Plain MRI Research Articles

Pancreatic neuroendocrine neoplasms: Correlation between MR features and pathological tumor grades

This study investigated the accuracy of MRI features in differentiating the pathological grades of pancreatic neuroendocrine neoplasms (PNENs). A total of 31 PNENs patients were retrospectively evaluated, including 19 cases in grade 1, 5 in grade 2, and 7 in grade 3. Plain and contrastenhanced MRI was performed on all patients. MRI features including tumor size, margin, signal intensity, enhancement patterns, degenerative changes, duct dilatation and metastasis were analyzed. Chi square tests, Fisher's exact tests, one-way ANOVA and ROC analysis were conducted to assess the associations between MRI features and different tumor grades. It was found that patients with older age, tumors with higher TNM stage and without hormonal syndrome had higher grade of PNETs (all P<0.05). Tumor size, shape, margin and growth pattern, tumor pattern, pancreatic and bile duct dilatation and presence of lymphatic and distant metastasis as well as MR enhancement pattern and tumor-topancreas contrast during arterial phase were the key features differentiating tumors of all grades (all P<0.05). ROC analysis revealed that the tumor size with threshold of 2.8 cm, irregular shape, pancreatic duct dilatation and lymphadenopathy showed satisfactory sensitivity and specificity in distinguishing grade 3 from grade 1 and grade 2 tumors. Features of peripancreatic tissue or vascular invasion, and distant metastasis showed high specificity but relatively low sensitivity. In conclusion, larger size, poorlydefined margin, heterogeneous enhanced pattern during arterial phase, duct dilatation and the presence of metastases are common features of higher grade PNENs. Plain and contrast-enhanced MRI provides the ability to differentiate tumors with different pathological grades.

Evaluation of Ulnar-sided Wrist Pain.

Determining the etiology of ulnar-sided wrist pain is often challenging. The condition may be acute or chronic, and differential diagnoses include injuries to the ulnar carpal bones, ligament tears, tendinitis, vascular conditions, osteoarthritis and systemic arthritis, and ulnar nerve compression. An anatomically based, methodical physical examination coupled with provocative maneuvers, including piano key, ulnar impaction, shuck, foveal stress, and extensor carpi ulnaris synergy tests, further defines the differential diagnosis. Diagnostic imaging used in the evaluation of ulnar-sided wrist pain includes plain radiographs and MRI with or without arthrography. Wrist arthroscopy is becoming increasingly important in the diagnosis and management of ulnar-sided intra-articular wrist pathology.

Functional evaluation of lumbar spinal stenosis treated with conservative treatment retrospective study

Background: Approximately 75% men have low-back pain, and most of them come to get treated for acute low-back pain and cure without operation. Conservative treatment procedures, including surgery, have never been evaluated carefully. Objectives: To assess the efficacy of conservative treatment in Lumbar Spinal Stenosis (LSS) and how to choose the patient for conservative treatment. Material and Methods: As many as 30 patients (9 men and 21 women) who were undergoing treatment between January and December 2014 in Orthopaedic and Traumatology Department, Faculty of Medicine, Airlangga Unversity-dr. Soetomo General Hospital, Orthopaedic and Traumatology Hospital (RSOT) Surabaya were recruited for the study. The mean of age of the participants was 51.9 years LSS (diagnostic with plain radiography and MRI) without indicated operation and they were treated conservatively with TENS, WSD, and ultrasonography and NSAIDs for 6–12 weeks. We evaluate VAS and ODI and assigned scores to predict the efficacy of conservative treatment. Results: VAS decreased significantly in patients with mild and moderate VAS prior to conservative treatment 68.1% (p < 0.001). ODI improved significantly in a patient with a mild and moderate disability prior to conservative treatment 87.5% (p < 0,000). On the basis of scores assigned to predict the efficacy of conservative treatment, we fixed sensitivity and specificity at cut point £ 3.50. Conclusions: Conservative treatment can be effective in some LSS patients if the indications are correctly presented.

Management of benign bone tumours

Benign bone tumours are rare, occurring most commonly in skeletally immature patients, and usually arising from cartilage or bone. The commonest locations are the distal femur, proximal tibia and proximal humerus. They present with pain, swelling or pathological fracture. Diagnosis is by plain radiographs, MRI and core needle biopsy if indicated. More aggressive tumours may appear radiologically similar to malignant tumours. Management depends upon anatomical location, symptoms, morbidity of treatment and the natural history of the tumour. In most cases it involves either simple excision or curettage, although occasionally it is necessary to perform a complete excision using the same principles as for malignant tumours.

Post-Operative Imaging of Shoulder (20 min)

: This presentation features, modalities: plain radiographs, CT, MRI, and ultrasound; arthroplasty; hardware loosening; suture anchor migration; AVN, collapse, arthritis; rotator cuff repair; labral repair.

Rapid diagnosis of “Fatigue” stress fractures using bone scintigraphy: A practical approach

Stress fractures can broadly classified into “fatigue” or “insufficiency” fractures depending on baseline bone health and amount of physical activity. Of these fatigue stress fractures present with a classical history of increased physical activity in healthy bones followed by pain typically after a few weeks. Imaging modalities include plain radiographs, MRI, CT Scan, Bone Scintigraphy (Scan) and Ultrasound. We discuss a short case series and explore key points for all these modalities and propose a simple algorithm for rapid diagnosis of fatigue stress fractures involving three phase bone scan.

Mobile Schwannomas of lumbar spine: A diagnostic dilemma

Mobile Schwannoma is a very rare entity and is reported sparsely in literature, with most of them occurring in lumbar spine region. We present a case of seventy-year-old male patient who had pain in lower back radiating to ipsilateral thigh. A diagnosis of migratory tumour was made based on findings of plain and contrast MRI preoperatively. We did a two level laminectomy and tumour excision. In this report, we intend to discuss various likely causes of tumour migration and various diagnostic methods to tackle this surgical dilemma, we have also attempted to review the sparse literature available till date on migratory lumber schwannoma.

Diffusional kurtosis imaging value for assessment of liver cancer and tumoral cell invasion of peritumoral zone

Objective Study the apply of diffusional kurtosis imaging(DKI) value to assess liver cancer and tumoral cell invasion of peritumoral liver zone. Methods This research belonging to prospective study which included 24 patients with liver cancer and confirmed by clinical history and imaging features (liver cancer group) , 10 healthy volunteers as control group. The liver cancer group underwent MRI plain and contrast enhanced scan, and DKI examination, while control group underwent MRI plain scan and DKI scan. The signal features of liver parenchyma and liver cancer lesion could be observed from the routine MRI and DKI. Fractional anisotropy (FA), mean diffusion (MD), axial diffusivity (Da), radial diffusivity (Dr), fractional anisotropy kurtosis (Fak), mean kurtosis (MK), kurtosis anisotropy (Ka) and radial kurtosis (Kr) value of four groups, the distant liver parenchyma(far away from the tumor>2 cm), peritumoral liver parenchyma(the distance ≤2 cm around the tumor) and liver cancer were recorded. The differences of DKI parameters were evaluated using one-way analysis of variance (ANOVA). Results The signal of liver cancer in MR plain scan showed mild long T1 and mild long T2 signal, fast in and fast out enhanced feature of the neoplasms could be observed from the enhanced MRI and signal of liver cancer would not lower in DKI with b value up to top. The difference of DKI parameters including FA, MD, Da, Dr and Ka value had statistical significance in these four groups excepted for MK and Kr value. MD, Da and Dr value of normal parenchyma were higher than that of peritumoral parenchyma and liver cancer,while the Ka value was reverse. The differences of MD, Da, Dr and Ka value only had no statistical significance between the distant liver parenchyma and peritumoral liver parenchyma(P>0.05),and the differences of them had statistical significance among the rest group(P<0.05). Conclusion The DKI quantitative parameters can reflect the differences of different tissue, meaning that they can provide molecular imaging information for evaluating liver cancer and peritumoral zone. Key words: Liver neoplasms; Magnetic resonance imaging; Comparative study

Utility of 18F sodium fluoride PET/CT imaging in the evaluation of postoperative pain following surgical spine fusion.

A retrospective case review of patients who underwent 18F sodium fluoride PET/CT imaging of the spine with postoperative pain following vertebral fusion. To determine the benefit of 18F sodium fluoride PET/CT imaging in the diagnosis of persistent pain in the postoperative spine. The diagnosis of pain generators in the postoperative spine has proven to be a diagnostic challenge. The conventional radiologic evaluation of persistent pain after spine surgery with the use of plain radiographs, MRI, and CT can often fall short of diagnosis in the complex patient. 18F sodium fluoride PET/CT imaging is an alternative tool to accurately identify a patient's source of pain in the difficult patient. This retrospective study looked at 25 adult patients who had undergone 18F sodium fluoride PET/CT imaging. All patients had persistent or recurrent back pain over the course of a 15-month period after having undergone spinal fusion surgery. All patients had inconclusive dedicated MRI. The clinical accuracy of PET/CT in identifying the pain generator and contribution to altering the decision making process was compared to the use of CT scan alone. Of the 25 patients studied, 17 patients had increased uptake on the 18F sodium fluoride PET/CT fusion images. There was a high-level correlation of radiotracer uptake to the patients' pain generator. Overall 88% of the studies were considered beneficial with either PET/CT altering the clinical diagnosis and treatment plan of the patient or confirming unnecessary surgery. 18F sodium fluoride PET/CT proves to be a useful tool in the diagnosis of complex spine pathology of the postoperative patients. In varied cases, a high correlation of metabolic activity to the source of the patient's pain was observed.

Osteoraticular Tuberculosis-Brief Review of Clinical Morphological and Therapeutic Profiles.

Osteoarticular tuberculosis (OATB) is a rare form of tuberculosis (TB) whose incidence rose significantly nowadays especially in the underdeveloped countries. The main risk factors predisposing to this new challenge for the medical system are the Human Immunodeficiency Virus (HIV) epidemic, the migration from TB endemic areas and the development of drug and multidrug-resistant strains of Mycobacterium tuberculosis (Mt). The disease affects both genders and any age group although the distribution depending on gender is controversial and that depending on age has a bimodal pattern. In most cases the initial focus is elsewhere in the organism and the most frequent pathway of dissemination is lympho-haematogenous. The clinical picture includes local symptoms as pain, tenderness and limitation of motion, with some particularities depending on the segment of the osteoarticular system involved, sometimes accompanying systemic symptoms specific for TB and other specific clinical signs as cold abscesses and sinuses. The radiographic features are not specific, CT demonstrates abnormalities earlier than plain radiography and MRI is superior to plain radiographs in showing the extent of extraskeletal involvement. Both CT and MRI can be used in patient follow-up to evaluate responses to therapy. TBhas been reported in all bones of the body, the various sites including the spine (most often involved) and extraspinal sites (arthritis, osteomyelitis and tenosynovitis and bursitis). Two basic types of disease patterns could be present: the granular type (most often in adults) and the caseous exudative type (most often in children) one of which being predominant. The algorithm of diagnosis includes several steps of which detection of Mt is the gold standard. The actual treatment is primarily medical, consisting of antituberculosis chemotherapy (ATT), surgical interventions being warranted only for selected cases. It is essential that clinicians know and refresh their knowledge about manifestations of OATB.

Locked knee in children owing to torn discoid lateral meniscus: the role of arthroscopic management

Background Discoid meniscusis a relatively rare congenital anatomical abnormality in which the meniscus is discoid rather than semilunar in shape. A torn discoid lateral meniscus (DLM) can be a potential cause of mechanical symptoms in children; moreover, it is considered the commonest reason for arthroscopic interventions performed on children. Hypothesis Arthroscopic reshaping of the meniscus (meniscoplasty) by partial excision of the central part achieves good results in these patients. Patients and methods Twenty patients (20 knees) presenting with symptomatic torn DLM were included in the study. The age ranged from 3 to 11 years, with a mean of 7.2 years. Five of them were males and 15 were females. Seventeen of them had locked knee owing to displaced bucket handle tear of DLM. Two patients had complex tear of DLM, whereas only one patient had a longitudinal cleavage tear. All the cases experienced knee pain and swelling. Clinical evaluation of the patients was done according to the subjective and objective International Knee Documentation Committee (IKDC) 2000 forms, and Lysholm knee score. Moreover, radiological evaluation was performed using plain radiographs and MRI. All patients were managed by reshaping of the meniscus by arthroscopic central partial meniscectomy regardless of the tear type. The duration of follow-up ranged from 22 to 36 months, with a mean of 26.4 months. Results All the patients showed dramatic improvement postoperatively. The average postoperative subjective IKDC score was 76% as compared with 29.25% preoperatively. Postoperative IKDC objective grade was A in six (30%) cases and B in 13 (65%) cases at the end of follow-up, as compared with the preoperative grade assessment, which was D in six (30%) cases and C in 14 (70%) cases, with statistically highly significant results (P Conclusion Torn DLM can be a potential cause of symptomatic knee pain and effusion in children and should not be overlooked. Arthroscopic central partial meniscectomy (meniscoplasty) can give good results in these cases.

Gambaran Radiologi pada Craniosynostosis

Craniosynostosis is a condition in which there is premature fusion of one or more cranial sutures, causing neurological disorders, distinctive deformities of the face and skull, also accompanied by increased intracranial pressure, visual impairment, deafness and cognitive deficits. Craniosynostosis may appear in primary or secondary secondary to other disorders. As many as 85% of primary craniosynostosis emerged as a single condition while the remaining 15% as part of the multisystem syndrome.&#x0D; Radiological examination is important for accurate diagnosis, surgical planning, therapeutic evaluation and identification of comorbid anomalies and complications related to craniosynostosis. Computed Tomography (CT) with 3-D reconstruction is a technique used to diagnose craniosynostosis because it can provide a better picture of bone. Nevertheless, the presence of radiation exposure from CT scan, especially in infants causes the authors to look for alternatives to other radiological examination techniques including the use of ultrasonography, plain cranial rontgen and MRI

Evaluation of the results of arthroscopic double row rotator cuff repair of isolated lesions

Background: Rotator cuff tears are one of the most common soft tissue injuries. The incidence of full thickness tears of the rotators cuff ranges from 5% to 40% of all cuff tears, and increasing in frequency with age. The double row (DR) rotator cuff (RC) repair technique has been developed to optimize healing biology at RC tendon insertion, by increasing pressurized contact area and mean foot print pressure. Patients and Methods: From 2012 to 2014 forty patients with full thickness rotator cuff tear were selected to undergo arthroscopic DR RC repair. All patients were examined clinically and neurologically after history taking. Plain radiography and MRI were done for all patients. All the operations were done under general anesthesia and in beech chair position. Evaluation of the results of this study based on, the University of California, Los Angeles (UCLA) score and Range of motion (ROM). Secondary outcome measures included a Visual Analogue Scale (VAS) for pain. Results: At the end of two years follow up, the average UCLA score was improved from 12 preoperative to 29.8 postoperative. The average abduction was improved from 90 degrees preoperative to 145 degrees postoperative. Secondary outcome measures showed that average Visual Analogue Scale for pain was 2.8.And Visual Analogue Scale for patients satisfaction was 8.8 at the end of follow up. Conclusion: Arthroscopic double row rotator cuff repair is a procedure with good post-operative functional outcome and low complications rate based on a short term follow-up.

Transoral Approach for Odontoidectomy Efficacy and Safety.

Odontoid process pathologies can cause upper motor neuron lesions. These pathologies can be approached through either a high retropharyngeal approach or a transoral approach. The introduction of the surgical microscope, proper instrumentations, and proper antibiotics has increased utilization of the transoral approach. Our approach to anterior odontoid resection through transoral approach for different pathologies resulting in compression the cervical cord or causing craniocervical instability is described here. We aim to explore the safety and efficacy of this approach. Twenty cases of different odontoid pathologies were managed by transoral surgery. Patients were assessed clinically for axial neck pain and radicular symptoms using visual analog scale. The Nurick score was used to get an overall functional evaluation of the difficulty of ambulation and walking. Radiological evaluation of the patients included plain radiographs, CT scans, and MRI of the cervical spine. Posterior surgery was done as a first stage for restoring the sagittal profile of the cervical spine. Transoral surgery was done as a second stage for odontoid resection and anterior decompression of the cord. Average follow-up was 29.4 ± 3.8months. Mean preoperative Nurick scale was 1.3 ± 1.2. Mean postoperative Nurcik scale was 0.5 ± 0.61. Patients with axial neck pain were improved after surgery except the 6 patients; mean VAS preoperative 8.2 ± 2.3 SD, mean postoperative VAS 3.7 ± 0.8SD, and radicular symptoms were not significantly changed after surgery; gait changes were improved in all patients with preoperative gait disturbance. The transoral approach is a safe and effective surgical method for the direct decompression of ventral midline extradural compressive disease of the craniovertebral junction.

Features of Avascular Osteonecrosis in Children Treated for Acute Lymphoblastic Leukaemia: Experience in a Single Center

Because survival of pediatric acute lymphoblastic leukaemia (ALL) has improved in the last years, adverse effects acquire increasing importance. Avascular osteonecrosis (ON) is a long term complication of ALL treatment affecting the patients' quality of life. Its pathogenesis recognizes multiple factors (age, race, genetics, chemotherapies and steroids). The different roles of dexamethasone (DXM) versus prednisone (PDN) is still under discussion, as dosages and rate of administration.The prevalence of ON varies in different series (0.43-17.6%). It affects mostly the weight-bearing epiphyseal bone, usually knee and hip. Multiple joint involvement is common. ON treatment is not established: efficacious drugs are not available; surgery is strongly invasive for pediatric patients (pts); among physical treatments, the use of hyperbaric oxygen therapy (HBO) is uncommon.We report our experience in children treated consecutively from 2000 to 2015 for ALL at the Pediatric Hematology Clinic of Padua, who developed ON. HBO was used in some pts with variable efficacy, suggesting its possible role in early stages.Materials and methods Prevalence ofON was assessed retrospectively in 469 pts with ALL enrolled in AIEOP 2000 Protocol (P 2000, 327 pts) and AIEOP BFM ALL 2009 Protocol (P 2009, 142 pts); median age was 5 years (yrs, range 1-17). Girls were 53% and boys 47% (Table 1).ON was defined as persistent pain in one or more major joints (hip, knee, elbow, shoulder, ankle) and peculiar radiological findings (plain XR or MRI). Severity was graded radiologically by the ARCO (Association of Research Circulation Osseous) staging system; clinically by the CTCAE v3.0.Statistical analysis was done using z- and t-tests.Results 19/469 pts (4%) developed ON of CTCAE grade 2-4. Age at leukaemia diagnosis was over 10 yrs in 17/19 pts. ON always presented during maintenance or off therapy. Median follow up after ON development in P 2000 was 54 months (range 21-170) and 28.5 months (8-48) in P 2009. The most frequent sites were knee, hip and ankle. Multiple joint involvement was frequent (11/19, 58%); 14/19 (74%) had also functional limitation at diagnosis (grade 3-4).Nine ON pts (3 in P 2000, 6 in P 2009) were at high risk, receiving higher steroid dosages than low risk (p<0.001). Four pts underwent TCSE in first remission (1 in P 2000 and 3 in P 2009).As for ON treatment, 14/19 (74%) pts were treated conservatively; 5/19 (26%) pts underwent joint replacement; 7/19 (37%) pts received HBO (25-40 sessions, 2.5 ATA).Four children showed complete recovery or only limited disturbances; 14 pts had more severe impairment (grade 3-4, 5 joint replacements). One patient developed osteosarcoma as secondary malignancy after first line chemotherapy, TCSE and HBO.HBO results: pain improvement was not obtained in any patient. The 5 pts with ON ARCO grade II-III showed lesion stability without joint collapse at control MRI. The 2 pts with very advanced ON (grade IV) placed implants.Comparing the two consecutive Protocols (P 2000 vs P 2009), we found different prevalence of ON (0,3 % vs 8,4% respectively, p <0.001), but no difference in gender nor steroid dosage. Notably, children aged over 10 yrs were more frequent in P 2000 than in P 2009 (p <0.001); however, older children had 3.1% of ON prevalence in P 2000 and 25% in P2009 (p 0.001, Table 2).Conclusion In our experience the prevalence of symptomatic ON in pts treated with two consecutive and similar ALL protocols was 4% (19/469) as reported by literature. No asymptomatic cases were reported, probably due to lack of screening. Boys were affected similarly than girls; age was significantly higher in patients with ON (p 0.001).A marked different prevalence between the two groups (0.3% vs 8.4%) was found, without apparent role of age, gender or steroid dosages. However, a possible underdiagnosis in P 2000 can be considered, due to higher attention given recently to this problem.High risk pts developed ON more frequently (p<0.001). The role of different steroids can not be inferred from our study, since both PDN and DXM were administered to all pts. As suggested by DFCI reports, the difference between the two Protocols could be due to the extensive use of L-Asparaginase, administered in its pegylate form in P 2009.HBO seems to stabilize the progression of early stage of ON, but it is not efficacious in advanced ON. Screening MRI could be useful for early diagnosis and to understand the utility of HBO in these cases. [Display omitted] [Display omitted] DisclosuresNo relevant conflicts of interest to declare.

Focal nodular and diffuse haematopoietic marrow hyperplasia in patients with underlying malignancies: a radiological mimic of malignancy in need of recognition

To report the authors' experience of focal nodular haematopoietic marrow hyperplasia (FNHMH) and diffuse haematopoietic marrow hyperplasia (DHMH) clinically masquerading as skip, distant, or disseminated metastasis in seven patients with underlying malignant neoplasms. Five patients with FNHMH and two with DHMH mistaken radiologically as skip and disseminated metastasis, respectively, were compared and contrasted with four patients with osteosarcomas and two with chondrosarcomas harbouring skip metastasis, noting the temporal relationship with their haematological profile. FNHMH and DHMH were undetectable by plain radiography and computed tomography (CT) except one showing subtle sclerosis on CT. They showed either isointense or hyperintense, but not hypointense, attenuation at T1-weighted imaging, and all showed hyperintense attenuation at T2-weighted MRI relative to skeletal muscle. Of the five patients who underwent bone scintigraphy, one showed mildly increased uptake, and one out of two showed markedly increased 2-[18F]-fluoro-2-deoxy-d-glucose (FDG)-positron-emission tomography (PET) uptake. The rates for sarcoma skip metastasis by plain radiography, CT, MRI, and bone scintigraphy were 40%, 66.7%, 100%, and 66.7%, respectively. At MRI, 60% showed hypointense and 40% isointense attenuation at T1-weighted, 80% hyperintense and 20% hypointense attenuation at T2-weighted imaging. Combined FDG-PET and CT, which was performed in only one patient, failed to show the skip metastasis. Not every patient with FNHMH or DHMH received granulocyte colony-stimulating factor (GCSF), but all had low or falling haemoglobin levels, which may thus be the prime cause for HMH. Due to overlapping radiological features, FNHMH and DHMH are great radiological mimics of malignancy. In some cases, needle biopsy is required for their definitive differentiation.

Plain Radiographic Evaluation of Degenerative Changes of Lumbosacral Spine-Correlation with Magnetic Resonance Imaging Findings

Back pain resulting from degenerative disease of the spine is one of the most common causes of disability in adults of working age. The structures which may be responsible for the origin of the degenerative spine are bone (spondylolisthesis, spondylolysis), ligaments (hypertrophy of the spinal ligaments, particularly the ligamentum flavum), facet joints (facet hypertrophy, synovial cyst) and intervertebral disc (bulging and herniation)1. This was a cross sectional study of 105 patients with low back pain. All Plain X-ray and MRI findings were collected for each patient in a pre-designed structured data collection sheet. In plain X-ray 74 subjects had posterior disc height &lt;6mm; out of them nerve root compression found in 56, spinal stenosis found in 54. Those who had posterior osteophytes, (86.8%) found to have disc herniation. Among facetal hyperthrophy (72 subjects), 62 (86.1%) had disc herniation. In this study significant correlation found between plain radiographic findings of degenerative changes of lumbosacral spine with MRI.Faridpur Med. Coll. J. Jul 2015;10(2): 68-70

Determining lesion size in osteonecrosis of the femoral head: A practical approach

Background: To provide the best possible evaluation and treatment for patients with osteonecrosis of the femoral head (ONFH) it is necessary to determine the size of the necrotic lesion and extent of joint involvement as well as the stage. There has been a steady trend towards the use of comprehensive classifications, but there remains a difference of opinion as how best to determine lesion size. Purpose: To determine the accuracy and ease of use of various angular measurements and other techniques for measuring lesion size in ONFH. Methods: Eighteen hips with Stage I, II ONFH were evaluated using three-dimensional MRI measurements of lesion volume as the standard against which to compare simple visual estimates and area and angle measurements on plain radiographs and MRI. Results: The necrotic region occupied between 2.2% and 59% of the femoral head volume on MRI measurements. Many plain films in this specific series did not depict the lesion margins well, which made delineation, estimation and measurements of lesion size less accurate than in previous studies. There was a rough correlation between angle measurements and lesion size. This correlation was closer with the Index of Necrosis than with the Combined Necrotic Angle, which routinely overestimated size. The accuracy of the Index was improved when adjusted to reflect a femoral head angle of 250 degrees rather than 180 degrees. Numerical limits were derived with which angular measurements could be correlated for 70% of hips with Grades 〞A〞, 〞B〞 and 〞C〞 lesion size, as described in the University of Pennsylvania and ARCO classifications. Simple visual estimates from MRI studies were as accurate as angular measurements. Conclusions: For routine clinical use, visual estimates from good quality radiographs or MRI are generally satisfactory. Angular measurements do give an indication of prognosis and treatment, although they are estimates rather than true measurements of lesion size. 3-D MRI volume measurements are the most accurate method of measuring lesion size. They are now easier to use and should be considered for research and publications.

ASSESSMENT OF ACUTE POISONING AMONG CHILDREN IN DAMIETTA GOVERNORATE

Background: Unintentional toxicology represented an important health problem in pediatrics. However, there was no appropriate map helping in design of proper preventive strategies. Objective: Investigating the pattern of acute toxicity of children aged 1–18 years in Damietta governorate. Subjects and methods: The study included children presented to Emergency Department of Damietta Poison Control Center (PCC) during the period from January 2015 to December 2015. In all children, the following parameters were studied: mean age, sex, residence, occupation, route of exposure, manner of poisoning, time elapsed between exposure to toxin and hospital arrival, past medical history, family history, seasonal distribution, admission place (ED, inpatient, ICU, or referral); and outcome (Improvement, referral and death). Clinical and Investigational aspect of the study included general examination, systemic examination and investigations (laboratory, ECG, Plain chest X-ray, Plain abdominal X-ray, CT and/or MRI in cases of coma or unexplained etiology). Curative aspect of the study included emergency measures, decontamination, enhancement of elimination, and administration of specific therapy). Results: There was a statistically significant difference between studied groups as regard gender distribution. Residence was rural in 78.4% and urban in 21.6%. The most common toxic agent(s) were insecticides (46.6%), hydrocarbons (24.1%), corrosives (19.8%) and medicinal agents (9.5%). The toxicity was mild in majority of children (72.4%), and the severity of toxicity increased with increasing age. The delay time was less than an hour in the majority of children (58.6%). The oral route was the most common (69.0%) and oral route intoxication increased with increasing age. Intoxication was accidental in the majority of studied children (84.5%) and no suicidal cases below the age of 6 years. Location of toxicity in studied children was home in the majority of subjects (84.5%) and outside home (15.5%), with a statistically significant difference between them. Outcome revealed that 30.2% and 69.8% were discharged from Emergency Department. The discharge rate from Emergency Department decreased with increasing age. Conclusion: The present study provided a road map for the pattern of childhood toxicity in Dameitta governorate. It is the first step to explore the magnitude of the problem in this area of Egypt. Future efforts are needed to complete the map with development of effective preventive strategies.

Physeal Disruption During ACL Reconstruction in Skeletally Immature Patients

Objectives:The purpose of this study was to radiographically assess differences in distal femoral physeal disruption between transtibial and independent femoral tunnel drilling techniques following ACL reconstruction in skeletally immature patients.Methods:A retrospective, matched comparative cohort study was performed of skeletally immature patients who underwent transphyseal ACL reconstruction between January 1, 2008 and March 31, 2011. All skeletally immature patients between ten and fifteen years old who underwent independent femoral tunnel drilling and had adequate baseline and post-operative radiographs were analyzed. These patients were matched with a transtibial technique cohort based on age and sex. Demographic characteristics and peri-operative metrics were collected. Radiographic measurements were recorded from pre-operative MRI and post-operative plain radiographs.Results:Twenty patients were analyzed. Between groups, there were significant differences between independent tunnel drilling and transtibial tunnel drilling in the estimated area of physeal disruption (1.64 cm2 vs. 0.74 cm2, P<0.001), femoral (32.1º vs. 72.8º, P<0.001) and tibial (50.1º vs. 60.5º, P=0.003) tunnel angles, medial/lateral location of the femoral tunnel (24.2 mm vs. 36.1 mm from lateral cortex, P=0.001), and distance from the lateral aspect of the distal femoral physis and the femoral tunnel exit (4.7 mm vs. 26.7 mm from the perichondrial ring, P<0.001), respectively. All patients who underwent femoral tunnel drilling at an angle of less than 25º from the transverse axis experienced a greater than 6% disruption of physeal area. There was a significant inverse correlation between femoral tunnel angle and estimated area of femoral physeal involvement (r=-0.8255, P=0.003).Conclusion:With femoral tunnel drilling techniques that create more oblique tunnels, the area of distal femoral physeal damage is larger, more eccentric and closer to the perichondrial ring. Since most studies noting the safety of transphyseal ACL reconstruction have utilized a vertical femoral tunnel, surgeons should be aware that if an independent femoral tunnel drilling technique is utilized during transphyseal ACL reconstruction, the physis is at greater risk when drilling at more horizontal angles. Angles greater than 25º from the transverse axis may safely create <6% physeal area damage.