly understood and incompletely described musculoskeletal entities, many of which are centered about the pubic symphysis and its tendinous attachments. In this article, we discuss the relevant anatomy and pathophysiology for the most frequently encountered of these disorders, using magnetic resonance (MR) images as a guide. We describe an MR imaging protocol tailored to clinical athletic pubalgia. We then review reproducible MRI patterns of pathology about the pubic symphysis, the rectus abdominis/adductor aponeurosis and the inguinal ring, as well as a group of clinically confounding entities remote from the symphysis but visible by MRI.

Evaluation of the Tarsometatarsal Joint Using Conventional Radiography, CT, and MR Imaging

The tarsometatarsal, or Lisfranc, joint complex provides stability to the midfoot and forefoot through intricate osseous relationships between the distal tarsal bones and metatarsal bases and their connections with stabilizing ligamentous support structures. Lisfranc joint injuries are relatively uncommon, and their imaging findings can be subtle. These injuries have typically been divided into high-impact fracture-displacements, which are often seen after motor vehicle collisions, and low-impact midfoot sprains, which are more commonly seen in athletes. The injury mechanism often influences the imaging findings, and classification systems based primarily on imaging features have been developed to help diagnose and treat these injuries. Patients may have significant regional swelling and pain that prevent thorough physical examination or may have other more critical injuries at initial posttrauma evaluation. These factors may cause diagnostic delays and lead to subsequent morbidities, such as midfoot instability, deformity, and debilitating osteoarthritis. Missed Lisfranc ligament injuries are among the most common causes of litigation against radiologists and emergency department physicians. Radiologists must understand the pathophysiology of these injuries and the patterns of imaging findings seen at conventional radiography, computed tomography, and magnetic resonance imaging to improve injury detection and obtain additional information for referring physicians that may affect the selection of the injury classification system, treatment, and prognosis.

MR Imaging of the Hip: Normal Anatomic Variants and Imaging Pitfalls

MR imaging of the hip is one of the most common musculoskeletal MR imaging studies performed today to assess for occult fractures, acetabular labral tears, hyaline cartilage loss, and musculotendinous injuries. Several developmental variations are seen in the hip, which can be mistaken for disease or potentially even contribute to the development of a pathologic condition. As in any imaging study, it is important to be cognizant of these variations as well as associated findings that help distinguish between true abnormality and developmental variation when interpreting an MR image of the hip. This article describes the numerous variants of the hip that are frequently seen on arthrographic and nonarthrographic MR imaging examinations.

Bifid insertion of the distal biceps brachii tendon with isolated rupture: Magnetic resonance findings

Victoria House Medical Imaging Prahran, Victoria, Australia Department of Radiology, Geisinger Medical Center, Danville, PA Department of Radiology, Northwestern Memorial Hospital, Chicago, IL Department of Musculoskeletal Imaging, Thomas Jefferson University Hospital, Phialdelphia, PA The Avenue Clinic, Windsor, Victoria, Australia Department of Radiology, Mater Misericordiae Hospital, Dublin, Ireland

Conventional diagnostic challenges in periprosthetic joint infection.

Periprosthetic joint infection remains a clinical challenge with no benchmark for diagnosis. The diagnosis is based on many different clinical variables that may be difficult to interpret, especially in the setting of chronic systemic disease. Synovial fluid aspiration, diagnostic imaging, traditional culture, peripheral serum inflammatory markers, and intraoperative frozen sections each have their limitations but continue to be the mainstay for diagnosis of periprosthetic joint infection. As molecular- and biomarker-based technologies improve, the way we interpret and diagnose periprosthetic joint infection will ultimately change and may even improve diagnostic accuracy and turnaround time. Future research on this topic should be focused on improving diagnostic criteria for low-virulence organisms, improving interpretation of intraoperative frozen sections, and establishing improved synovial fluid and peripheral serum biomarker profiles for periprosthetic joint infection.