Plain Film Research Articles

Perforated Meckel’s Diverticulum: A Case Report

Meckel’s diverticulum is a true diverticulum that consists of all layers of bowel normally found in a normal small bowel wall. The three most common presentations in children are intestinal bleeding (30–56%), intestinal obstruction (14–42%), and diverticular inflammation (6–14%). Complications result in more severe symptoms, such as acute abdomen and signs of peritonitis. These presentations are not specific to Meckel’s diverticulum and can be found in many other conditions, making the diagnosis difficult. A five-year-old child came to the emergency department with complaint of acute abdominal pain, especially in the right lower quadrant. The pain was accompanied by vomiting. On physical examination, patient was febrile and signs of peritonitis were found. Abdominal plain film revealed the probability of focal inflammation in the right lower region of the abdomen, with partial intestinal obstruction. Ultrasonography showed a presence of a mass in right iliac region with the size of 24x20x23 mm, with normal appendix. During exploratory laparotomy, a necrotic and perforated Meckel’s diverticulum was found, with associated purulent matter. Diverticulectomy with segmental resection of ileum followed by end-to-end anastomosis were done. Diagnosis of Meckel’s diverticulum requires a high index of suspicion, especially in the pediatric population. It is important for clinicians to be aware of unusual presentations of Meckel’s diverticulum.

Reporting a Rare HLA Allele with Sequence Analysis Prevents Potentially Lethal Allopurinol Hypersensitivity Reaction

Abstract Introduction/Objective In addition to their essential role in histocompatibility testing, human leukocyte antigen (HLA) alleles have informative pharmacogenomic and disease associations. For example, HLA-B*58:01 carriers have 100- fold greater risk of allopurinol hypersensitivity syndrome (AHS), a lethal T-cell mediated Type IV reaction with a 20- 25% mortality rate. To prevent AHS, patients are tested for carrier status before treatment. Methods/Case Report Patient presented for workup of intermittently flaring right knee pain and uricemia. Uric acid is elevated, plain film imaging is ordered, arthrocentesis is planned, and HLA testing is performed to inform uricemia treatment. Next generation sequencing (NGS) typing reveals the patient carries HLA-B*58:11. Sequence analysis demonstrates the allele’s open reading frame differs from HLA-B*58:01 by a single I194V substitution. Amino acid sequences of peptide binding regions (PBR) encoded by these alleles are identical. Presentation of allopurinol/oxypurinol peptides to T-cells by B*58:01 is the putative mechanism underlying AHS pathogenesis. Identical protein sequence in the PBR of B*58:11 favors similar function. Findings are reported and treatment with allopurinol foregone. Results (if a Case Study enter NA) NA Conclusion High resolution HLA testing is essential to appropriately interpret and report results for disease risk and pharmacogenomics assessments. However, NGS detects rare alleles that have yet to be associated with a disease process. When pathogenesis is thought to be linked to the PBR, rare HLA alleles with identical or similar PBR to disease associated alleles may confer similar risk. In this case, NGS identified PBR similarity between the patient’s allele and an established AHS risk allele. Although B*58:11 has not been shown to be associated with AHS, likely due to low prevalence, the risk was deemed sufficient to select an alternative therapy and potentially prevent a lethal drug reaction.

Effects of Parallax and Distortion in Total Ankle Arthroplasty.

Surgeons rely on intraoperative fluoroscopy to assist in placement of implant components during total ankle arthroplasty (TAA). Parallax alters the direction of an object when viewed from two different points, resulting in image distortion. The purpose of this study was to evaluate parallax/distortion in intraoperative fluoroscopic images during TAA. A retrospective review of all TAAs performed by two surgeons (R.W.M. and B.S.) from August 2019 to April 2023 were reviewed. Intraoperative fluoroscopic anteroposterior (AP) ankle views were evaluated for any obvious parallax image distortion. Cases with obvious parallax distortion were included for angular evaluation of AP intraoperative fluoroscopic and first postoperative plain films. The tibia was marked at 2-centimeter intervals to create zones from the proximal stem of the implant. The anatomical axis of the tibia (AAT) was drawn at the mid-diaphysis. The anatomic lateral distal tibial angle (aLDTA) and anatomic axis deviation (AAD) were measured for each zone. A total of 22 TAAs were performed during the study period. Four cases were excluded due to inadequate imaging, leaving a total of 18 TAAs for review. We found 6 of 18 (33.3%) cases had obvious parallax distortion. We found the average aLDTA was 90.9° (84°-101°). At the most proximal tibial zone, the average aLDTA was 94° (91°-101°). We found the average AAD was 4.7 (0.5-17.2) mm. The AAD ranged from 0.5 to 17.2 mm lateral to 0.8 to 8.2 mm medial. Postoperative plain film radiographs displayed a normal aLDTA and an AAT centered within the ankle joint. Parallax can distort the appearance of the tibia on fluoroscopic images. Deviation from the normal aLDTA and anatomical axis should be anticipated. Surgeons should be aware of the potential impact of parallax and ways to mitigate these effects.

3D bone shape from CT-scans provides an objective measure of osteoarthritis severity: Data from the IMI-APPROACH study

Decisions regarding total knee arthroplasty are usually made using a patient's own assessment of pain and the structural disposition of the joint as seen on plain film radiographs. Pain severity can fluctuate, and radiographs can be misleading, with the apparent joint status affected by anatomical orientation. An important component of the surgical management of knee osteoarthritis (OA) is the timing of surgical intervention: knee arthroplasty performed too early in the course of the disease may increase the need for revision surgery.Femoral 3D bone shape (B-score) from MR images is an objective measure of OA severity and has been correlated with current and future risk of pain. We aimed to derive the B-score from CT images and compare it against the B-score derived from MR images.We used baseline and 24-month image data from the IMI-APPROACH 2-year prospective cohort study, comprising pairs of CT and MR images taken for each subject-timepoint. The femur was automatically segmented in both CT and MR modalities using an active appearance model, a machine-learning method, to measure the B-score. Linear regression was used to test for correlation between measures. Limits of agreement and bias were tested using Bland-Altman analysis.CT-MR pairs of the same knee were available from 424 participants (78 % women). B-scores from CT and MR were strongly correlated (CCC = 0.980) with negligible bias of 0.0106 (95 % CI: −0. 0281, +0.0493).The strong correlation and small B-score bias suggests that B-scores may be measured reliably using CT images. Since CT images are used in planning robot-assisted knee arthroplasty, with further study B-scores derived from CT surgical planning images could in principle provide a useful objective input to deciding the appropriateness, timing and type of knee arthroplasty.

EP120 - A Retrospective Review of Pregnant Patients Referred to an Emergency General Surgery Service

Abstract Aims To gain insight into the journey and outcomes of pregnant patients referred to an emergency general surgery service. Methods Surgical handover lists from Jan 2021-Dec 2023 were reviewed to identify pregnant patients referred to the service. Data was collected from the electronic patient record on demographics, timeline, imaging, diagnosis, management and subsequent delivery method if pregnancy reached term. Results There were 91 referrals of pregnant women to the emergency general surgery service over the 3 year period. 80% were for abdominal pain. 64% of patients received a documented review by a general surgery consultant, and 35% received a documented review by an obstetric consultant. For those presenting with abdominal pain, 79% had imaging other than plain film, the most common being ultrasound abdomen (75%). 5% of patients had an MRI abdomen and pelvis, and 4% of patients had a CT abdomen and pelvis. Of the 21 patients treated for a confirmed abdominal surgical diagnosis who had a documented delivery, 29% required emergency c-sections. In comparison, out of 17 patients who had either non-surgical pathologies or extra-abdominal surgical pathologies, excluding pregnancy-related complications, 0 went on to have emergency c-sections. This is statistically significant (p=0.0241). Conclusion The investigation and management of an acute abdomen in pregnancy poses a number of unique challenges. Our dataset, though small, has hinted at unacceptable rates of consultant review and under-utilisation of cross-sectional imaging. Furthermore, there is the suggestion that patients with confirmed abdominal surgical pathology may be at increased risk of delivering via emergency c-section. There is a need for further research into this patient population.

Dynamic plain abdominal film provides simple and effective diagnosis of delayed shunt insufficiency caused by abdominal adhesions after VP shunt

BackgroundMany complications may occur after placement of the ventriculoperitoneal shunt (VP shunt) for hydrocephalus, and delayed shunt insufficiency (DSI) is among the most common. It is often caused by abdominal adhesions, which increases the difficulty of diagnosis. This study aimed to explore the clinical value of dynamic plain abdominal radiography (DPAR) as a simple diagnostic method for patients with DSI due to terminal adhesion of the peritoneal shunt after VP surgery.MethodsA total of 30 patients with high suspicion of DSI due to abdominal adhesions after VP surgery were included. DPAR was used for prospective assessment. The interval between the first and second PAR was 4–6 h before surgery. If two plain abdominal radiography at different times indicated that the end of the shunt tube in the abdominal segment was fixed, it was diagnosed as DSI due to adhesion of the shunt tube at the abdominal end. The peritoneal end of the shunt tube was surgically repositioned. Postoperative DPAR was repeated to evaluate the distance of the shunt outlet within the abdominal segment.ResultsAll cases showed clinical symptoms or imaging findings of shunt insufficiency. The diagnostic accuracy of DPAR was 96.67% (29/30). The end of the shunt tube in the abdominal segment of the preoperative group was fixed with abdominal plain film twice with a mean difference of 1.74 ± 1.18 cm. The mean postoperative change in the position of the end of the shunt tube in the abdominal section was 9.36 ± 2.64 cm, showing a significant difference compared with the preoperative group (P < 0.001). The mean postoperative EVANs index (0.37 ± 0.08) was significantly lower than the preoperative (0.42 ± 0.08) (P = 0.007), Glasgow coma scale score (12.8 ± 2.69) was higher than the mean preoperative score (11.36 ± 2.43) (P = 0.013).ConclusionDPAR is a simple and effective method for the diagnosis of shunt insufficiency caused by delayed abdominal end adhesion after VP shunt.

Thorn-induced Injury of the Knee Mimicking Pigmented Villonodular Synovitis (PVNS): A Case Report

Background and Aims: Plain film radiography is the first imaging modality in the detection of most foreign bodies. However, it is not sensitive for detection of radiolucent objects such as organic material including plant thorns. Case report: Herein, we present the case of a 19-year-old male patient, presenting with an 8-month history of right knee pain and laxity, whose radiographic appearance mimicked that of pigmented villonodular synovitis (PVNS) but was found to have a retained neglected plant thorn in his knee. Upon ultrasound evaluation for image-guided biopsy to confirm the provisional diagnosis of PVNS, he was found to have a retained neglected plant thorn in his knee. Discussion: Plant thorn injuries can present as knee synovitis, as in our case, and should be kept in the differential diagnosis. An ultrasound-guided removal is possible and is a useful minimally invasive procedure.

Oxygen desorption enabled visible light sensing in embossed TiO2 nanogratings fabricated via thermal nanoimprinting

In this work, the fabrication of the nanoimprinted titanium dioxide (TiO2) gratings via thermal nanoimprinting lithography method (T-NIL) and its visible light response are studied. A polydimethylsiloxane (PDMS) primary mould, which in turn made via pattern transfer of micro/nano tracks present in the optical discs is used in T-NIL process. A transparent TiO2 film on a FTO substrate was subjected to pattern transfer from the PDMS mould. The imprinted TiO2 was post annealed to obtain anatase phase. The optical properties and photo response behaviour of plain and nanoimprinted TiO2 films were measured and compared. Raman spectroscopy measurements indicated the surface enhanced Raman scattering in imprinted samples. The imprinted TiO2 showed reduced reflectance compared to plain TiO2 films due to the increased light path length because of multiple reflections leading to in coupling of light. Photo response was observed under visible light illumination conditions, wherein imprinted TiO2 films showed appreciable photocurrent, which is otherwise very minimal in plain TiO2. The visible light photosensing in imprinted TiO2 occur due to the oxygen adsorption-desorption during the post deposition annealing and under illumination respectively. This work makes use of low-cost PDMS primary mould and T-NIL at favourable temperature and pressure conditions with a promising outlook for fabricating imprinted TiO2 with photo sensing ability and adaptability for large area upscaling.

DOES THE ADDITION OF CT IMPROVE THE ACCURACY OF DETERMINATION OF IMPLANT FIXATION STATUS FOR PERIPROSTHETIC FRACTURES OF THE PROXIMAL FEMUR?

When treating periprosthetic femur fractures (PPFFs) around total hip arthroplasty (THA)], determining implant fixation status preoperatively is important, since this guides treatment regarding ORIF versus revision. The purpose of this study was to determine the accuracy of preoperative implant fixation status determination utilizing plain films and CT scans.Twenty-four patients who underwent surgery for Vancouver B type PPFF were included in the study. Two joint surgeons and two traumatologists reviewed plain films alone and made a judgment on fixation status. They then reviewed CT scans and fixation status was reassessed. Concordance and discordance were recorded. Interobserver reliability was assessed using Kendall's W and intraobserver reliability was assessed using Cohen's Kappa. Ultimately, the “correct” response was determined by intraoperative findings, as we routinely test the component intraoperatively.Fifteen implants were found to be well-fixed (63%) and 9 were loose. Plain radiographs alone predicted correct fixation status in 53% of cases. When adding the CT data, the correct prediction only improved to 55%. Interestingly, concordance between plain radiographs and CT was noted in 82%. In concordant cases, the fixation status was found to be correct in 55% of cases. Of the 18% of cases with discordance, plain films were correct in 43% of cases, and the CT was correct in 57%. Interobserver reliability demonstrated poor agreement on plain films and moderate agreement on CT. Intraobserver reliability demonstrated moderate agreement on both plain films and CT.The ability to determine fixation status for proximal PPFFs around uncemented femoral components remains challenging. The addition of routine CT scanning did not significantly improve accuracy. We recommend careful intraoperative testing of femoral component fixation with surgical dislocation if necessary, and the surgeon should be prepared to revise or fix the fracture based on those findings.

The Role of Cone Beam Computed Tomography (CBCT) in the Diagnosis and Clinical Management of Medication-Related Osteonecrosis of the Jaw (MRONJ).

Medication-related osteonecrosis of the jaw (MRONJ) is a debilitating condition associated with antiresorptive and antiangiogenic medications that are frequently used in treating osteoporosis and cancers. With the ability to produce high-resolution images with a lower radiation dose, cone beam computed tomography (CBCT) is an emerging technology in maxillofacial imaging that offers several advantages in evaluating MRONJ. This review aims to summarise the radiological features of MRONJ as observed via CBCT and highlight its advantages over two-dimensional plain films in assessing MRONJ. CBCT has the capability to detect early MRONJ lesions, characterise the extent and nature of lesions, distinguish MRONJ from other osseous pathologies, and assist in treatment planning. By leveraging the advantages of CBCT, clinicians can enhance their understanding of MRONJ, improve decision making, and ultimately optimize patient care.

Case report: Rare case of a traumatic isolated rupture of the conoid ligament

Acromioclavicular (AC) joint injuries can involve disruption of the AC and coracoclavicular ligaments. We report a case in aprofessional rugby player of an isolated disruption of the conoid ligament with no injury to the AC and trapezoid ligaments. A 24-year-old professional rugby player fell onto his outstretched hand, injuring his right shoulder. The differential diagnosis was an AC joint injury, coracoid fracture, stress fracture of the coracoid process, or subtle clavicle fracture, which could not be diagnosed on plain film X-ray. An MRI confirmed an isolated rupture of the conoid ligament. No injury to the AC ligament or trapezoid was identified. Five weeks after the injury, the patient returned to full contact training and match play. This case demonstrates that in AC joint injuries, it is possible that the trapezoid ligament and conoid ligament are not simultaneously disrupted, and management is per a Grade II/III AC joint injury.

Pelvic Fixation for Non-Ambulatory Patients with Neuromuscular Scoliosis Treated with Magnetically Controlled Growing Rods-A 4-Year Comparison of Two Different Fixation Methods.

Background/Objectives: This study aims to analyze the efficacy and safety of the two pelvic fixation systems, S-hooks (SH) and lumbar-sacral-alar-iliac (SAI) screws, when used in association with magnetically controlled growing rods (MCGRs) in non-ambulatory children with severe neuromuscular scoliosis (NMS). Methods: Forty-one patients were retrospectively examined and subdivided corresponding to ilium hook fixation or SAI screws. The major curve correction (%) and pelvic obliquity (PO) correction (%) were assessed utilizing scoliosis plain film radiographs over time. Complications and unplanned return to the operating room (UPROR) were recorded. Patient-specific pre- and postoperative values were included in a backward stepwise regression model to assess UPROR. Results: Mean age at index intervention was 9.4 years. Preoperative main curve was 81° and PO was 22°. 21 and 20 patients were categorized into the SH and SAI subgroups, respectively. Initial curve correction was significantly better in the SAI subgroup (63 vs. 42% in the SH, p = 0.045), while PO correction was equally good. Curve and PO correction were maintained throughout the follow-up period of 55 months. UPROR rate was 38% in the SH subgroup, and 5% in the SAI subgroup (p = 0.010). Regression analysis identified postoperative curve correction as predictive value for UPROR (p = 0.006). Conclusions: SAI screw fixation has a low UPROR rate and achieves superior curve correction. S-hooks are a viable option to correct PO and NMS in children with high operative risk to reduce operative time, but revision surgery is not uncommon.

Imaging the acute complications of gender-affirming surgeries: a primer for radiologists in the emergency setting.

Gender-affirming surgery (GAS) is increasingly being performed. GAS is tailored to the patient leading to a diverse spectrum of radiologic post-operative findings. Radiologists who are unfamiliar with expected anatomic alterations after GAS may misdiagnose important complications leading to adverse patient outcomes. This collaborative multi-institutional review aims to: Describe relevant embryology and native anatomy. Describe relevant Gender-Affirming Surgery (GAS) techniques and expected neo-anatomy with associated complications, including common terminology. Review expected imaging appearance of neo-anatomy/postoperative findings. Review multi-modality [ultrasound, plain film, retrograde urethrogram, computed tomography] emergent imaging findings. Understand unique patient evaluation and imaging protocol considerations in the GAS population. Discuss pearls and pitfalls of imaging in the acute post-GAS setting.

Applicant Perception and Content Exploration of the 2024 podiatric Residency Interview Process

Considerable resources are dedicated on an annual basis to the podiatric medicine and surgery residency interview by both students and programs. Despite this, relatively little is known about student perception of the process, nor the format and content of interview. The objective of this investigation was to study and organize experiences of fourth-year podiatric medical students following the 2024 Centralized Residency Interview Program (CRIP) process. An anonymous and voluntary survey was developed and made available to fourth year podiatric medical students. It was relatively common for there to be academic, social/personal, case work-up, and rapid-fire academic question components to the interview. It was also very common to be provided with the opportunity to ask programs questions. It was relatively uncommon for there to be ethical/moral questions, personality/psychologic assessments, logic assessments, and hands-on demonstrations. The most common hands-on demonstrations were suturing, hand ties and performance of fixation principles. Relatively high yield academic topics included plain film radiography interpretation, rearfoot/ankle osseous trauma, diabetic foot infection, advanced imaging interpretation, and fixation constructs/principles. When evaluating programs, students placed high value on surgical volume, surgical variety, relative resident autonomy, program location, exposure to outpatient clinics, salary, future connections as a program alumnus, unique off-service rotations, exposure to business management/coding/billing, scope of practice, exposure to inpatient management, resident salary, and who the senior co-residents would be. The results of this investigation provide unique information for both medical students and residency programs with respect to the perception, format and content of the podiatric residency interview process.

Renal colic

Renal colic accounts for 5-10% of all emergency department visits, making it acommon condition in acute medicine. The typical clinical presentation is an early indication of urolithiasis. Diagnostic measures include laboratory tests, ultrasound, and low-dose noncontrast computed tomography (CT) scans. Kidney, ureter, bladder (KUB) plain film radiography has been widely replaced by low-dose noncontrast CT with similar radiation dosage. In special patient groups such as children or pregnant women, ionizing radiation should be avoided if possible. General measures involve pain management (non-steroidal anti-inflammatory agents, opioids) and empirical antibiotic treatment for suspected bacterial infection. Depending on the location/size of the stone, pharmacological stone expulsion therapy may be considered. In cases of obstructive pyelonephritis or acute renal insufficiency, early urinary drainage (JJ stent/nephrostomy) is recommended. Definitive stone removal may be performed primarily in some cases (rather small and rather distal ureterolithiasis). It is common to schedule stone removal as asecondary intervention.

Abstract PO2-17-11: Management guidelines for epithelial atypia diagnosed in breast screening, based on an analysis of a large prospective cohort study (Sloane Project)

Abstract Background: Epithelial atypia in the breast is most frequently detected through breast screening. Internationally, guidelines differ between advising diagnostic surgical excision of screen-detected atypia versus vacuum-assisted excision (VAE), often with annual follow up surveillance mammography. Prospective data with detailed follow-up and outcomes for subsequent cancer events is lacking. We evaluated a large prospective cohort of screen-detected atypia (Sloane Project) and an expert consensus meeting to develop management recommendations. Methods: We undertook an observational analysis of women with screen-detected epithelial atypia (Atypical Ductal Hyperplasia (ADH), Flat Epithelial Atypia (FEA), Lobular In Situ Neoplasia (LISN), or mixed atypia) reported to the National Health Service (NHS) Breast Screening Programme (BSP) between 01/04/03 and 20/06/18. We estimated cumulative incidence of invasive cancers per 1000 women within 1 and 2 subsequent screening rounds using cumulative incidence functions and repeated these by women’s age, type of atypia and year of diagnosis. Flexible parametric modelling produced hazard ratios (HR). The results were presented at a consensus meeting with clinical experts, patient representation, national decision-makers and commissioners from the NHS in England. A consensus on management recommendations was reached. Results: Among 3238 women (19088 person-years of follow up) with screen-detected atypia, diagnoses increased from 2010 (n=119) to 2015 (n=502). This coincided with the introduction of digital mammography into English screening centres from 2010 and changes in biopsy technique. A total of 141 invasive breast cancers were detected up to December 2018. Cumulative incidence of invasive breast cancer per 1000 women with atypia (ADH, FEA, LISN or mixed) was 14.2 (95% CI 10.3, 19.1) and 45.0 (36.3, 55.1) at 3- and 6-years post atypia based on 40 and 94 cancers, respectively. Women diagnosed with atypia during 2013-2018 had an invasive cancer detected less frequently within 3 years than women with an atypia diagnosis between 2003-2007 or 2008-2012 (6.0 invasive cancers (3.1, 10.9) per 1000 women in 2013-2018 Vs 24.3 (13.7, 40.1) and 24.6 (14.9, 38.3) in 2003-2007 and 2008-2012), suggesting that atypia diagnosis may increasingly contribute to ‘overdiagnosis’. Cancers detected were similar to the general screening population regarding grade, size and nodal involvement. Ipsilateral and contralateral cancers were detected in equal numbers, supporting the concept that atypia represents a risk factor rather than precursor of invasive cancer in the short term. Results by age and type of atypia did not suggest a need for risk-stratified management. Considering subsequent invasive cancer, VAE appeared to be as safe as diagnostic surgical excision of atypia (HR 0.75 (0.45, 1.25)). The expert consensus considered that increased screening of women with screen-detected atypia over and above routine 3-yearly screening was not beneficial, given the overall low numbers of cancers at three years. This applied to all types of atypia and all women who received digital mammography and diagnosis of atypia on core or vacuum-assisted biopsy followed by VAE within a quality assured NHS BSP. Conclusions: Breast atypia represents a risk factor for invasive cancer and does not necessitate surgical excision. Changes to mammography (digital vs plain film) and biopsy techniques (gauge of needle and use of vacuum-assistance) may lead to detection of atypia which is then ‘over-managed’. Current recommendations for annual mammography for 5 years after a diagnosis of epithelial atypia may be overly cautious. We suggest that women with screen detected atypia should be followed up with routine screening appointments. Citation Format: Karoline Freeman, David Jenkinson, Karen Clements, Matthew Wallis, Sarah E Pinder, Elena Provenzano, Hilary Stobart, Nigel Stallard, Olive Kearins, Nisha Sharma, Abeer Shaaban, Cliona Kirwan, Bridget Hilton, Alastair Thompson, Sian Taylor-Phillips. Management guidelines for epithelial atypia diagnosed in breast screening, based on an analysis of a large prospective cohort study (Sloane Project) [abstract]. In: Proceedings of the 2023 San Antonio Breast Cancer Symposium; 2023 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2024;84(9 Suppl):Abstract nr PO2-17-11.

Nexplanonectomy—the surgical removal of an embolized implanted contraceptive device: a case report and review of the literature

BackgroundNexplanon implants are a common hormonal contraceptive modality. Though rare, these devices can embolize into the injured wall of the basilic vein, through the right heart, and finally wedge itself into a pulmonary artery. With adherence to the arterial wall over time, it becomes less amenable to endovascular retrieval. Patients may present with symptoms mimicking a pulmonary embolism, or without any symptoms at all. In asymptomatic cases, endovascular retrieval and/or surgery is required when patients wish to begin having children prior to biological inactivity. The current literature showed as little as nine case reports detailing lung tissue removal in the aim of reversing a patient’s implanted contraceptive device.Case presentationA 22-year-old asymptomatic active-duty Caucasian female presented for elective outpatient Nexplanon removal. The suspicion of possible implant migration arose when it was discovered to be non-palpable in her left arm. After plain film x-rays failed to localize the implant, a chest x-ray and follow-up Computed Tomography (CT) scan revealed that the Nexplanon had migrated to a distal branch of the left pulmonary artery. Due to the patient’s strong desires to begin having children, the decision was made for removal. Initial endovascular retrieval failed due to Nexplanon encapsulation within the arterial wall. Ultimately, the patient underwent a left video-assisted thoracoscopic surgery (VATS) for exploration and left lower lobe basilar S7–9 segmentectomy, which successfully removed the Nexplanon.ConclusionsImplanted contraceptive devices can rarely result in migration to the pulmonary vasculature. These radiopaque devices are detectable on imaging studies if patients and clinicians are unable to palpate them. An endovascular approach should be considered first to spare lung tissue and avoid chest-wall incisions, but can be complicated by encapsulation and adherence to adjacent tissue. A VATS procedure with single-lung ventilation via a double-lumen endotracheal tube allows surgeons to safely operate on an immobilized lung while anesthesiologists facilitate single-lung ventilation. This patient’s case details the uncommon phenomenon of Nexplanon migration, and the exceedingly rare treatment resolution of lung resection to remove an embolized device.

Misdiagnosis or Missed Diagnosis - Hallux Sesamoid Fractures among Active-Duty Females in the United States Air Force: A Case Series

Background: Female service members tend to have a higher level of foot injuries than males. The United States Army spent $103 million in 2017 on fractures in toes and feet. Fractures of the tibial and fibular sesamoids are problem that often can be nonspecific, mainly related to pain at the plantar aspect of the first metatarsal head without an obvious traumatic event. Anatomic variation in these sesamoids exist after ossification which results in the possibility of multipartite sesamoids. Of the multipartite sesamoids, bipartite sesamoids are the relatively common and tripartite sesamoids are quite rare. The overall prevalence of bipartite sesamoids is presumed to be between 7 and 30%, with a majority occurring bilaterally. Methods: We completed a case series on three female active-duty Airmen. All three patients were active with their pain beginning following activity. All three were subsequently misdiagnosed, resulting in at least 6 months of pain prior to diagnosis and treatment. Results: Plain film radiography and subsequent imaging confirmed the diagnosis of a tibial or fibular sesamoid fracture. Following conservative treatment all three patients made a full recovery as confirmed by imaging and self-reported pain levels and they were able to return to full activity. Conclusion: Providers should keep a sesamoid fracture in the differential diagnosis when evaluating active female patients with pain in the area around the base of the great toe, especially in women in the military and others that may do higher levels of physical activity compared to the average patient. While the diagnosis of sesamoid fractures can be challenging, it is standard practice to obtain multiple views if using plain film radiography. Magnetic resonance imaging, weightbearing computed tomography and bone scans can be useful confirmatory studies.

The Windshield Wiper Sign Is an Instability-Related Osteochondral Defect of the Anterolateral Femoral Head

PurposeTo investigate a radiographic sign believed to be indicative of hip instability and acetabular suction seal disruption in the native hip, coined the “windshield wiper” (WSW) sign. Materials and MethodsA retrospective review was performed for patients who underwent periacetabular osteotomy (PAO) with the senior author between March 2021 and September 2023. A WSW sign was identified on plain films as a concave or flat osteochondral defect on the anterolateral femoral head extending medial to the head-neck junction with resultant loss of femoral head sphericity in the native hip. Every patient underwent a standardized series of radiographs, as well as computed tomography and magnetic resonance imaging. All patients underwent arthroscopy prior to PAO to address intra-articular pathology and other indicated procedures. The osteochondral defect and resultant suction seal disruption were verified during arthroscopy. These patients were then compared with a control group of arthroscopically treated hips without hip instability. ResultsOf 250 patients reviewed, a total of 19 hips in 17 patients (prevalence of 7.6%) demonstrated radiographic evidence of the WSW sign. All patients with a WSW sign presented with symptomatic clinical hip instability requiring a PAO. The mean patient age was 31.2 years, with a mean lateral center edge angle (LCEA) of 14.3 degrees. There were 13 hips (68.4%) with dysplasia, 4 (21.1%) with borderline dysplasia, and 2 (10.5%) with a normal LCEA. All patients with a WSW sign and LCEA ≥20° displayed significant femoral antetorsion abnormalities. All arthroscopic videos and images demonstrated a compromised suction seal. Of the 50 control group hips reviewed, the WSW sign was not identified. ConclusionsThe WSW sign is an uncommon radiographic finding in patients with hip instability. When identified, it can be predictive of substantial instability, especially in cases which are otherwise considered borderline dysplasia or normal based on LCEA. Level of EvidenceIII, case-control study

Potential of Cytokines in the Management of Intervertebral Disc Degeneration

The illness known as intervertebral disc degeneration (IDD) is characterized by discomfort in the intervertebral discs. The IDD is made up of the annulus fibrosus (AF) and nucleus pulposus (NP), which function as a joint and cushion for the spine. IDD can develop with ageing, which can cause the NP to herniate and cause pain. IDD patients experience detrimental effects on their quality of life and mental health in addition to their physical health. It also poses a critical economic burden on society as a whole. Imaging techniques used for the diagnosis are disc herniation, X-ray plain film, CT, and MRI are discussed as imaging modalities, with MRI being particularly useful for diagnosing disc herniation. Treatment approaches range from conservative methods to surgical intervention, related to the type of IDD. Nonsteroidal anti-inflammatory medications, rest, traction therapy, and physical therapy are examples of non-surgical therapies. Options for surgery include conventional open surgery, microsurgical lumbar discectomy, minimally invasive IVD removal surgery, and artificial IVD replacement surgery. Many studies are focused on the role of cytokines to explain the cause of IDD. And these cytokines can be classified as cell cycle inhibitor, proinflammatory factor and growth factor. The article highlights cell cycle inhibitors (p16INK4a and p53), proinflammatory factors (IL-1β and TNF-α), and growth factor (TGF-β) involvement in IDD. However, currently, there are no cytokine-based treatments available for IDD in clinical practice. Future research could focus on developing new treatment or prevention targets for IL-1β or TNF-α.