Posteroanterior View Research Articles

Use of oblique view in periacetabular osteotomy and delayed postoperative weight bearing reduce delayed union in the ischium after one year

This study aimed to determine the efficacy of using both the postero-anterior and oblique image intensifier views intra-operatively and late start of post-operative partial weight-bearing (PWB) in reducing the incidence of delayed union in the ischium at one year after curved periacetabular osteotomy. We evaluated computed tomography images to clarify the incidence of delayed union at the osteotomy sites at one year post-operatively for 117 hips in 104 patients. Fifty-eight hips in 54 patients with use of both the postero-anterior and oblique image intensifier views intra-operatively and late start of post-operative PWB were assigned to the oblique view and late PWB group (OL group) and 59 hips in 50 patients with use of only the postero-anterior image intensifier view intra-operatively and early start of post-operative PWB were assigned to the control group (C group). In univariate analyses, the incidence of delayed union in the ischium at one year post-operatively was significantly lower in the OL group (3.5%) than in the C group (22%). Use of both the postero-anterior and oblique image intensifier views during curved periacetabular osteotomy and late start of PWB were effective for reducing delayed union of the ischium at one year post-operatively.

Getting a Grip on Triangular Fibrocartilage Complex Tears: A Retrospective Comparative Study on Triangular Fibrocartilage Complex Debridement Outcomes

Abstract Background A retrospective analysis was performed to compare the clinical outcomes and complications of patients who underwent triangular fibrocartilage complex (TFCC) debridement based on gripping posteroanterior (PA) view ulnar variance measures. Methods Patients in Group A (N = 17) demonstrated ulnar variance measures <1.0 mm on the standard PA view and ≥1.0 mm on the gripping PA view. Patients in Group B (N = 13) maintained ulnar variance measures <1.0 mm on standard and gripping PA views. Clinical outcome measures included return to work, visual analog scale (VAS) scores, and range of motion. Complications included persistent pain, postoperative injections, and indication for revision surgery. Qualitative and quantitative measures were analyzed using Fisher exact tests and Student's t-tests, respectively. Results Significantly more patients in Group A (7/17) did not return to work compared with Group B (1/13) (p < 0.05). Mean VAS scores decreased from 7.0 to 5.3 in Group A and from 6.8 to 2.0 in Group B. Group A reported lower flexion–extension and pronation–supination arcs compared with Group B (110 vs. 130 degrees and 161 vs. 174 degrees) (p < 0.05). Significantly more patients in Group A (10/17) reported persistent pain at ≥3 months postoperatively compared with Group B (2/13) (p < 0.05). Seven cases were indicated for revision surgery in Group A, while no cases were indicated in Group B (p < 0.05). Conclusion Patients in Group A reported inferior clinical outcomes compared with Group B based on pain, range of motion, and indication for revision surgery. Dynamic ulnar variance may play a role in the clinical outcomes of patients treated with TFCC debridement. Level of Evidence Level IV. Type of Study/Level of Evidence Retrospective Comparative Study/Level IV.

Radiological Assessment of Hand and Wrist Bones in Malnourished Children

Abstract Background Protein energy malnutrition (PEM) is still an important health problem that is responsible for childhood morbidity and mortality leading to permanent impairment of physical and mental growth. Objective This study is designed to assess the appearance of ossification centers of lower end of radius and ulna, carpals, metacarpals and phalanges in normal children and malnourished children then comparing between them, to detect early changes in bone growth in malnourished children. Subjects and Methods This case-control cross-sectional study included 45 malnourished children and 45 age and sex matched controls whose ages ranged between 6 months and 5 years. The patients were recruited from Pediatric Nutrition Clinic of Ain Shams University. All children (malnourished and control) were examined for anthropometric parameters (weight, height, body mass index (BMI) and mid upper arm circumference (MUAC)), investigated for serum calcium, phosphorus, alkaline phosphates and had a plain X-ray done on left hand and wrist (posteroanterior (P-A) view), the X-ray was analyzed by using A Digital Atlas of Skeletal Maturity. Results The plain X-ray hand and wrist showed delayed appearance of ossification centers in malnourished infants and children (97.8% had delayed bone age) when compared to controls (25.5% had delayed bone age) which was statistically highly significant with P-value < 0.01. Signs of vitamin D deficiency rickets together with serum calcium, phosphorus and alkaline phosphatase were statistically significantly lower in the cases when compared to the controls with P-value < 0.01. The statistical measurements of mean ± SD regarding weight of case group and control group was (9.05 ± 2.48, 13.54 ± 3.81) with P-value < 0.01 which is highly significant, regarding length or height was (79.51 ± 12.78, 88.94 ± 15.02) with P-value < 0.01 which is highly significant, regarding MUAC was (11.38 ± 1.91, 16.02 ± 1.26) with P-value < 0.01 which is highly significant. Conclusion X-ray hand and wrist for malnourished infants and children showed delayed appearance of ossification centers when compared to matched controls.

Normative Data of Carpal Bone Measurements in the Sample Adult Indian Population.

Introduction Radiography is the most often accessible and affordable imaging modality. Accurate assessments of wrist X-rays can aid in the diagnosis and prognostic evaluation of various wrist problems. This study aims to identify normal radiographic anthropometry reference values and variations of carpal bones and joints by gender and age in sample Indian population, with the potential to be clinically applicable. Materials and Methods Two investigators conducted a prospective analysis of normal wrist radiographs in a single center. Radiology Information Systems and Picture Archiving and Communication Systems were used to collect standard digitized normal X-rays without significant osseous pathology over a year. We conducted measurements of length, angles, and indices in a standard posteroanterior and lateral wrist X-rays in order to establish the standard dimensions and variances based on age and gender. Results A total of 18 measurements which included eight linear measurements, eight angles, and two ratios were documented. A total of 500 X-rays of 250 males and 250 females with 125 of each in two age groups of 20 and 40 years and 41 and 60 years were evaluated. Conclusion This work is a comprehensive database of the Indian population measuring parameters in normal wrist radiographs of posteroanterior and lateral views. The results of our study indicate that men and younger individuals had a significantly higher carpal height ratio. The width of distal radial ulnar joint space was significantly lesser in older subjects. Additionally, males showed a significantly higher lunate uncovered ratio and radial height. When compared to the literature, the study revealed a significant positive ulnar variance in elderly people and women. However, we noted an overall increase in the percentage of positive ulnar variance individuals in our study. We also recorded a marginal increase in radial inclination with no variations across gender and age.

Radiographic Morphometric Analysis of the Distal Radius in the Tamil Nadu Population: A Retrospective Study.

Background and objectives Morphometric parameters such as radial inclination, palmar tilt, radial height, and ulnar variance exhibit considerable variations influenced by geographical, ethnic, racial, and individual factors. These parameters are pivotal in the context of distal radius fractures, distal radius plate design, and kinesiology. Understanding these variations is crucial for surgical precision and predicting complications. Methods This observational, retrospective study, conducted in a single hospital, aimed to determine the morphometric values of the distal end radius, specifically in the South Indian population. We analyzed 300 plain radiographs, encompassing 53.7% males and 46.3% females, with ages ranging from 17 to 89 years (mean age: 41.05 ± 15.8). Radial inclination, radial height, palmar tilt, and ulnar variance were measured on posteroanterior views, while palmar tilt was assessed on lateral wrist X-rays. Results In our study, significant gender-based and side-specific differences were observed. The mean length of the styloid process, palmar tilt, ulnar variance, anteroposterior diameter of the radius, transverse diameter of the radius, oblique width of the radius, and carpal height of the radius exhibited notable variations between males and females. Similarly, significant differences were noted between the right and left sides concerning ulnar variance and teardrop angle. Among males, a significant difference was observed only in the teardrop angle between the right and left sides (59.11 ± 7.25 vs. 62.01 ± 7.97). Conclusion The findings underscore the importance of recognizing local morphometric variations in the South Indian population. This knowledge not only enhances the ability to restore normal alignment post-distal radius fractures but also provides fundamental values for future research endeavors within the local demographic. The study acts as a foundational resource for advancing our understanding of the normal anatomy and variations in the distal radius, facilitating improved clinical outcomes and tailored surgical interventions.

Association of Inflammatory Markers With Disease Progression and the Severity of COVID-19.

Introduction InDecember 2019, there was a massive outbreak of viral pneumonia, which had a high case fatality rate. Genetic sequencing of the virus showed similarity with severe acute respiratory syndrome coronavirus (SARS-CoV). It was later named novel coronavirus 2019 while the disease it caused was given the nomenclature of COVID-19. This deadly pneumonia outbreak was declared a pandemic by the World Health Organization (WHO). Aim To derive the strength of the correlation between blood levels of various inflammatory markers with the severity of COVID-19 pneumonia in patients affected with novel coronavirus 2019. Materials and methodology A prospective study was conducted on 300 confirmed cases of COVID-19 infection from August 2020 to July 2021 in SSG Hospital, Vadodara. Diagnosis of patients as confirmed cases of COVID-19 infection was done according to the WHO interim guidance for COVID-19. Their inflammatory markers were done for this study. All COVID-19-positive patients who had given negative consent for enrollment were excluded from the study. Patients were classified based on the severity of acute respiratory distress syndrome (ARDS). Comprehensive medical record information, encompassing biodata, clinical symptoms, comorbidities, and laboratory investigations, was systematically collected. Patients were given the standard treatment protocol as per guidelines. Patients were subjected to detailed investigations comprising complete blood counts and inflammatory markers like C-reactive protein (CRP), lactate dehydrogenase (LDH), serum ferritin, and D-dimer. Patients were further investigated by chest X-ray (posteroanterior view) or high-resolution computed tomography of the thorax. Results A total of 300 confirmed cases of COVID-19 infection were included in this study. Most of them were males (52%) with a mean age of 51 years and 48% were females with a mean age of 55 years. The majority of patients(40%) did not have ARDS, 23.3% of patients had mild, 16.7% of patients had moderate, and 20% of patients had severe ARDS. Higher CRP levels, serum ferritin, and serum D-dimer were significantly associated with the severity of COVID-19 infection as compared to those having no symptoms (p < 0.05). Increased levels were associated with severe clinical manifestations of COVID-19. The sensitivity of CRP is 69% and specificity is 100% as a diagnostic marker for COVID-19 pneumonia in terms of ARDS. The sensitivity of ferritin is 88% and specificity is 81% as a diagnostic marker for COVID-19 pneumonia in terms of ARDS. The sensitivity of D-dimer is 94% and specificity is 89% as a diagnostic marker for COVID-19 pneumonia in terms of ARDS. The sensitivity of LDH is 93% and specificity is 84% as a diagnostic marker for COVID-19 pneumonia in terms of ARDS. Conclusions Current evidence from our study showed that higher levels of inflammatory markers such as CRP, LDH, D-dimer, and ferritin are associated with the severity of COVID-19 in terms of ARDS and thus could be used as significant prognostic factors of the disease.These indicators might support clinical decisions to identify highfatality casesand poor diagnosis in the initial admission phase.

Ulnar-Sided Wrist Pain: A Diagnostic Evaluation Guide From 30-Plus Years of Experience.

While multiple ulnar-sided wrist pain (USWP) diagnostic evaluation guides have been presented, none have included original clinical data or statistical analysis. The purpose of this study is to provide a diagnostic evaluation guide derived from original clinical data and analysis to help clinicians arrive at a differential diagnosis for USWP. Using a computer search of patients presenting with sprains, instability, and laxity of the wrist, 385 patient charts were identified. Patient demographics, mechanism of injury, subjective complaints, physical findings, and diagnostic test findings were reviewed. Statistical analysis was performed to determine sensitivity and specificity of diagnostic methods on their ability to identify lunotriquetral ligament tears, triangular fibrocartilage complex (TFCC) tears, and ulnar impaction syndrome. Diagnostic arthroscopy was used as the reference standard. Ninety-three patients, comprising 101 cases of USWP, were included in the study. The onset of injury was traumatic in 83 out of 101 cases with motor vehicle accidents (N=46) being the most common, followed by overuse (N=18), and a fall onto an outstretched hand (N=16). The ulnocarpal tenderness test exhibited sensitivity/specificity of 72%/33%; lunotriquetral ligament laxity test of 42%/62%; bone scan of 80%/33%; radiocarpal arthrogram of 90%/98% for TFCC tears and 50%/91% for lunotriquetral ligament tears; midcarpal arthrogram of 82%/86% for lunotriquetral ligament tears.The mean ulnar variance on standard posteroanterior view radiograph was 0.95 mm, increasing to 2.67 mm on gripping posteroanterior view. Physicians should suspect a lunotriquetral ligament and/or TFCC tear with the acute onset of USWP following a loaded dorsiflexed mechanism of injury. Ulnocarpal tenderness tests and pre-operative ulnar variance measures are effective for increasing suspicion of USW pathology. Bone scans are helpful in diagnosing ulnar impaction syndrome in conjunction with radiographic findings. A combination of midcarpal arthrogram for lunotriquetral ligament tears and radiocarpal arthrogram for TFCC tears should be employed.

Hematological parameters as predictors of OSA severity

BackgroundObstructive sleep apnea syndrome (OSAS) is a common disease that has a prevalence of 6 to 13% of the adult population. It is characterized by recurrent obstruction partial or total upper airway and subsequent paroxysmal nocturnal hypoxia, leading to intermittent arousals from sleep and excessive daytime sleepiness.This work aimed to evaluate the relationship between the hematological parameters in CBC with differential as a new biomarker showing systemic inflammation and as an indicator of OSAS severity.Patient and methodsThis retrospective cross-sectional analysis included 100 subjects with OSA from those attending Chest departments in Benha University Hospital from 2021 to 2022 and 2022 to 2023 period. All patients were subjected to full history taking and clinical examination, electrocardiogram, chest X-ray posteroanterior view, full night of polysomnography, and complete blood count with differential.ResultsThere was a statistically significant difference between mild; moderate and severe OSA patients regarding platelets to lymphocyte ratio. A statistically significant difference between mild and severe OSA regarding neutrophil to lymphocyte ratio was found. There was a statistically significant positive correlation between OSA severity and platelet level, N/L, and P/L ratio.ConclusionThe hematological indices including neutrophil to lymphocyte ratio and platelet to lymphocyte ratio could be alternatives to expensive time-consuming biochemical markers to evaluate the inflammation and severity in the OSAS population.

Intraoperative assessment of hindfoot alignment using C-arm fluoroscopy

BackgroundHindfoot malalignment can cause various foot and ankle problems. For better surgical performance and correction of hindfoot malalignments, reliable intraoperative determination of hindfoot alignment is essential. However, there is no standard method for the intraoperative assessment of hindfoot alignment. We devised an intraoperative modified Méary posteroanterior (IOPPA) view to assess intraoperative hindfoot alignment. This study aimed to compare this intraoperative method with other radiographic hindfoot alignment measurements. MethodsThirty-seven patients (47 feet) with various foot and ankle conditions scheduled to undergo surgery were prospectively recruited. Before surgery, the Saltzman, long axial, and modified Méary views were taken in a controlled and standardized fashion. IOPPA views were obtained under simulated weight bearing conditions using C-arm fluoroscopy in the operating room before surgery. The relationship between the IOPPA view and the three radiographic hindfoot alignments was evaluated using Pearson's correlation. ResultsThe mean hindfoot alignment angle was varus 3.50° (CI, varus 1.91 to 5.08) on the Saltzman view, varus 2.00° (CI, varus 0.60 to 3.39) on the long axial view, varus 0.13° (CI, valgus 1.41 to varus 1.67) on the modified Méary view, and varus 1.32° (CI, valgus 0.02 to varus 2.65) on IOPPA view. The IOPPA view and the three other hindfoot alignment views were found to be significantly correlated (r = 0.60 for the Saltzman view, r = 0.50 for the long axial view, r = 0.71 for the modified Méary view, P < .05). The intraobserver ICC (Intraclass Correlation Coefficient) value was 0.974 and interobserver ICC (Intraclass Correlation Coefficient) value was 0.988 for the IOPPA view (P < .001). ConclusionThere was a statistically significant correlation between the IOPPA view and the other three hindfoot alignment views. We also found that interobserver and intraobserver ICC values were excellent. This study proposes that the IOPPA view can be used as a reliable intraoperative assessment tool for hindfoot alignment. Level of evidenceProspective study.

Comparative Study of Intravenous Methylprednisolone Pulse Therapy versus Oral Prednisolone Minipulse Therapy in Progressive Vitiligo

Abstract Background: Vitiligo is an idiopathic acquired illness characterized by limited depigmented macules and patches. We aim to compare intravenous (IV) methylprednisolone pulse therapy with oral prednisolone minipulse therapy in the treatment of progressive vitiligo. Objective: The assessment of the efficacy of both treatment methods in the arrest of the progression of vitiligo and repigmentation of the existing lesions. Materials and Methods: A total of 60 patients, 30 in each group, were enrolled for the study. Each patient underwent a detailed clinical, general physical, systemic, and thorough dermatological examination. A set of routine investigations, consisting of hemoglobin%, total leukocyte count, differential leukocyte count, urine routine examination, blood sugar (fasting and postprandial), liver function tests, renal function test, serum electrolytes, Montoux test, chest X-ray posteroanterior view, and thyroid profile were carried out before the analysis. Clinical photographs were taken before the start of therapy and after each month thereafter were used for the analysis after taking written consent. Results: The age of vitiligo patients considered for the study ranged from 13 to 70 years. The ratio of male-to-female patients considered for the study was 22:38 (36.6%: 63.3%). The duration of instability in vitiligo cases studied varied from 6 months to 2 years. In both Group A and Group B, the maximum number of patients (66.7% and 86.7%, respectively) had unstable vitiligo for 6 months to 1 year. Percentage repigmentation was better in Group A (IV) than Group B (OMP). In Group A, 17 out of 20 (85%) patients had shown different degrees of repigmentation, while 20 out of 30 (66.7%) patients of Group B had shown the same. This was statistically insignificant. Types of repigmentation observed in patients were of the following types: perifollicular, marginal, and combined. In both groups, all patients showed perifollicular regimentation. Conclusions: In progressive vitiligo, it was observed that oral mini pulse with prednisolone is superior to IV methylprednisolone pulse therapy for the arrest of progression. Considering the cost, mode of administration, hospital admission, loss of man-hours, and patients’ compliance, OMP was considered simpler and cost-effective.

The Performance of a Deep Learning-Based Automatic Measurement Model for Measuring the Cardiothoracic Ratio on Chest Radiographs.

Prior studies on models based on deep learning (DL) and measuring the cardiothoracic ratio (CTR) on chest radiographs have lacked rigorous agreement analyses with radiologists or reader tests. We validated the performance of a commercially available DL-based CTR measurement model with various thoracic pathologies, and performed agreement analyses with thoracic radiologists and reader tests using a probabilistic-based reference. This study included 160 posteroanterior view chest radiographs (no lung or pleural abnormalities, pneumothorax, pleural effusion, consolidation, and n = 40 in each category) to externally test a DL-based CTR measurement model. To assess the agreement between the model and experts, intraclass or interclass correlation coefficients (ICCs) were compared between the model and two thoracic radiologists. In the reader tests with a probabilistic-based reference standard (Dawid-Skene consensus), we compared diagnostic measures-including sensitivity and negative predictive value (NPV)-for cardiomegaly between the model and five other radiologists using the non-inferiority test. For the 160 chest radiographs, the model measured a median CTR of 0.521 (interquartile range, 0.446-0.59) and a mean CTR of 0.522 ± 0.095. The ICC between the two thoracic radiologists and between the model and two thoracic radiologists was not significantly different (0.972 versus 0.959, p = 0.192), even across various pathologies (all p-values > 0.05). The model showed non-inferior diagnostic performance, including sensitivity (96.3% versus 97.8%) and NPV (95.6% versus 97.4%) (p < 0.001 in both), compared with the radiologists for all 160 chest radiographs. However, it showed inferior sensitivity in chest radiographs with consolidation (95.5% versus 99.9%; p = 0.082) and NPV in chest radiographs with pleural effusion (92.9% versus 94.6%; p = 0.079) and consolidation (94.1% versus 98.7%; p = 0.173). While the sensitivity and NPV of this model for diagnosing cardiomegaly in chest radiographs with consolidation or pleural effusion were not as high as those of the radiologists, it demonstrated good agreement with the thoracic radiologists in measuring the CTR across various pathologies.

Deep learning discrimination of rheumatoid arthritis from osteoarthritis on hand radiography.

To develop a deep learning model to distinguish rheumatoid arthritis (RA) from osteoarthritis (OA) using hand radiographs and to evaluate the effects of changing pretraining and training parameters on model performance. A convolutional neural network was retrospectively trained on 9714 hand radiograph exams from 8387 patients obtained from 2017 to 2021 at seven hospitals within an integrated healthcare network. Performance was assessed using an independent test set of 250 exams from 146 patients. Binary discriminatory capacity (no arthritis versus arthritis; RA versus not RA) and three-way classification (no arthritis versus OA versus RA) were evaluated. The effects of additional pretraining using musculoskeletal radiographs, using all views as opposed to only the posteroanterior view, and varying image resolution on model performance were also investigated. Area under the receiver operating characteristic curve (AUC) and Cohen's kappa coefficient were used to evaluate diagnostic performance. For no arthritis versus arthritis, the model achieved an AUC of 0.975 (95% CI: 0.957, 0.989). For RA versus not RA, the model achieved an AUC of 0.955 (95% CI: 0.919, 0.983). For three-way classification, the model achieved a kappa of 0.806 (95% CI: 0.742, 0.866) and accuracy of 87.2% (95% CI: 83.2%, 91.2%) on the test set. Increasing image resolution increased performance up to 1024 × 1024 pixels. Additional pretraining on musculoskeletal radiographs and using all views did not significantly affect performance. A deep learning model can be used to distinguish no arthritis, OA, and RA on hand radiographs with high performance.

Deep learning‐based high‐dimensional multiple regression estimator for chest x‐ray image classification in rapid cardiomegaly screening

AbstractChest x‐ray (CXR) examination is a common first‐line, non‐invasive, and rapid screening method in clinical examinations. The posteroanterior (PA) and anteroposterior (AP) view modes can both be used to detect related cardiopulmonary diseases, such as pneumonitis, tuberculosis, pulmonary fibrosis, lung tumors, and cardiomegaly. Compared with cardiac computed tomography and cardiac magnetic resonance imaging methods, CXR examination has a short scanning duration and costs less, and is suitable for routine and follow‐up health examinations. Cardiomegaly is an asymptomatic disease in the early stage and cannot be detected through electrocardiography measurements. Thus, early cardiomegaly classes detections, such as cardiac hypertrophy and ventricular dilatation, can help make decisions regarding drug treatments and surgeries. In addition, an automatic assistive tool is required to differentiate between normal individuals and those with cardiomegaly to address the problem of manual inspection and labor shortage. Hence, PA view‐based CXR classification is used to develop a deep learning (DL)‐based high‐dimensional multiple regression analysis (MRA) model for CXR image classification in rapid cardiomegaly screening. This multilayer network model uses a two‐channel three‐layer convolution‐normalization‐pooling process with two‐dimensional (2D) multi convolution operations to enhance images and to extract feature patterns; and then a one‐dimensional feature conversion is used to estimate the four coordinate points of the maximal horizontal cardiac diameter (MHCD) and maximal horizontal thoracic diameter (MHTD), which can be used to estimate cardiothoracic ratio and detect cardiomegaly. For experimental tests, the training and testing datasets are collected from the National Institutes of Health CXR Image Database (Clinical Center, USA), and 10‐fold cross‐validation was used for model evaluation in terms of precision (%), recall (%), accuracy (%), and F1 score. These indexes are used to evaluate the feasibility of the proposed MRA estimator. In addition, the performances of the proposed model are compared with those of conventional DL‐based multilayer classifiers.

Lateral Teardrop Sign: A New Distinguishing Feature of Anteroposterior Projection of Chest Radiograph

Abstract Introduction: The posteroanterior (PA) projection is the standard view for chest radiographs with the alternative of anteroposterior (AP) chest view. Proper identification of the projection of any chest radiograph is critical to the interpretation and eventual inferences made. The teardrop sign in radiology is a well-known feature that is observed wherever two or more bones are projected over one another. This article aims to introduce a lateral teardrop sign seen on AP projections of the chest and to assess its prevalence and predictive value as a distinguishing parameter between AP and PA views of the chest radiograph. Methodology: This retrospective observational study was conducted at the outpatient X-ray unit of the Department of Radiology, University College Hospital, Ibadan. Chest radiographs with AP and PA projections acquired between August 25, 2021, and July 15, 2022, were retrieved from the Picture Archival Communication System and assessed for the presence of lateral teardrop sign. Data were analyzed using the Statistical Package for the Social Sciences (SPSS) version 25. Results: Two hundred and seven radiographs were retrieved and analyzed. These included radiographs of 106 (51.2%) males and 101 (48.8%) females. Eighty-eight (42.5%) were taken in the AP projection while 119 (57.5%) were PA. Only 46 (22.2%) of these radiographs showed the lateral teardrop sign. Of the 46 radiographs showing the sign, 45 (97.8%) were AP constituting 51.1% of all AP radiographs. One hundred and eighteen (73.3%) of radiographs without the sign were PA. A negative and positive predictive value of 73.5% and 98.9% were calculated, respectively, for the lateral teardrop sign, with a sensitivity of 67.2% and specificity of 99.2%. Conclusion: Even though there are already existing parameters used to differentiate between AP and PA views, the presence of lateral teardrop sign can be a useful addition in the identification and distinguishing of AP radiographs.

Foundation of Diagnosing and Treating a Hoffa Fracture

Introduction: Hoffa fractures are a rare type of intra-articular fracture characterized by disruption in the coronal plane. They are challenging to diagnose because of the orientation of the fracture and the common radiography views used to evaluate knee pain. Methods: A literature review search was obtained with PubMed. Primary and secondary sources were included. Results: Hoffa fractures are typically found after highly traumatic events such as motor vehicle accidents or falls from great heights. Hoffa fractures are classified by the Letenneur system, which categorizes fractures into 1 of 3 types. Hoffa fractures typically go undiagnosed on typical radiographs, so CT scans are necessary for proper diagnosis. Physical symptoms can include trouble walking, swelling, and periarticular pain. Conservative treatment is not favorable compared with surgical reduction and fixation. Postop care and rehabilitation can affect the outcome of the surgery and should be closely monitored. Discussion: Hoffa fractures often go unnoticed because traumas result in other injuries and might overlook a fracture that is not detected on radiographs especially traditional anteroposterior (AP) or posteroanterior (PA) views. Once they are diagnosed, they are difficult to manage conservatively because these fractures have a slow healing process and may lead to nonunion of the femur. Surgical treatment is the most reliable option regarding healing and returning to normal weight-bearing and activities. Conclusion: Hoffa fractures are fractures involving the femoral condyle in the coronal plane, which are more rare than fractures in the sagittal plane and therefore commonly missed. This type of fracture is complicated to assess and treat because of its positioning and is easily missed on standard AP/PA radiographs. Surgical intervention is the best option to ensure the best outcomes.

Patient Identification Based on Deep Metric Learning for Preventing Human Errors in Follow-up X-Ray Examinations

Biological fingerprints extracted from clinical images can be used for patient identity verification to determine misfiled clinical images in picture archiving and communication systems. However, such methods have not been incorporated into clinical use, and their performance can degrade with variability in the clinical images. Deep learning can be used to improve the performance of these methods. A novel method is proposed to automatically identify individuals among examined patients using posteroanterior (PA) and anteroposterior (AP) chest X-ray images. The proposed method uses deep metric learning based on a deep convolutional neural network (DCNN) to overcome the extreme classification requirements for patient validation and identification. It was trained on the NIH chest X-ray dataset (ChestX-ray8) in three steps: preprocessing, DCNN feature extraction with an EfficientNetV2-S backbone, and classification with deep metric learning. The proposed method was evaluated using two public datasets and two clinical chest X-ray image datasets containing data from patients undergoing screening and hospital care. A 1280-dimensional feature extractor pretrained for 300 epochs performed the best with an area under the receiver operating characteristic curve of 0.9894, an equal error rate of 0.0269, and a top-1 accuracy of 0.839 on the PadChest dataset containing both PA and AP view positions. The findings of this study provide considerable insights into the development of automated patient identification to reduce the possibility of medical malpractice due to human errors.

Serum Bone-Specific Alkaline Phosphatase as an indicator of the quantity of callus formation in mandibular fracture patients seen in a Nigerian Teaching Hospital

It is important to evaluate the level of bone-specific alkaline phosphatase as it relates to the quantity of callus formed in mandibular fracture healing. The objective of the present study was to assess Serum Bone-Specific Alkaline Phosphatase (BsALP) as an indicator of callus formation in patients with mandibular fracture and determine the relationship between BsALP and callus formation using two treatment methods. Fifty-five patients with isolated mandibular fractures were enrolled. BsALP was measured at presentation, 3rd and 6th week. The patients were recruited into two treatment groups: Closed Reduction with Mandibulomaxillary Fixation (MMF) and Open Reduction and Internal Fixation (ORIF). The Callus Index was measured at 3rd and 6th week after treatment using digital postero-anterior view of the jaws on DICOM viewer software. The mean value of BsALP was 26.2±9.5 ng/mL. BsALP concentration in patients with double site fractures was higher than those with a single fracture, p=0.102. Peak serum BsALP observed in the 3rd week post-intervention was (28.1±8.2 ng/mL). Statistically significant differences were observed between the BsALP concentration in the 3rd and 6th week, and between BsALP concentration at presentation and 6th week, p&lt;0.001, respectively. There was no significant correlation between the Callus Index and mean serum BsALP at 6 weeks (r=-0.08, p=0.580). MMF treatment group had higher levels of serum BsALP compared with ORIF group in the 3rd week (p=0.14) and in the 6th week (p=0.18). BsALP is an indicator of the amount of callus formed in patients treated for mandibular fractures. Hence, it could be used as an adjunct to monitor the healing of mandibular fractures.

Automatic classification of distal radius fracture using a two-stage ensemble deep learning framework

Distal radius fractures (DRFs) are one of the most common types of wrist fracture and can be subdivided into intra- and extra-articular fractures. Compared with extra-articular DRFs which spare the joint surface, intra-articular DRFs extend to the articular surface and can be more difficult to treat. Identification of articular involvement can provide valuable information about the characteristics of fracture patterns. In this study, a two-stage ensemble deep learning framework was proposed to differentiate intra- and extra-articular DRFs automatically on posteroanterior (PA) view wrist X-rays. The framework firstly detects the distal radius region of interest (ROI) using an ensemble model of YOLOv5 networks, which imitates the clinicians’ search pattern of zooming in on relevant regions to assess abnormalities. Secondly, an ensemble model of EfficientNet-B3 networks classifies the fractures in the detected ROIs into intra- and extra-articular. The framework achieved an area under the receiver operating characteristic curve of 0.82, an accuracy of 0.81, a true positive rate of 0.83 and a false positive rate of 0.27 (specificity of 0.73) for differentiating intra- from extra-articular DRFs. This study has demonstrated the potential in automatic DRF characterization using deep learning on clinically acquired wrist radiographs and can serve as a baseline for further research in incorporating multi-view information for fracture classification.

Analysis of the determinant factor of the medial joint space width after medial opening wedge high tibial osteotomy.

The decrease in the medial joint space width (MJSW) in patients with osteoarthritis (OA) is proportional to the degree of arthritis. The purpose of this study was to evaluate the affecting factors of the MJSW by serial radiologic assessment after medial open wedge high tibial osteotomy (MOW-HTO). Between March 2014 and March 2019, 162 MOW-HTO knees that underwent serial radiologic assessment and follow-up MRI were enrolled. Changes in the MJSW were analyzed by dividing into three groups: group I, low quartile (< 25%); II, middle quartile (25-75%); and III, high quartile (> 75%), according to the magnitude of the MJSW. The correlation between the MJSW and weight-bearing line ratio (WBLR), hip knee ankle angle (HKA), joint line convergence angle (JLCA), medial proximal tibial angle (MPTA), mechanical lateral distal femoral angle (m-LDFA), joint line orientation angle (JLOA), and MRI cartilage status was analyzed. Multiple linear regression analysis was used to analyze factors affecting the amount of change in the MJSW. The clinical outcome was also correlated with the MJSW. The amount of change in the JLCA, which has the largest beta value (weight-bearing standing anteroposterior (AP) view and 45° flexion posteroanterior view (Rosenberg view) β = - 0.699 and β = -5.221, both p < 0.001, respectively), had the greatest contribution to the change in the MJSW. The WBLR was also related (standing AP and Rosenberg β = 0.177 and β = 0.264, p = 0.015 and p = 0.004, respectively). There was no statistical difference between the amount of change in the MJSW and the change in cartilage. The clinical outcomes did not differ between the groups. The JLCA was the most important contributing factor for the MJSW, followed by WBLR. This contribution was more pronounced in Rosenberg view than standing AP view. Changes in cartilage status were not related to the MJSW and JLCA. The clinical outcome was not related to the MJSW, either. Level of evidence Cohort study; level III.

What's New in Hand and Wrist Surgery.

What's New in Hand and Wrist Surgery.