Purpose To evaluate outcomes and magnetic resonance imaging (MRI) findings after use of particulated juvenile cartilage for the treatment of focal Outerbridge grade 4 articular cartilage defects of ...the patella. Methods From 2007 to 2011, 16 patients (2 bilateral) underwent a novel single-stage articular cartilage restoration procedure using particulated juvenile articular cartilage allograft. We enrolled 15 knees (13 patients) in this study. The mean age at surgery was 26.4 ± 9.1 years, and the mean postoperative follow-up was 28.8 ± 10.2 months. A musculoskeletal radiologist evaluated each knee with postoperative MRI for the International Cartilage Repair Society cartilage repair assessment score, graft hypertrophy, bony changes around the graft, and percent fill of the defect. All patients also completed the Knee Injury and Osteoarthritis Outcome Score, International Knee Documentation Committee Subjective Knee Evaluation, and Kujala clinical outcome survey (scale, 0 to 100), as well as the Tegner activity scale and visual analog pain scale (scale, 0 to 10). Results The mean International Cartilage Repair Society cartilage repair assessment score on MRI was 8.0 ± 2.8, a nearly normal assessment. Of 15 knees, 11 (73%) were found to have normal or nearly normal cartilage repair. Three patients had mild graft hypertrophy whereas 2 had gross graft hypertrophy, 2 of whom required arthroscopic debridement because of symptoms. The mean fill of the defect at follow-up was 89% ± 19.6%, with 12 of 15 knees (80%) showing at least 90% defect coverage. The mean clinical outcome score at follow-up was 73.3 ± 17.6 for the International Knee Documentation Committee evaluation, and the mean scores for each subdomain of the Knee Injury and Osteoarthritis Outcome Score were as follows: 84.2 ± 14.2 for pain, 85.0 ± 12.3 for symptoms and stiffness, 88.9 ± 12.9 for activities of daily living, 62.0 ± 25.1 for sports and recreation, and 60.8 ± 28.6 for quality of life. The median score for the Kujala survey was 79 (range, 55 to 99). The median score on the Tegner activity scale was 5 (range, 3 to 9), and the mean score on the visual analog scale was 1.9 ± 1.4, indicating minimal pain. Conclusions Preliminary results suggest that cartilage restoration using particulated juvenile articular cartilage allograft offers a viable option for patients with focal grade 4 articular cartilage defects of the patella. Level of Evidence Level IV, therapeutic case series.
Clinical decision support (CDS) software designed around the ACR Appropriateness Criteria assists health care providers in choosing appropriate imaging studies at the time of order entry. The goal of ...this study was to determine the impact of commercially available CDS on the ordering habits of inpatient and emergency providers.
In 2014, ACR Select was integrated into our electronic health record, though without displaying appropriateness scores in a "silent" mode for 6 months. Then, feedback regarding examination appropriateness was "turned on" at order entry for adult patients in the emergency and inpatient settings for 24 months. We retrospectively compared the appropriateness scores of imaging tests before and after displaying feedback at order entry and evaluated these data by modality and attending versus trainee status.
The commercially available CDS-generated scores for 34% and 20.4% of pre- and postintervention studies, respectively. After feedback, the relative frequency of low utility studies decreased to 5.4% from 11%, and the relative frequency of indicated studies increased to 82% from 64.5%. This was most pronounced in trainees for whom the percentage of low utility studies decreased from 10.8% (95% confidence interval CI: 10.0%, 11.7%) to 4.8% (95% CI: 4.4%, 5.2%) and the percentage of indicated studies increased from 65.6% (95% CI: 64.3%, 66.9%) to 83.7% (83.0%, 84.3%).
After implementation of a commercially available decision support tool integrated into the electronic health record, there was a significant improvement in imaging study appropriateness scores, more pronounced in studies ordered by trainees.
Since the beginning of the COVID-19 pandemic, numerous strategies have been proposed to allow for continued resident education while following social distancing guidelines. Diagnostic radiology is ...largely electronic work, allowing for relatively easy transition to telehealth. Our institution deployed home workstations to interested upper level radiology residents and fellows in order to maintain high volume workload and education, while complying with CDC social distancing and quarantine guidelines.
We deployed 28 home workstations with integrated PACS, electronic health record, and reporting system, supporting workflow that matched our on-site processes and allowing residents to work from home while on diagnostic rotations. Two months into the pilot, surveys were sent to trainees and faculty to assess satisfaction related to education, productivity, and wellness. A retrospective study count was performed for a sample of residents in order to assess productivity.
Residents perceived their remote productivity as unchanged or better than at the hospital, while faculty were more likely to perceive it as decreased, however, objective results showed no difference. Education was largely considered worse or unchanged with very few regarding it as improved. Those utilizing shared-screen signout platforms rated education better than those utilizing voice/telephone communications only. Trainees expressed improvement in wellness and quality of life.
Home workstations for trainees represent a feasible solution for implementing social distancing or even quarantine while maintaining operational productivity. There is the added benefit of scheduling flexibility, option to overcome space constraints, and improved quality of life.
Our objectives were to evaluate the reliability of MRI in distinguishing simple lipomas, lipoma variants, and well-differentiated liposarcomas (atypical lipomas) and to identify various imaging ...mimics of well-differentiated liposarcoma.
One hundred twenty-six consecutively imaged grossly fatty masses were retrospectively reviewed. MRI examinations, their prospective interpretations, and their corresponding pathology reports were compared to determine the reliability of MRI in distinguishing simple lipomas, lipoma variants, and well-differentiated liposarcomas.
The success of MRI in identifying well-differentiated liposarcomas among other fatty masses was as follows: sensitivity, 100%; specificity, 83%; accuracy, 84%; positive predictive value, 38%; and negative predictive value, 100%. MRI was 100% specific in the diagnosis of simple lipoma. Sixty-three percent of lesions considered suspicious for well-differentiated liposarcoma were actually simple lipomas (13%) and benign lipoma variants (50%), including chondroid lipoma (13%), osteolipoma (6%), hibernoma (6%), lipoleiomyoma (6%), angiolipoma (6%), and infarcted lipoma (13%).
Because of differences in treatment, prognosis, and long-term follow-up, it is important to preoperatively distinguish simple lipomas from well-differentiated liposarcomas. MRI is highly sensitive in the detection of well-differentiated liposarcomas and highly specific in the diagnosis of simple lipomas. However, when an extremity or body wall lesion is considered suspicious for well-differentiated liposarcoma, it is more likely (64%) to represent one of many benign lipoma variants.
Due to mandates from recent legislation, clinical decision support (CDS) software is being adopted by radiology practices across the country. This software provides imaging study decision support for ...referring providers at the point of order entry. CDS systems produce a large volume of data, providing opportunities for research and quality improvement. In order to better visualize and analyze trends in this data, an interactive data visualization dashboard was created using a commercially available data visualization platform. Following the integration of a commercially available clinical decision support product into the electronic health record, a dashboard was created using a commercially available data visualization platform (Tableau, Seattle, WA). Data generated by the CDS were exported from the data warehouse, where they were stored, into the platform. This allowed for real-time visualization of the data generated by the decision support software. The creation of the dashboard allowed the output from the CDS platform to be more easily analyzed and facilitated hypothesis generation. Integrating data visualization tools into clinical decision support tools allows for easier data analysis and can streamline research and quality improvement efforts.
Purpose
To assess reader performance and subjective workflow experience when reporting bone age studies with a digital bone age reference as compared to the Greulich and Pyle atlas (G&P). We ...hypothesized that pediatric radiologists would achieve equivalent results with each method while digital workflow would improve speed, experience, and reporting quality.
Materials and methods
IRB approval was obtained for this HIPAA-compliant study. Two pediatric radiologists performed research interpretations of bone age studies randomized to either the digital (Digital Bone Age Companion, Oxford University Press) or G&P method, generating reports to mimic clinical workflow. Bone age standard selection, interpretation-reporting time, and user preferences were recorded. Reports were reviewed for typographical or speech recognition errors. Comparisons of agreement were conducted by way of Fisher’s exact tests. Interpretation-reporting times were analyzed on the natural logarithmic scale via a linear mixed model and transformed to the geometric mean. Subjective workflow experience was compared with an exact binomial test. Report errors were compared via a paired random permutation test.
Results
There was no difference in bone age determination between atlases (
p
= 0.495). The interpretation-reporting time (
p
< 0.001) was significantly faster with the digital method. The faculty indicated preference for the digital atlas (
p
< 0.001). Signed reports had fewer errors with the digital atlas (
p
< 0.001).
Conclusions
Bone age study interpretations performed with the digital method were similar to those performed with the Greulich and Pyle atlas. The digital atlas saved time, improved workflow experience, and reduced reporting errors relative to the Greulich and Pyle atlas when integrated into electronic workflow.
Background: During anatomic anterior cruciate ligament (ACL) reconstruction, we have found that the femoral footprint can best be visualized from the anteromedial portal. Independent femoral tunnel ...drilling can then be performed through an accessory medial portal, medial and inferior to the standard anteromedial portal.
Purpose: To compare the accuracy of independent femoral tunnel placement relative to the ACL footprint using an accessory medial portal versus tunnel placement with a traditional transtibial technique.
Study Design: Controlled laboratory study.
Methods: Ten matched pairs of cadaveric knees were randomized such that within each pair, one knee underwent arthroscopic transtibial (TT) drilling, and the other underwent drilling through an accessory medial portal (AM). All knees underwent computed tomography (CT) both preoperatively and postoperatively with a technique optimized for ligament evaluation (80 keV with maximum mAs). Computed tomography was performed with a dual-energy scanner. Commercially available third-party software was used to fuse the preoperative and postoperative CT scans, allowing anatomic comparison of the ACL footprint to the drilled tunnel. The ACL footprint was marked in consensus by an orthopaedic surgeon and a musculoskeletal radiologist and then compared with the tunnel aperture after drilling. The percentage of tunnel aperture contained within the native footprint as well as the distance from the center of the tunnel aperture to the center of the footprint was measured.
Results: The AM technique placed 97.7% ± 5% of the tunnel within the native femoral footprint, significantly more than 61.2% ± 24% for the TT technique (P = .001). The AM technique placed the center of the femoral tunnel 3.6 ± 1.2 mm from the center of the native footprint, significantly closer than 6.0 ± 1.9 mm for the TT technique (P = .003).
Conclusion: This study demonstrates that use of an accessory medial portal will facilitate more accurate placement of the femoral tunnel in the native ACL femoral footprint.
Clinical Relevance: More accurate placement of the femoral tunnel in the native ACL femoral footprint should improve the ability to achieve more anatomic positioning of the ACL graft.
To determine if radiologists find enough value in available interactive multimedia reporting technology to routinely adopt it into clinical practice.
Our institution’s reporting application (Vue ...Reporting, Carestream Health) allows the incorporation of multimedia elements, including active hyperlinks, into clinical reports, but would radiologists find enough value in this technique to change their practice? We retrospectively reviewed 559,841 diagnostic reports issued July 2016 to February 2018 for the presence of text hyperlinks that interactively connect to imaging findings in the PACS. Results were subdivided by modality, reporting radiologist role (ie, resident, fellow, attending physician), and subspecialty. Average percentages over the final 6 months were chosen to represent established adoption rates.
For each modality, the 6-month average percentages of reports containing hyperlinks to imaging findings subdivided by the role of the radiologist who created the report were found to be as follows: CT: residents = 27.6%, fellows = 19.5%, attending physicians = 26.0%; MRI: residents = 26.6%, fellows = 8.7%, attending physicians = 5.1%; and PET/CT: residents = 53.3%, fellows = 46.7%, attending physicians = 19.4%. Rates were 0% to 4% among ultrasound, radiography, and nuclear medicine reports, regardless of radiologist role. The 6-month average percentages of CT and MRI reports with hyperlinks to imaging findings varied by subspecialty from 5.4% to 57.1%.
Our radiologists found enough value in available interactive multimedia reporting technology to adopt it into their clinical practice, commonly inserting hyperlinks into their CT, PET/CT, and MRI reports to create interactive connections to key imaging findings in the PACS.
In the skeletally immature patient, physeal stress injury is a common diagnosis in repetitive stress injury; in this case, we present an atypical location of physeal stress injury of the bilateral ...proximal fibulae. There are multiple well-documented diagnoses of physeal stress injury involving the shoulder, elbow, wrist and tibia, often considered when patients present with the typical history of intensive sports training and pain exacerbated by repetitive movements. However, isolated proximal fibular physeal stress injury is either unusual or under-recognized and underreported. Although less common, proximal fibular physeal stress injury should be among the diagnostic considerations in active adolescents complaining of lower extremity pain as failure to identify this entity can lead to delayed care and preventable potential long-term musculoskeletal effects.
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