Yoshimi Endo

Stress fractures about the tibia, foot, and ankle.

&NA; In competitive athletes, stress fractures of the tibia, foot, and ankle are common and lead to considerable delay in return to play. Factors such as bone vascularity, training regimen, and equipment can increase the risk of stress fracture. Management is based on the fracture site. In some athletes, metabolic workup and medication are warranted. High‐risk fractures, including those of the anterior tibial diaphysis, navicular, proximal fifth metatarsal, and medial malleolus, present management challenges and may require surgery, especially in high‐level athletes who need to return to play quickly. Noninvasive treatment modalities such as pulsed ultrasound and extracorporeal shock wave therapy may have some benefit but require additional research.

Retrospective Analysis of Postinjection Ultrasound Imaging After Platelet-Rich Plasma or Autologous Blood: Observational Review of Anatomic Distribution of Injected Material

OBJECTIVE Characterization of the distribution and imaging characteristics of platelet-rich plasma (PRP) and autologous blood after injection is currently limited despite the growing use. We sought to improve understanding of the distribution of PRP or autologous blood after it has been injected into a tendon to evaluate whether injected materials truly stayed within the local region of injection. MATERIALS AND METHODS Fifty ultrasound-guided PRP or autologous blood injections performed for tendinopathy were retrospectively reviewed. Consensus review of the imaging data was performed by two radiologists to characterize the distribution of the injectate (i.e., within the tendon, along the tendon sheath, along the paratenon, or leakage into the adjacent joint or surrounding soft tissues). The presence of fluid and microbubbles from the injectate served as an indicator of material distribution. RESULTS Image review verified the injectate within the tendon in 100% of cases. In 98% of reviewed cases, injected PRP or autologous blood dissected beyond the local injection site (defined as >2 cm from the site of injection) and was identified in adjacent soft tissues in 51% of cases. Visualization of injectate along a paratenon or tendon sheath (when applicable) was seen in 86% and 100% of cases respectively; however, intraarticular extension was uncommon (8%). CONCLUSION Our study showed that postinjection imaging may be of value in assessing the anatomic distribution of injectate after intratendinous therapy. Furthermore, our initial review found that in the majority of cases injected blood products tended to distribute beyond the local area of injection.

Evaluation of Two Appropriateness Criteria for Total Knee Replacement

Insurance expansion under the Affordable Care Act will amplify a projected 6‐fold increase in total knee replacement (TKR) utilization by 2030 but will not fully address TKR disparities. Promoting appropriate use of TKR would help reduce disparities and improve outcomes. There are currently no validated appropriateness criteria (AC) for TKR in the US. We evaluated the performance of 2 non‐US AC in a cohort of US TKR patients.

Correction of multiplanar deformity of the second toe with metatarsophalangeal release and extensor brevis reconstruction.

Background: Surgical treatment of multiplanar (varus and dorsal angulation) second toe deformities due to degenerative instability can lead to recurrence, stiffness, and pain. The goal of this study was to evaluate the short-term outcomes associated with a new technique using an extensor digitorum brevis (EDB) tendon reconstruction to correct such deviation of the second metatarsophalangeal (MTP) joint. Methods: Ten patients (10 female, 0 male) with 11 operated second toes having undergone correction with a reconstruction using the EDB tendon were assessed at an average of 18.5 months (range, 12-34) after surgery. The technique was indicated when MTP and medial partial plantar plate release alone were not sufficient to correct multiplanar deformity. Radiographic parameters (AP and lateral metatarsal-proximal phalanx angles), physical exam (MTP joint range of motion), and subjective outcomes (the Foot and Ankle Outcome Score [FAOS]) were assessed. A toe-specific survey captured more detailed subjective information, including patient satisfaction. Results: Preoperatively, the average MTP joint angle was 4.5 degrees in the varus direction, which changed to 14.2 degrees in the valgus direction postoperatively. On exam, the average MTP joint range of motion was 60.9 ± 11.6 degrees dorsiflexion and 11.1 ± 2.5 degrees plantarflexion. Postoperative FAOS scores demonstrated an average of 89.9 ± 9.8 for the symptoms domain. In all, 9 of 11 patients were either highly satisfied or moderately satisfied (none dissatisfied). Conclusion: With the stated limitations, the EDB tendon reconstruction technique described in conjunction with collateral ligament and partial plantar plate release provided powerful correction. Minimal release of the medial plantar plate and not overtightening the reconstruction are recommended to avoid shifting the toe in the opposite direction. Level of Evidence: Level IV, retrospective study.

Spontaneous nerve torsion: unusual cause of radial nerve palsy

Spontaneous nerve torsion is a rare cause of nerve palsy. We describe a case of nerve torsion affecting the radial nerve in order to inform radiologists of the existence of this condition and subtle features on cross-sectional imaging that can suggest the diagnosis preoperatively.

Radiologic Assessment of Patellofemoral Pain in the Athlete

Context: Although disorders of the patellofemoral joint are common in the athlete, their management can be challenging and require a thorough physical examination and radiologic evaluation, including advanced magnetic resonance imaging techniques. Evidence Acquisition: Relevant articles were searched under OVID and MEDLINE (1968 to 2010) using the keywords patellofemoral joint, patellofemoral pain or patella and radiography, imaging, or magnetic resonance imaging, and the referenced sources were reviewed for additional articles. The quality and validity of the studies were assessed on the basis of careful analysis of the materials and methods before their inclusion in this article. Results: Physical examination and imaging evaluation including standard radiographs are crucial in identifying evidence of malalignment or instability. Magnetic resonance imaging provides valuable information about concomitant soft tissue injuries to the medial stabilizers as well as injuries to the articular cartilage, including chondral shears and osteochondral fractures. Quantitative magnetic resonance imaging assessing the ultrastructure of cartilage has shown high correlation with histology and may be useful for timing surgery. Conclusions: Evaluation of patellofemoral disorders is complex and requires a comprehensive assessment. Recent advancements in imaging have made possible a more precise evaluation of the individual anatomy of the patient, addressing issues of malalignment, instability, and underlying cartilage damage.

Imaging of ceramic liner fractures in total hip arthroplasty: the value of CT.

Fracture of a ceramic liner of a total hip arthroplasty is rare and is radiographically occult if not displaced. We report on two patients in whom ceramic liner fracture was radiographically occult but was diagnosed on subsequent CT scan through appropriate windowing.

Lumbar discal cyst: Diagnostic discography followed by therapeutic computed tomography-guided aspiration and injection.

Discal cysts are extradural masses that communicate with the intervertebral disk and are a rare cause of lower back pain and lumbar radiculopathy. This case report describes a lumbar discal cyst, the diagnosis of which was confirmed on conventional discography, and which was treated with computed tomography-guided aspiration and steroid injection. Several reports have described this procedure, but only one in the radiology literature, and thus the purpose of this report is to remind the radiology community of the existence of this entity and propose a minimally invasive means of treatment.

Churg-strauss syndrome with eosinophilic myocarditis: a clinical pathology conference held by the division of rheumatology at hospital for special surgery.

Keywords Churg–StraussSyndrome.eosinophilicmyocarditis.hypereosinophilaHistory and Physical ExaminationAn 85-year-old Chinese woman with a 4-year history ofasthma presented with a severe headache for 1 week andsubsternal chest pain for 1 day.Seven days prior to presentation, the patient was seen byher primary care physician for evaluation of a new-onsetsevere headache; she was prescribed an unknown dose ofibuprofen, which she took for 2 days before developing facialswelling and hives. The facial swelling and rash resolvedshortly after discontinuing ibuprofen, but the headache con-tinued. Two days prior to presentation, the patient went to theemergencyroombecauseofherheadache;anon-contrastheadcomputed tomography (CT) scan was negative and she wasdischargedwithoutfurtherworkup.Twodayslater,thepatientdeveloped substernal chestpain. She returnedtotheemergen-cy room and was admitted for further evaluation.On admission, the patient reported frontal and temporalheadache without nausea or photosensitivity. She also com-plained of gradually intensifying, substernal, nonpleuriticchest pain that did not radiate and was not associated withcough or shortness of breath. She denied fever, chills,changes in weight, rash, alopecia, visual disturbance, oralor nasal ulcers, sinus pain, hemoptysis, abdominal pain,nausea, vomiting, diarrhea, dysuria, hematuria, joint pain,or focal weakness. She reported intermittent episodes of drycough and shortness of breath over the past 4 years that hadbeen diagnosed and treated as asthma.Past medical history was significant for pulmonary tu-berculosis, diagnosed and treated with an unknown medica-tion regimen in 1968. Despite this treatment, she developeddisseminated tuberculosis of the thoracic and pelvic lymphnodes, liver, and spine in 1990. She required spine surgery atthat time and was treated with an unknown multidrug regi-men for the next 4 years. Her other medical history includedasthma, hyperlipidemia, and gastroesophageal reflux dis-ease. She had undergone a meningioma resection in the late1980s.Medications on admission included metoprolol 50 mgdaily, aspirin 81 mg daily, simvastatin 20 mg daily, flutica-sone/salmeterol 250 mcg inhaled twice daily, gabapentin300 mg three times daily, pantoprazole 20 mg daily, traza-done 25 mg nightly, and zolpidem 5 mg nightly. There wereno known drug allergies.The patient was born in China and moved to the USA in1968. She had last traveled back to China in 1990. She livedalone but had family nearby. She did not use tobacco,alcohol, or illicit drugs. She had no family history of auto-immune disease.

Do Changes in the Production Process Affect the Outcome of Ceramic Liners: A 3-Year Follow-Up Study

BACKGROUND In 2011, the current liner was withdrawn from the market because of the potential risk for liner fracture secondary to increased pressures used to assemble the metal locking ring. The present study provides a short-term follow-up of patients with this implant. METHODS We retrospectively evaluated 63 consecutive hips in 53 patients operated by a single surgeon using a recalled ceramic-on-ceramic bearing. There were 30 women and 23 men with an average age of 50.6 years (range 20.3-63.5 years). The mean follow-up was 36.8 months. RESULTS Six hips in 6 patients were revised (9.5%) because of a liner-fracture during the follow-up period. All liner fractures were identified on computer tomography imaging. Nine patients had self-reported episodes of squeaking (14.3%). All 6 patients that underwent revision surgery for liner fracture described squeaking before revision. There were no revisions for other causes. Two of the revised patients had a subsequent dislocation (33%). CONCLUSION The recalled ceramic liner lots have an increased liner fracture rate. Patients with mechanical symptoms or squeaking should undergo computer tomography to rule out liner facture.