Naveen Parasu

Multimodality Imaging of Peripheral Neuropathies of the Upper Limb and Brachial Plexus

The peripheral nerves of the upper limb are affected by a number of entrapment and compression neuropathies. These discrete syndromes involve the brachial plexus as well as the musculocutaneous, axillary, suprascapular, ulnar, radial, and median nerves. Clinical examination and electrophysiologic studies are the traditional mainstay of diagnostic work-up; however, ultrasonography and magnetic resonance imaging provide spatial information regarding the affected nerve and its surroundings, often assisting in narrowing the differential diagnosis and guiding treatment. Imaging is particularly valuable in complex cases with discrepant nerve function test results. Familiarity with the clinical features of various peripheral neuropathies of the upper extremity, the relevant anatomy, and the most common sites and causes of nerve entrapment assists in diagnosis and treatment.

Use of a calcium sulfate-calcium phosphate synthetic bone graft composite in the surgical management of primary bone tumors.

Benign primary bone tumors are commonly treated with intralesional curettage with or without the use of surgical adjuvants. The reconstructive approach to the resulting contained bone defects is controversial, and clinical practice is varied. Synthetic bone substitutes may provide early mechanical support while minimizing the risks of disease transmission, nonunion, infection, and donor-site morbidity. Limited data exists regarding the use of calcium sulfate-calcium phosphate composite bone substitute for this purpose. The authors retrospectively reviewed the clinical outcomes of 24 patients with benign primary bone tumors who underwent intralesional curettage followed by reconstruction with a calcium sulfate-calcium phosphate composite bone substitute. Mean follow-up was 23 months. The most common diagnosis was giant cell tumor of bone. Six patients had upper-extremity tumors and 18 had lower-extremity tumors. Mean preoperative radiographic tumor volume was 41.0 cm(3). Mean volume of PRO-DENSE (Wright Medical Technology, Arlington, Tennessee) used in each patient was 15.6 cm(3). Mean time to full weight bearing for all patients was 7.3 weeks. Two patients sustained local tumor recurrences. No postoperative fractures occurred, and no complications occurred related to the use of the calcium sulfate-calcium phosphate composite. One case of deep infection occurred secondary to wound breakdown. The use of a calcium sulfate-calcium phosphate composite was associated with rapid biological integration and an early return to activities of daily living, with no composite-related complications. This technique is a viable option in the reconstruction of cavitary bone defects following intralesional curettage of primary benign bone tumors.

Radiographic union score for hip substantially improves agreement between surgeons and radiologists

BackgroundDespite the prominence of hip fractures in orthopedic trauma, the assessment of fracture healing using radiographs remains subjective. The variability in the assessment of fracture healing has important implications for both clinical research and patient care. With little existing literature regarding reliable consensus on hip fracture healing, this study was conducted to determine inter-rater reliability between orthopedic surgeons and radiologists on healing assessments using sequential radiographs in patients with hip fractures. Secondary objectives included evaluating a checklist designed to assess hip fracture healing and determining whether agreement improved when reviewers were aware of the timing of the x-rays in relation to the patients’ surgery.MethodsA panel of six reviewers (three orthopedic surgeons and three radiologists) independently assessed fracture healing using sequential radiographs from 100 patients with femoral neck fractures and 100 patients with intertrochanteric fractures. During their independent review they also completed a previously developed radiographic checklist (Radiographic Union Score for Hip (RUSH)). Inter and intra-rater reliability scores were calculated. Data from the current study was compared to the findings from a previously conducted study where the same reviewers, unaware of the timing of the x-rays, completed the RUSH score.ResultsThe agreement between surgeons and radiologists for fracture healing was moderate for “general impression of fracture healing” in both femoral neck (ICC = 0.60, 95% CI: 0.42-0.71) and intertrochanteric fractures (0.50, 95% CI: 0.33-0.62). Using a standardized checklist (RUSH), agreement was almost perfect in both femoral neck (ICC = 0.85, 95% CI: 0.82-0.87) and intertrochanteric fractures (0.88, 95% CI: 0.86-0.90). We also found a high degree of correlation between healing and the total RUSH score using a Receiver Operating Characteristic (ROC) analysis, there was an area under the curve of 0.993 for femoral neck cases and 0.989 for intertrochanteric cases. Agreement within the radiologist group and within the surgeon group did not significantly differ in our analyses. In all cases, radiographs in which the time from surgery was known resulted in higher agreement scores compared to those from the previous study in which reviewers were unaware of the time the radiograph was obtained.ConclusionsAgreement in hip fracture radiographic healing may be improved with the use of a standardized checklist and appears highly influenced by the timing of the radiograph. These findings should be considered when evaluating patient outcomes and in clinical studies involving patients with hip fractures. Future research initiatives are required to further evaluate the RUSH checklist.

Assessment of radiographic fracture healing in patients with operatively treated femoral neck fractures.

Objectives: This study was conducted to determine interrater and intrarater reliabilities on the healing assessment of femoral neck fractures between orthopedic surgeons and radiologists and to test the performance of a checklist system for hip fracture healing. Methods: We developed and used a scoring system [radiographic union score in hip fracture (RUSH) score] to determine the validity of quantifying fracture healing. A panel of 6 reviewers (3 orthopedic surgeons and 3 radiologists) independently assessed fracture healing with the RUSH system using radiographs of 150 femoral neck fractures at various stages in healing on 2 occasions 4 weeks apart. Results: Using subjective assessment, the interrater agreement between reviewer groups for fracture healing was fair [intraclass coefficient = 0.22, 95% confidence interval (CI): 0.01–0.41] with no significant difference in agreement within the orthopedic surgeon and radiologist groups (0.17 vs. 0.21). There was higher agreement for fracture healing using the RUSH score (intraclass coefficient = 0.53, 95%CI: 0.30–0.69) compared with physician impression of healing, highlighting the difficulties with plain radiographic assessments of healing. Intrarater agreement was consistently high across all measures for both surgeons and radiologists. The RUSH score and medial cortex bridging correlated well with overall assessment of healing (r = 0.868 and 0.643, respectively). Conclusions: The level of agreement between and within orthopedic surgeon and radiologist reviewers in the assessment of fracture healing is low, though intrarater agreement is high. The RUSH score shows promise as a tool to improve agreement on fracture healing. Studies evaluating reliability and accuracy of healing with clinical information and temporal evaluation are needed and may further improve agreement.

The Role of Ultrasonography in the Assessment of Carpal Tunnel Syndrome

EMBASE and MEDLINE databases were searched by using PUBMED and OVID software. The search terms ‘‘carpal tunnel syndrome’’ (CTS), and ‘‘carpal tunnel syndrome and ultrasound’’ were used to identify 1,537 citations. Prospective clinical trials with defined control groups and clinical criteria for gold reference standard were selected for inclusion in this meta-analysis. The study group included at least 50 wrists, so to provide adequate power to the study, and the study compared results with a healthy control group. Blinding of the sonographer involved in measurements was also integrated in the study design. The study by Nakamichi and Tachibana [1] involved large patient and control group numbers (414 symptomatic wrists vs 408 control wrists). Nerve conduction studies (NCS) were performed in both groups and were compared with sonography. The median nerve cross-sectional area (CSA) was measured by using the tracing method at 3 anatomical levels: the distal edge of the flexor retinaculum (level 1), the hook of

Imaging of Ulnar-Sided Wrist Pain

Pain on the ulnar side of the wrist is a complex diagnostic dilemma. This is mainly due to the small size and complexity of the anatomical structures. The issue is compounded by the occurrence of positive imaging findings that are clinically asymptomatic. This pictorial essay deals with the imaging manifestations of different causes of ulnar-sided wrist pain.

Chronology of the Radiographic Appearances of the Calcium Sulfate-Calcium Phosphate Synthetic Bone Graft Composite Following Resection of Bone Tumors: A Follow-up Study of Postoperative Appearances.

Purpose The objective of the study was to characterize the radiographic appearance of graft resorption and new bone incorporation into a postresection defect of the calcium-sulfate calcium-phosphate synthetic bone graft composite following resection of benign bone tumours. Methods Twenty-five patients who underwent treatment with the CaSO4/CaPO4 synthetic graft following bone tumour resection were retrospectively identified from our oncology database. Postoperative radiographs were assessed for: 1) combined partial graft resorption and ingrowth at the graft site; 2) complete graft resorption with complete incorporation of new bone into the defect. After chronologically grouping radiographs, the volume of graft material used to fill bony defects, radiographic evidence of complications, and patterns of resorption were recorded. Results Partial resorption of graft material/partial ingrowth of new bone was seen in 21 patients at 2.5 months postoperatively. Complete resorption of graft with complete new bone incorporation at the graft site was seen in 94% of cases (15 of 16) by 10 months after surgery. Mean time to complete incorporation of new bone was 6.7 months. Time to resorption of the graft with new bone ingrowth was found to be related to the volume of graft used with smaller volumes showing earlier resorption. For all cases demonstrating resorption (21 of 21), the pattern observed was peripheral to central. Five patients developed complications, including tumour recurrence, cyst formation, and graft site infection. Conclusion Our study suggests a characteristic time and volume related radiographic pattern of resorption and new bone ingrowth with the CaSO4/CaPO4 synthetic graft. Findings that deviate from this pattern may represent complication and warrant additional follow-up.

Radiologic and Histopathologic Features of Calcifying Pseudoneoplasm of the Neural Axis

Aim To describe the radiologic and corresponding histopathologic features of calcifying pseudoneoplasms of the neural axis. Methods Two cases of calcifying pseudoneoplasm of the neural axis were retrospectively reviewed. The first case was documented in a 64-year-old woman, who presented with lower back pain with radiation to her left leg. The second case was documented in a 70-year-old man, who presented with headaches. Medical records, radiologic and histologic findings, and related literature were reviewed. Results In the first case, imaging of the lumbar spine revealed a 3.8 × 2.2-cm calcified lesion at the level of vertebrae L5 and S1. A subsequent excision exposed an extradural lesion at L5. Histopathologic examination showed amorphous and granular calcifying material with occasional fibrohistiocytic and giant cell reaction, consistent with calcifying pseudoneoplasm of the neural axis. In the second case, imaging of the head revealed a 2.4 × 2.6-cm well-circumscribed, lobulated, calcified lesion within the basal frontal lobe. Subsequent resection exposed an intradural mass with a nodular arrangement of amorphous and granular calcifying material associated with fibrohistiocytic and giant cell reaction. Both patients had a favorable postoperative course and failed to show any clinical or radiologic sign of recurrence. Conclusion Calcifying pseudoneoplasm of the neural axis is an uncommon condition with an excellent prognosis but is often misdiagnosed due to its nonspecific clinical presentation and varied findings on radiology.

Infrapatellar fat pad osteochondroma: three cases and a systematic review.

Extraskeletal para-articular osteochondromas of the infrapatellar fat pad are unique soft-tissue tumors whose etiology and clinical history remain poorly understood. We report three cases and a systematic review of the literature. Three females, aged 47, 54, and 70 years, presented with pain and a parapatellar knee mass. All three underwent marginal excision with no complications and no recurrence. In the literature, 32 reports describing 42 cases were identified. Mean age at presentation was 51.1 years (range: 12-75). There were 25 females and 20 males. Seven patients (15.6%) had a history of antecedent trauma. Mean duration of presenting symptoms was 63.9 months (range: 2-300). All patients except for one underwent open excision. Mean follow-up was 14.9 months (range: 3-96). There were no reports of recurrence or malignant transformation. Para-articular extraskeletal osteochondromas of the infrapatellar fat pad have a benign clinical history regardless of whether they are managed by arthroscopic or open marginal excision.