MRI for paediatric flatfoot: Is it necessary?

Objective: To determine the additional benefit of MRI for children with flatfoot deformity assessed with weight-bearing radiographs in a specialist paediatric orthopaedic unit. Methods and materials: Patient cohort was obtained by searching the Radiology Information System for children referred for investigation of flatfoot. All patients with flatfoot on weight bearing radiographs who had undergone MRI were included. Radiographs were classified by a consultant musculoskeletal radiologist as showing no underlying abnormality, talo-calcaneal coalition, calcaneo-navicular coalition, accessory navicular or other abnormality. MRI studies were classified similarly by a different consultant musculoskeletal radiologist blinded to the radiographic findings. Results: 33 males and 24 females were included (mean age 12.5 years; range 3–18 years). Twenty-four had bilateral abnormality, so 81 feet were assessed. Radiographs showed no specific abnormality (n = 51), talo-calcaneal coalition (n = 6), calcaneo-navicular coalition (n = 3), os naviculare (n = 12) or other abnormality (n = 9). MRI showed no specific abnormality (n = 40), talo-calcaneal coalition (n = 10), calcaneo-navicular coalition (n = 5), os naviculare (n = 12) or other abnormality (n = 14). Assuming MRI as the diagnostic gold standard, additional relevant diagnostic information was identified in 19 (23.5%) cases, while in the 51 cases for which radiographs provided no specific diagnosis MRI confirmed no underlying abnormality in 31 (60.8%). Conclusion: MRI is a valuable adjunct to weight bearing radiography for investigating paediatric flatfoot deformity. Advances in knowledge: MRI is of value in the assessment of paediatric flatfoot, additional diagnostic information to radiography being identified in 23.5% cases, while in 60.8% of cases for which radiographs provided no specific diagnosis MRI confirmed no underlying abnormality.

Pediatric Musculoskeletal Radiologist in India – Challenges and Opportunities

Pediatric musculoskeletal (MSK) radiology is a relatively under developed superspeciality in India. It encompasses many different entities such as bone tumors, congenital bone dysplasias, endocrine and metabolic bone disorders, and trauma. We conducted a survey of Indian pediatricians and radiologists to assess to ascertain their view regarding the role of pediatric MSK radiologist. In this article, we discuss the challenges, opportunities, and importance of pediatric MSK radiologist in India.

A radiological diagnostic approach to tumours and tumour-like lesions of the calcaneus

Objective: The calcaneus is a rare location for the development of primary bone tumours. The purpose of the study is to review the imaging findings in a cohort of patients presenting with tumours and tumour-like lesions of the calcaneus and to develop a more structured approach to the diagnosis of calcaneal lesions. Methods: A retrospective study with a collection of 167 cases of calcaneal tumours and tumour like lesions from our tertiary orthopedic oncology institution over a period of 13 years. Cases were reviewed by two consultant musculoskeletal radiologist and the location of the lesion within the calcaneus and demographics of the patient were noted for each case. A diagnostic algorithm which is based on patient age and tumour location was then extrapolated. Results: Out of the 167 cases we identified 24 different calcaneal pathologies which included both tumours and tumour-like lesions. The most common being simple bone cysts (18.3% of cases) and intra osseous lipoma (15% of cases) sited in the diaphyseal equivalent of the calcaneus. A diagnostic algorithm was formulated which describes the most common location of the different pathologies including both benign and malignant pathologies, subdivided by age. Conclusion: Our algorithm should help the radiologist narrow down the differential diagnosis when evaluating calcaneal lesions. Advances in knowledge: This article provides a radiological approach to calcaneal lesions.

Imaging of Pediatric Lower Limb Sports Injuries

The importance of physical activity during childhood and adolescence has come to light, with an increase in sports-related acute traumatic and overuse injuries as a major disadvantage. A solid understanding of the physiology of the growing skeleton, together with knowledge about age- and sex-related differences in the occurrence of acute traumatic and overuse injuries is necessary. Every musculoskeletal radiologist should also be familiar with the appearances of these injuries on different imaging modalities. This review focuses on all these aspects concerning acute traumatic and overuse injuries among children and adolescents.

Limited sequence MRI to improve standards of care for suspected cauda equina syndrome

Aims Early cases of cauda equina syndrome (CES) often present with nonspecific symptoms and signs, and it is recommended that patients undergo emergency MRI regardless of the time since presentation. This creates substantial pressure on resources, with many scans performed to rule out cauda equina rather than confirm it. We propose that compression of the cauda equina should be apparent with a limited sequence (LS) scan that takes significantly less time to perform. Methods In all, 188 patients with suspected CES underwent a LS lumbosacral MRI between the beginning of September 2017 and the end of July 2018. These images were read by a consultant musculoskeletal radiologist. All images took place on a 3T or 1.5T MRI scanner at Stoke Mandeville Hospital, Aylesbury, UK, and Royal Berkshire Hospital, Reading, UK. Results The 188 patients, all under the age of 55 years, underwent 196 LS lumbosacral MRI scans for suspected CES. Of these patients, 14 had cauda equina compression and underwent emergency decompression. No cases of CES were missed. Patients spent a mean 9.9 minutes (8 to 10) in the MRI scanner. Conclusion Our results suggest that a LS lumbosacral MRI could be used to diagnose CES safely in patients under the age of 55 years, but that further research is needed to assess safety and efficacy of this technique before changes to existing protocols can be recommended. In addition, work is needed to assess if LS MRIs can be used throughout the spine and if alternative pathology is being considered. Cite this article: Bone Joint J 2020;102-B(4):501–505.

Platelet-rich plasma (PRP) Shortens Return to Play in National Football League (NFL) Players with Acute Hamstring Injuries

Objectives: Hamstring injuries are common in professional athletes and subsequent delays in healing are common, costly, and even career ending. The efficacy of platelet-rich plasma (PRP) for augmentation of non-operative treatment of partial musculotendinous hamstring injuries has not yet been established. Methods: NFL players from a single team who sustained acute grade 2 hamstring injuries as diagnosed on MRI by a musculoskeletal radiologist from 2009 to 2017 were retrospectively reviewed. Average days, practices, and games missed were recorded. Players that did and did not receive PRP injections were compared. Those who received PRP did so within 24 to 48 hours after injury. Results: Ninety-four NFL players had MRI evidence of a hamstring injury, while 61 athletes sustained grade 2 injuries. Thirty-one were treated with PRP injections and 30 were not. Average time missed in those treated with PRP injections was 22.4 days, 18.5 practices, and 1.7 games. In those who did not receive PRP injections, time missed was 25.8 days (p = 0.81), 22.2 practices (p = 0.68), and 2.7 games (p < 0.05). Conclusion: PRP injection treatment for acute grade 2 hamstring injuries in NFL players allows for faster return to play with a 1 game overall difference. Due to the possible large financial impact of return to play 1 game sooner, PRP injections for treatment of grade 2 hamstring injuries may be advantageous in professional athletes. Additional evaluation of PRP treatment of acute hamstring injuries in a larger cohort is necessary.

Artificial Intelligence in Musculoskeletal Imaging: Review of Current Literature, Challenges, and Trends

Artificial intelligence (AI) has gained major attention with a rapid increase in the number of published articles, mostly recently. This review provides a general understanding of how AI can or will be useful to the musculoskeletal radiologist. After a brief technical background on AI, machine learning, and deep learning, we illustrate, through examples from the musculoskeletal literature, potential AI applications in the various steps of the radiologist's workflow, from managing the request to communication of results. The implementation of AI solutions does not go without challenges and limitations. These are also discussed, as well as the trends and perspectives.

Prevalence of Coexistent Plantaris Tendon Pathology in Patients with Mid-Portion Achilles Pathology: A Retrospective MRI Study

Co-existence of Plantaris tendinopathy (PT) in patients with mid-Achilles tendinopathy (Mid-AT) is of clinical significance. This study aims to describe the MRI-based pathological characteristics of co-existing PT and Mid-AT. One-hundred MRI studies of patients diagnosed with Mid-AT were retrospectively analysed by an experienced musculoskeletal radiologist. Presence or absence of a Plantaris tendon, co-existing PT with Mid-AT, insertional characteristics of Plantaris tendon, and maximum anteroposterior thickness of the tendon in Mid-AT (axial images) were evaluated. When PT co-existed with Mid-AT, the location of the tendon pathologies in relation to calcaneal insertion was assessed (sagittal images) and their association was analysed using the coefficient of variation (CV) and Pearson’s correlation coefficient. Plantaris was present in 84 cases (84%), and Mid-AT and PT co-existed in 10 cases (10%). A greater variability in the location of Plantaris pathology (CV = 42%) than Achilles tendinopathy (CV = 42%) was observed. The correlation coefficient also revealed a low and non-significant association between the location of two pathologies when they exist together (r = +0.06; p = 0.88). Clinical evaluation of Achilles tendon pain needs careful consideration into the possible co-existence of Plantaris pathology. The considerable difference observed in the location of PT and Mid-AT suggest possible isolated pathologies and differentials for Achilles tendon pain.

Accuracy of MRI and Varus Stress Radiographs in Diagnosing Fibular Collateral Ligament Injuries

Objectives: To evaluate the diagnostic accuracy of magnetic resonance imaging and varus stress radiographs for FCL tears, and compare these modalities to intraoperative findings. Methods: All patients who underwent an isolated FCL or combined ACL/FCL reconstruction by a single surgeon between 2010 and 2017 with preoperative varus stress radiographs and MRI were included in this study. A control group was comprised of patients with an MRI and intact ACL and FCL. Sensitivity and specificity of diagnosing FCL injuries on MRI were determined based on review by a fellowship-trained musculoskeletal radiologist. The sensitivity of diagnosing an FCL injury based on varus stress radiographs was also determined. Furthermore, the ability of both imaging modalities to identify an FCL injury was stratified based on acute versus chronic etiology. Results: A total of 232 patients were included: 98 patients in the FCL tear group and 134 patients in the control group. Varus stress radiographs were determined to be more sensitive in diagnosing FCL injuries compared to MRI, with an overall sensitivity of 70% compared to 66%. Based on chronicity of the injuries, MRI was more accurate for detecting acute FCL injuries than chronic injuries (p=0.002), and varus stress radiographs were more accurate for detecting chronic FCL injuries than acute injuries (p=0.041). Conclusion: To our knowledge, this is the first clinical study to directly compare the diagnostic accuracy of FCL tear detection utilizing MRI and varus stress radiographs in the same patient cohort. While varus stress radiographs appear to have a higher accuracy overall, the results from our study support the use of both varus stress radiographs and MRI in diagnosing FCL injuries, as MRI is more sensitive in diagnosing an acute FCL tear, and varus stress radiographs are more sensitive in diagnosing a chronic FCL tear.