Radiographic Guidelines Research Articles

Compliance with evidence-based radiographic imaging guidelines by chiropractic interns at a chiropractic training program.

Evidence-based radiographic guidelines are used to justify the need for radiographs and prevent their overuse. This study aimed to assess whether 4th-year chiropractic interns at the International Medical University plan to use x-ray imaging in their future private practice in line with the principles taught throughout their chiropractic program and the evidence-based imaging guidelines. A survey questionnaire was distributed to 74 final year chiropractic interns, with 62 completed responses. The questionnaire consisted of 8 case scenarios representing potential chiropractic patients. The interns were asked to decide whether to x-ray the patient or not, and which x-ray views to request if they chose to x-ray the patient. Results were compared with the gold standard using percentage agreement. The findings revealed that the chiropractic students adhered to the gold standard answers for 6 out of 8 cases. However, they did not perform well in selecting the correct x-ray views for the 3 cases where radiography was indicated by the gold standard. Results suggest that while the interns have a good understanding of when radiography is necessary, they may need additional training in selecting the appropriate x-ray views for each case.

Rabbit model for the study of nasal tip plasty: a comparative cephalometric analysis after rhinoplasty

Background Open rhinoplasty and septoplasty have emerged as popular surgical techniques for both functional and aesthetic procedures. To study open rhinoplasty with or without septoplasty, the use of animals is necessary. However, no reports have been published on radiologic methods for evaluating rhinoplasty or nasal tip plasty in animals using cephalometry. In this study, a validated model of open rhinoplasty and septoplasty was utilized in rabbits to establish radiographic guidelines for assessing the degree of tip plasty in these animals.Methods Eight adult New Zealand rabbits were used to establish an autologous septal extension graft (SEG) model. The rabbits underwent concurrent submucosal septal resection and open rhinoplasty. The SEG was implanted using nasal septal cartilage. To evaluate the results of nasal tip plasty, lateral-view X-ray images were obtained preoperatively, as well as 2 days, 2 months, and 12 months postoperatively.Results This open rhinoplasty rabbit model appears to be a practical tool for studying open rhinoplasty and tip plasty, demonstrating statistically significant results following SEG implantation. Furthermore, it is suitable for training purposes, specifically for the submucosal resection of septal cartilage.Conclusions This study presents a statistical analysis of the long-term (1-year) postoperative results of SEG implantation, using experimental procedures like those utilized in humans. Through a cephalometric comparison of rabbit noses, the effect of various SEG and tip plasty methods on the rabbit nose can be objectively measured.

An investigation into chiropractic intern adherence to radiographic guidelines in clinical decisions with a descriptive comparison to clinical practitioners.

The purpose of this study was to assess chiropractic interns' knowledge and adherence to radiographic clinical practice guidelines (CPGs) and compare their clinical decisions to previous surveys of established practitioners in Canada and Australia. A clinical decision-making survey was administered to 88 interns. The survey contained clinical scenarios and vignettes with inquiries regarding indications for radiographic referral, the likelihood of referral, and the application of CPGs. Forty-four percent (43.75%) of the interns were aware of CPGs, 38.75% were unsure, and 17.5% were not aware. When asked specific questions about the appropriateness of diagnostic imaging, the interns' responses were similar to those of practitioners in Canada and Australia. When interns evaluated a clinical vignette, there was lower compliance with CPGs. The interns' clinical decisions regarding the use of diagnostic radiography did not significantly differ from those of practitioners who were surveyed in other related studies. Interns were inconsistent in applying their decision making in clinical cases. Notwithstanding the similarities with practitioners, some deviation from the guidelines indicates the need for further intern education to improve the implementation of CPGs for optimal cost-effective and clinically appropriate care.

Exploring factors influencing chiropractors’ adherence to radiographic guidelines for low back pain using the Theoretical Domains Framework

BackgroundThe inappropriate use of lumbar spine imaging remains common in primary care despite recommendations from evidence-based clinical practice guidelines to avoid imaging in the absence of red flags. This study aimed to explore factors influencing ordering behaviours and adherence to radiographic guidelines for low back pain (LBP) in chiropractors in Newfoundland and Labrador (NL), Canada.MethodsWe conducted two focus groups in December 2018 with chiropractors in different regions of NL (eastern, n = 8; western, n = 4). An interview guide based on the Theoretical Domains Framework (TDF) served to identify perceived barriers to, and enablers of, target behaviours of guideline adherence and managing LBP without X-rays. We conducted thematic analysis of chiropractors’ statements into relevant theoretical domains, followed by grouping of similar statements into specific beliefs. Domains key to changing radiographic guideline adherence, LBP imaging behaviours, and/or informing intervention design were identified by noting conflicting beliefs and their reported influence on the target behaviours.ResultsSix of the 14 TDF domains were perceived to be important for adherence to radiographic guidelines and managing non-specific LBP without imaging. Participating chiropractors reported varying levels of knowledge and awareness of guidelines for LBP imaging (Knowledge). Many chiropractors based their decision for imaging on clinical presentation, but some relied on “gut feeling” (Memory, attention, and decision processes). While chiropractors thought it was their role to manage LBP without imaging, others believed ordering imaging was the responsibility of other healthcare providers (Social/professional role and identity). Contrasting views were found regarding the negative consequences of imaging or not imaging LBP patients (Beliefs about consequences). Communication was identified as a skill required to manage LBP without imaging (Skills) and a strategy to enable appropriate imaging ordering behaviours (Behavioural regulation). Chiropractors suggested that access to patients’ previous imaging and a system that facilitated better interprofessional communication would likely improve their LBP imaging behaviours (Behavioural regulation).ConclusionWe identified potential influences, in six theoretical domains, on participating chiropractors’ LBP imaging behaviours and adherence to radiographic guidelines. These beliefs may be targets for theory-informed behaviour change interventions aimed at improving these target behaviours for chiropractors in NL.

Knowledge of and adherence to radiographic guidelines for low back pain: a survey of chiropractors in Newfoundland and Labrador, Canada

BackgroundLow back pain (LBP) rarely requires routine imaging of the lumbar spine in the primary care setting, as serious spinal pathology is rare. Despite evidence-based clinical practice guidelines recommending delaying imaging in the absence of red flags, chiropractors commonly order imaging outside of these guidelines. The purpose of this study was to survey chiropractors to determine the level of knowledge, adherence to, and beliefs about, clinical practice guidelines related to the use of lumbar radiography for LBP in Newfoundland and Labrador (NL), Canada.MethodsA cross-sectional survey of chiropractors in NL (n = 69) was conducted between May and June 2018, including questions on demographics, awareness of radiographic guidelines, and beliefs about radiographs for LBP. We assessed behavioural simulation using clinical vignettes to determine levels of adherence to LBP guideline recommendations.ResultsThe response rate was 77% (n = 53). Half of the participants stated they were aware of current radiographic guideline recommendations, and one quarter of participants indicated they did not use guidelines to inform clinical decisions. The majority of participants agreed that x-rays of the lumbar spine are useful for patients with suspected pathology, are indicated when a patient is non-responsive to 4 weeks of conservative treatment for LBP, and when there are neurological signs associated with LBP. However, a small proportion indicated that there is a role for full spine x-rays (~ 21%), x-rays to evaluate patients with acute LBP (~ 13%), and that patient expectations play a role in decision making (4%). Adherence rate to radiographic guidelines measured using clinical vignettes was 75%.ConclusionsWhile many chiropractors in this sample reported being unsure of specific radiographic guidelines, the majority of respondents adhered to guideline recommendations measured using clinical vignettes. Nonetheless, a small proportion still hold beliefs about radiographs for LBP that are discordant with current radiographic guidelines. Future research should aim to determine barriers to guideline uptake in this population in order to design and evaluate tailored knowledge translation strategies to reduce unnecessary LBP imaging.

The Role of MRI in the Diagnosis of Pelvic Floor Disorders.

This article provides an overview of MRI as a dynamic imaging modality as well as recent updates on the role of MRI in the evaluation of female pelvic floor disorders, including pelvic organ prolapse (POP), rectal prolapse, and defecatory dysfunction. Pelvic floor disorders in women are common, and demand for treatment is high. Recently, multidisciplinary guidelines for dynamic MRI have been published to reflect this need. Despite criticisms that MRI is an expensive modality, cost-analysis studies are demonstrating utility for MRI in surgical decision-making trees for patients at risk for treatment failure after POP repairs. Novel measures such as anterior pelvic area and levator volumes are being used to predict and study patients with and at risk for POP. Recent standardized radiographic guidelines as reviewed in this paper will likely lead to improved reproducibility of dynamic MRI techniques across institutions, making complex pelvic floor assessment increasingly accessible to patients while creating opportunities for novel and collaborative research.

Mid Term 5-Year Follow Up of a Novel Algorithm for Non-Operative Weber B Ankle Fractures

Category:Ankle, Ankle Arthritis, TraumaIntroduction/Purpose:It is important to understand which isolated fibular fractures require surgical intervention. Several different radiographic guidelines have been used to interpret and predict stability of the injured ankle. Holmes et al previously described a novel algorithm used to assess stability and the ability to treat the stable injuries non-operatively. The one year results demonstrated favorable outcomes of these non-operative patients, however there is a question about the durability of these results and whether these patients developed post-traumatic degenerative changes over mid to long term follow up.Methods:An observational study based on a previous cohort of 51 patients studied from 2010 to 2013 with isolated Weber B ankle fractures was performed. These were defined as stable at the time of injury when the medial clear space (MCS) was less than 7 mm on the initial gravity stress radiographs along with a normal mortise relationship on weight bearing radiographs. 27 patients that were treated non-surgically, were brought back for a mid-term follow up with a mean of 6.8 years. American Orthopaedic Foot & Ankle Society (AOFAS) Hindfoot scores, Olerud-Molander Ankle (OMA) Score, and visual analog scale (VAS) pain score were collected in accordance with the prior study. Patient Reported Outcome Measurement Information System (PROMIS) scores were also collected including lower extremity, physical function, depression, and pain interference. Standing bilateral ankle radiographs were obtained, and assessed for MCS widening, and ankle arthritis using the Kellgren-Lawrence grading scale.Results:Average functional score results were (in comparison to 1-year outcomes): AOFAS Hindfoot, 95.7 (93.2); OMA Score, 95.2 (91.0); and visual analog scale pain score, 0.24 (0.57). Using a Wilcox Signed Ranks Test, there was a statistically significant increase in 5-year AOFAS Hindfoot scores as compared to 1-year scores in those same patients (p=0.005) There was no evidence of significant post-traumatic osteoarthritis based on the Kellgren-Lawrence grading scale.Conclusion:The previously described, novel at the time, algorithm for assessing stability of isolated Weber B ankle fractures and nonsurgical treatment with protected weight bearing has shown to produce excellent results for mid-term follow up with an average of 6.8 years. Additionally, these patients are not at increased risk for rapid progression of post-traumatic osteoarthritis. This further supports initial weight bearing radiographs as a reasonable assessment of ankle stability and validates the aforementioned algorithm as a safe and cost-effective functional treatment regimen.

Abstract P3-02-09: Do radiographic features influence the decision to order a breast MRI? A prospective cohort study

Abstract Background: The clinical impact of breast MRI in the neoadjuvant setting is unclear. It is assumed that MRI may help with surgical planning. Factors that may affect whether an MRI is ordered for breast cancer in the neoadjuvant setting may include both imaging and tumour characteristics. Literature suggests MRI can be used in the neoadjuvant therapy (NAT) if there is evidence of high density of breast tissue, multifocal disease, multi-centric disease, lymph node involvement or presence of calcifications. In a non-trial setting, it is unclear when MRI is ordered and if it is indeed ordered based on the above imaging criteria. We sought to determine how MRI is currently implemented in a provincial practice to determine which patients are selected for MRI prior to NAT. Specifically, we aimed to determine if the imaging characteristics determined likelihood of use of MRI in the neoadjuvant setting. Methods: Patients who received neoadjuvant therapy between May 2012 and May 2016 were captured in a prospective database at the BC Cancer Agency in Vancouver. Patients were reviewed and identified as those who either received a breast MRI or not. A random sample of 80 cases, 40 who received MRI and 40 who did not, was taken from this database. Charts were reviewed in detail, and detailed review of the radiographic features from mammogram and ultrasound imaging reports was recorded. Results: 80 patients were reviewed in detail. There were no differences in patient demographics or tumour characteristics. Imaging review demonstrated no statistical significant difference in use of MRI based on reported density, multi-centric disease, calcifications, and nodal involvement. The only radiographic feature that was different was presence of multifocal disease on conventional imaging, where 40.0% of patients who had an MRI had multifocal disease reported whereas only 17.5% of those who did not have an MRI had multifocality reported (p = 0.03). Discussion/Conclusions: Despite radiographic guidelines for use of MRI, the decision by the ordering physician regarding who should receive an MRI prior to NAT still appears to be unsystematic. This could be due to incorrect interpretation of radiographic reports by the ordering physicians and lack of availability or access to the interpreting radiologist. Results suggest that the ordering physician is already aware of multifocal disease and is utilizing MRI to verify this presence, rather than using MRI to investigate the possibility of multifocality in dense breast tissue. Based on this strategy of use it is unlikely that MRI will reduce the rate of mastectomy in this patient population. Table 1: Summary of radiographic features in MRI vs. non-MRI cohorts MRI (N=40)No MRI (N=40)Chi SquareDensity (C or D)25 (62.5%)16 (40.0%)p=0.11Multifocal Disease16 (40.0%)7 (17.5%)p=0.03Multi-centric Disease7 (17.5%)3 (7.5%)p=0.19Lymph Node Involvement31 (77.5%)25 (62.5%)p=0.25Calcifications Present23 (57.5%)21 (52.5%)p=0.56 Citation Format: Illmann C, Simmons CE, McDermott M, Xu J, Wilson C. Do radiographic features influence the decision to order a breast MRI? A prospective cohort study [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P3-02-09.

Awareness of radiographic guidelines for low back pain: a survey of Australian chiropractors.

BackgroundChiropractors have been shown to refer for lumbar radiography in clinical scenarios inconsistent with the current clinical guidelines for low back pain. It is unknown whether this is due to lack of adherence with known guidelines or a lack of awareness of relevant guidelines. Therefore, the aim of this study is to determine Australian chiropractors’ awareness of, and reported adherence to, radiographic guidelines for low back pain. Demographic, chiropractic practice and radiographic usage characteristics will be investigated for association with poor guideline adherence.MethodsAn online survey was distributed to Australian chiropractors from July to September, 2014. Survey questions assessed demographic, chiropractic practice and radiographic usage characteristics, awareness of radiographic guidelines for low back pain and the level of agreement with current guidelines. Results were analysed with descriptive statistics and logistic regression analysis.ResultsThere were 480 surveys completed online. Only 49.6 % (95 % confidence interval (95 % CI): 44.9, 54.4) reported awareness of radiographic guidelines for low back pain. Chiropractors reported a likelihood of referring for radiographs for low back pain: in new patients (47.6 % (95 % CI: 42.9, 52.3)); to confirm biomechanical pathologies (69.0 % (95 % CI: 64.5, 73.1)); to perform biomechanical analysis (37.5 % (95 % CI: 33.1, 42.0)); or to screen for contraindications (39.4 % (95 % CI: 35.0, 44.0)). Chiropractors agreed that radiographs for low back pain could be useful for: acute low back pain (54.0 % (95 % CI: 49.2, 58.7)); screening for contraindications (55.8 % (95 % CI: 51.0, 60.5)); or to confirm diagnosis and direct treatment (61.3 % (95 % CI: 56.5, 65.9)). Poorer adherence to current guidelines was seen if the chiropractor referred to in-house radiographic facilities, practiced a technique other than diversified technique or was unaware or unsure of current radiographic guidelines for low back pain.ConclusionOnly 50 % of Australian chiropractors report awareness of current radiographic guidelines for low back pain. A poorer awareness of guidelines is associated with an increase in the reported likelihood of use, and the perceived usefulness of radiographs for low back pain, in clinical situations that fall outside of current guidelines. Therefore, education strategies may help to increase guideline knowledge and compliance.Electronic supplementary materialThe online version of this article (doi:10.1186/s12998-016-0118-7) contains supplementary material, which is available to authorized users.

Adult Closed Distal Radius Fracture Reduction: Does Fluoroscopy Improve Alignment and Reduce Indications for Surgery?

This study compared the radiological outcomes of adult closed distal radius fractures (DRFs) reduction with and without fluoroscopy. We hypothesized that fluoroscopy-assisted reduction would not improve radiographic alignment or decrease the need for surgery. Hospital medical records and radiographic images of all patients who presented with DRFs between April to June 2009 and April to June 2013 were reviewed. All patients underwent closed reduction and immobilization with or without fluoroscopic assistance. Reduction attempts were noted and pre- and postreduction posteroanterior and lateral radiographs were reviewed for fracture stability. Eighty-four patients underwent reduction without fluoroscopy (group 1), and 90 patients underwent reduction with the aid of fluoroscopy (group 2). According to accepted radiographic guidelines, nonsurgical treatment was indicated for 62% of patients in group 1 and 56% of patients in group 2 ( P = .44). In addition, no significant difference between the groups was observed in any postreduction radiographic parameters ( P > .53) or postreduction alignment of unstable fractures ( P = .47). Reduction without the use of fluoroscopy demonstrated noninferiority when compared with fluoroscopy-assisted reduction in the emergency department for closed adult DRFs.

Galeazzi fractures: Is DRUJ instability predicted by current guidelines?

IntroductionClinically significant distal radioulnar joint (DRUJ) injuries can occur with radial shaft fractures. Several radiographic methods of diagnosis, such as radial shortening of >5mm or fracture line within 7.5cm from the lunate facet, have been proposed but not clinically validated. The purpose of this study was to compare radiographic measurements of radial shaft fractures associated with and without clinically significant DRUJ injury (i.e., true Galeazzi fracture-dislocation) in order to evaluate the predictive value of reported parameters of DRUJ injury. Patients and methodsA retrospective record and radiographic review was performed of 66 consecutive skeletally mature patients with isolated radial shaft fractures from 2004 to 2014 treated at one level 1 academic trauma center. Intraoperatively determined DRUJ instability after radial shaft fixation was used as the gold standard for diagnosis of a Galeazzi fracture-dislocation. ResultsAverage age was 34 years old (range: 18–90). By thirds, there were 10 proximal (15%), 27 middle (41%), and 29 distal (44%) fractures. 13 (20%) had an associated ulnar styloid fracture. 7 (11%) patients had DRUJ instability after radial fixation. Radial shortening averaged 4.4±5.2mm (−2.6–22), and 21 had shortening of >5mm. Twenty-six (39%) fractures were within 7.5cm of the wrist joint. Previous guidelines were only moderately accurate. Even greater shortening did not predict instability (3/7 patients with >10mm shortening had a true injury). Four out of 7 cases with instability had ulnar styloid fractures (p=0.02). Discussion and conclusionsUsing a larger data set than has historically been evaluated, previously reported radiographic guidelines are only moderately accurate. The presence of an ulnar styloid fracture can be helpful. Surgeons should be aware of these associations but rely primarily on intraoperative assessment of the DRUJ after radial fixation to determine treatment.

Radiographic Identification of Arthroscopically Relevant Proximal Femoral Structures

Background: Anatomic landmarks located on the proximal femur have only recently been defined, and there is a lack of radiographic guidelines for their locations presented in the literature. With the confident identification of these landmarks, radiographs could provide more assistance in preoperative evaluations, intraoperative guidance, and postoperative assessments. Purpose: To quantify the radiographic locations of endoscopic landmarks of the proximal femur. Study Design: Descriptive laboratory study. Methods: Ten cadaveric specimens were dissected, and radio-opaque hardware was placed for each landmark of interest. Radiographs were obtained and measurements recorded in anteroposterior (AP) and Dunn 45° views. Results: In the AP view, the gluteus medius insertion was located a mean 12.9 ± 2.4 mm and 34.7 ± 5.1 mm from the piriformis fossa and vastus tubercle, respectively. The piriformis fossa was a mean 14.8 ± 5.9 mm and 4.9 ± 1.9 mm from the anterior and posterior tips of the greater trochanter, respectively. The anterior and posterior tips of the greater trochanter were a mean 14.8 ± 5.1 mm from each other. In the Dunn 45° view, the piriformis fossa was a mean 13.3 ± 2.0 mm, and the vastus tubercle was a mean 21.5 ± 6.0 mm, from the gluteus medius insertion. Moreover, the vastus tubercle was a mean 33.5 ± 6.4 mm from the anterior tip of the greater trochanter and 31.6 ± 8.5 mm from the posterior tip of the greater trochanter. Conclusion: In spite of the variation in cadaveric sizes, quantitative descriptions of endoscopic landmarks were reproducible in clinical views. Clinical Relevance: A detailed understanding of how the described landmarks present radiographically is relevant to preoperative planning, intraoperative evaluations, and postoperative assessments.

Radiographic Identification of the Deltoid Ligament Complex of the Medial Ankle

Background: An injury to the deltoid ligament complex of the ankle can require surgical intervention in cases of chronic instability. There is an absence of data describing medial ankle ligament anatomy on standard radiographic views. Purpose: To quantitatively describe the anatomic origins and insertions of the individual ligamentous bands of the superficial and deep deltoid on standard lateral and mortise radiographic views with reference to osseous landmarks and anatomic axes. Study Design: Descriptive laboratory study. Methods: Twelve nonpaired, fresh-frozen cadaveric foot and ankle specimens were utilized. Specimens were dissected free of all overlying soft tissue to identify individual ligamentous bands of the superficial and deep deltoid ligaments and to isolate their distinct origins and insertions. Footprint centers were identified on standard lateral and mortise radiographs by 2-mm stainless steel spheres embedded at the level of the cortical bone. Distances to osseous landmarks were measured independently by 2 blinded reviewers to calculate mean distances and evaluate reliability and repeatability measures using intraclass correlation coefficients. Results: Varying subsets of the 4 superficial deltoid bands including the tibionavicular (12/12), tibiospring (12/12), tibiocalcaneal (9/12), and superficial posterior tibiotalar (9/12) ligaments were found across specimens. On the lateral view, the tibionavicular ligament was the most anterior and attached 7.6 ± 1.9 mm superior and anterior to the inferior tip of the medial malleolus. The tibiospring ligament attached 12.1 ± 2.2 mm superior and anterior to the inferior tip of the medial malleolus and attached to the spring ligament, which coursed from its origin 12.3 ± 1.6 mm anterior and slightly inferior to the posterior point of the sustentaculum tali to its insertion on the navicular tuberosity. The tibiocalcaneal ligament and superficial posterior tibiotalar ligament were found posteriorly in the majority of specimens. Two constituents of the deep deltoid, including the deep anterior tibiotalar (11/12) and deep posterior tibiotalar (12/12) ligaments, were found in the majority of specimens. The deep posterior was larger and coursed from the tibia, 8.1 ± 2.2 mm posterior and superior to the inferior tip of the medial malleolus, to its attachment on the talus, 15.5 ± 2.4 mm superior and anterior to the posterior inferior point of the talus on the lateral view. Conclusion: Quantitative radiographic relationships describing the anatomic origins and insertions of the individual superficial and deep deltoid constituents were defined with excellent reliability and reproducibility. Clinical Relevance: Radiographic parameters will augment current anatomic data by assisting with preoperative planning, intraoperative guidance, and postoperative assessment. These radiographic guidelines will facilitate the development of novel anatomic reconstructions and allow surgeons to plan the locations of reconstruction tunnels.

Asymmetry of the Odontoid Lateral Mass Interval in Pediatric Trauma CT: Do We Need to Investigate Further?

Odontoid lateral mass interval asymmetry can be within the normal spectrum or the result of traumatic atlantoaxial injury. We sought to set radiographic guidelines for further investigation of odontoid lateral mass interval asymmetry in cervical spine CT studies of pediatric trauma patients. Fourteen children with C1-2 ligamentous injury or atlantoaxial rotational fixation/subluxation were retrospectively identified. We identified an additional 56 children fulfilling the following inclusion criteria: 1) They underwent C-spine CT to exclude traumatic injury, and 2) C-spine clearance and follow-up. Those were matched for age, sex, and severity of traumatic insult with the injured group. Clinical data were collected, and we measured the following parameters: anterior atlantodental interval; odontoid lateral mass interval; and the rotation of the head, C1, and C2. A significant difference (P < .001) was found between the groups in cervical tenderness and torticollis. There was a significant difference in the atlantodental interval value (3.3 ± 0.8 mm in injured and 2.2 ± 0.5 mm in noninjured). The directionality of head, C1, and C2 rotation was significantly (P < .05) more toward the same direction in the noninjured group. We found significant linear correlation between head rotation and ipsilateral odontoid lateral mass interval asymmetry only in the noninjured at C1-2. With multivariant analysis, the presence of cervical tenderness and an abnormal atlantodental interval were the most significant variables. Odontoid lateral mass interspace asymmetry in the absence of cervical tenderness and with a normal atlantodental interval is likely in the normal range and need not be further investigated.

Radiographic identification of the primary structures of the ankle syndesmosis.

The purpose of this study was to quantitatively describe the locations of the syndesmotic ligaments and the tibiofibular articulating cartilage surfaces on standard radiographic views using reproducible radiographic landmarks and reference axes. Twelve non-paired ankles were dissected to identify the anterior-inferior tibiofibular ligament (AITFL), posterior-inferior tibiofibular ligament (PITFL), interosseous tibiofibular ligament (ITFL), and the cartilage surfaces of the syndesmosis. Structures were marked with 2-mm radiopaque spheres prior to obtaining lateral and mortise radiographs. Measurements were performed by two independent raters to assess intra- and interobserver reliability via intraclass correlation coefficients (ICCs). Measurements demonstrated excellent agreement between observers and across trials (all ICCs≥0.960). On the lateral view, the AITFL tibial origin was 9.6±1.5mm superior and posterior to the anterior tibial plafond. Its fibular insertion was 4.4±1.7mm superior and posterior to the anterior fibular tubercle. The centre of the tibial cartilage facet of the tibiofibular contact zone was 8.4±2.1mm posterior and superior to the anterior plafond. The proximal and distal aspects of the ITFL tibial attachment were 45.9±7.9 and 12.4±3.4mm proximal to the central plafond, respectively. The superficial and deep PITFL coursed anterior and distally from the posterior tibia to fibula. On the mortise view, the AITFL tibial attachment centre was 5.6±2.4mm lateral and superior to the lateral extent of the plafond (4.3mm lateral, 3.3mm superior), and its fibular insertion was 21.2±2.1mm superior and medial to the inferior tip of the lateral malleolus. Quantitative radiographic guidelines describing the locations of the primary syndesmotic structures demonstrated excellent reliability and reproducibility. Defined guidelines provide additional clinically relevant information regarding the radiographic anatomy of the syndesmosis and may assist with preoperative planning, augment intraoperative navigation, and provide additional means for objective postoperative assessment.

Radiographic positions of femoral ACL, AM and PL centres: accuracy of guidelines based on the lateral quadrant method.

Femoral tunnel positioning is an important factor in anatomical ACL reconstructions. To improve accuracy, lateral radiographic support can be used to determine the correct tunnel location, applying the quadrant method. Piefer et al. (Arthroscopy 28:872-881, 2012) combined various outcomes of eight studies applying this method to one guideline. The studies included in that guideline used various insertion margins, imaging techniques and measurement methods to determine the position of the ACL centres. The question we addressed is whether condensing data from various methods into one guideline, results in a more accurate guideline than the results of one study. The accuracy of the Piefer's guideline was determined and compared to a guideline developed by Luites et al. (2000). For both guidelines, we quantified the mean absolute differences in positions of the actual anatomical centres of the ACL, AM and PL measured on the lateral radiographs of twelve femora with the quadrant method and the positions according to the guidelines. The accuracy of Piefer's guidelines was 2.4mm (ACL), 2.7mm (AM) and 4.6mm (PL), resulting in positions significantly different from the actual anatomical centres. Applying Luites' guidelines for ACL and PL resulted in positions not significantly different from the actual centres. The accuracies were 1.6mm (ACL) and 2.2mm (PL and AM), which were significantly different from Piefer for the PL centres, and therefore more accurate. Condensing the outcomes of multiple studies using various insertion margins, imaging techniques and measurement methods, results in inaccurate guidelines for femoral ACL tunnel positioning at the lateral view. An accurate femoral tunnel positioning for anatomical ACL reconstruction is a key issue. The results of this study demonstrate that averaging of various radiographic guidelines for anatomical femoral ACL tunnel placement in daily practice, can result in inaccurate tunnel positions. Diagnostic study, Level 1.

Radiographic Identification of the Syndesmotic Structures of the Ankle

Objectives:Syndesmotic ligament sprains may result in significant time lost from sport and can lead to chronic pain and instability. While syndesmotic anatomy has been well-defined, quantitative radiographic guidelines for identifying the anatomic ligament attachment sites and tibiofibular cartilage surfaces have not been adequately defined. The purpose was to define quantitative radiographic guidelines for identifying the origins and insertions of the syndesmotic ligaments and tibiofibular articulating cartilage surfaces with respect to radiographic landmarks and standard reference lines.Methods:Twelve non-paired fresh-frozen ankles were dissected to identify the attachments of the anterior inferior tibiofibular ligament (AITFL), posterior inferior tibiofibular ligament (PITFL), interosseous tibiofibular ligament (ITFL), and the cartilage surfaces of the tibiofibular articulation. The center of each structure was marked with a 2 mm radiopaque sphere at the level of the cortex. Standard lateral and mortise radiographs were obtained using a fluoroscopy c-arm and calibrated using a 25.4 mm diameter radiopaque sphere positioned in the field of view. Using a picture archiving and communications system, measurements were performed twice by two independent raters to calculate intra- and inter-rater reliability via intraclass correlation coefficients (ICCs).Results:Measurements demonstrated excellent agreement between raters and across trials (All inter- and intra-rater ICCs ≥ 0.960) for all structures and radiographic views. On the lateral view, the AITFL tibial origin was 9.6 ± 1.5 mm superior and posterior to the anterior tibial plafond (Table 1). Its fibular insertion was 4.4 ± 1.7 mm superior and posterior to the anterior fibular tubercle. The superficial PITFL originated 7.4 ± 1.6 mm superior to the posterior plafond and inserted 22.0 ± 2.3 mm superior and posterior to the lateral malleolus. The corresponding measurements for the deep PITFL were 3.2 ± 1.5 mm superior and 15.4 ± 3.4 mm superior and posterior, respectively. The proximal and distal edges of the ITFL tibial origin were 45.9 ± 7.9 mm and 12.4 ± 3.4 mm proximal to the central aspect of the plafond respectively. The center of the tibiofibular contact area was 8.4 ± 2.1 mm posterior and superior to the anterior plafond. On the mortise view, the AITFL tibial attachment was 5.6 ± 2.4 mm medial and superior to the lateral extent of the plafond and its fibular insertion was 21.2 ± 2.2 mm superior and medial to the lateral malleolus. The corresponding superficial PITFL measurements were 2.7 ± 1.7 mm and 21.5 ± 3.2 mm respectively. The ITFL distal tibial margin was 11.1 ± 3.5 mm proximal to the tibial plafond.Conclusion:Radiographic measurements demonstrated excellent agreement among reviewers and across trials suggesting clinical reproducibility and surgical utility of the defined parameters. Regardless of the type of surgical treatment, these parameters will assist with preoperative planning, augment intraoperative navigation, and provide additional means for objective post-operative assessment of hardware and tunnel placement. Furthermore, radiographic landmarks may be of particular use in revision or arthroscopic assisted cases where surgical landmarks may be obscured or not readily visible.

Radiological findings in the thoracic spine of the horse according to the german Radiographic Guidelines 2007 considering the clinical relevance

Radiological findings in the thoracic spine of the horse according to the german Radiographic Guidelines 2007 considering the clinical relevance

Radiographic Identification of the Anterior and Posterior Root Attachments of the Medial and Lateral Menisci

Background: Anatomic root placement is necessary to restore native meniscal function during meniscal root repair. Radiographic guidelines for anatomic root placement are essential to improve the accuracy and consistency of anatomic root repair and to optimize outcomes after surgery. Purpose: To define quantitative radiographic guidelines for identification of the anterior and posterior root attachments of the medial and lateral menisci on anteroposterior (AP) and lateral radiographic views. Study Design: Descriptive laboratory study. Methods: The anterior and posterior roots of the medial and lateral menisci were identified in 12 human cadaveric specimens (average age, 51.3 years; age range, 39-65 years) and labeled using 2-mm radiopaque spheres. True AP and lateral radiographs were obtained, and 2 raters independently measured blinded radiographs in relation to pertinent landmarks and radiographic reference lines. Results: On AP radiographs, the anteromedial and posteromedial roots were, on average, 31.9 ± 5.0 mm and 36.3 ± 3.5 mm lateral to the edge of the medial tibial plateau, respectively. The anterolateral and posterolateral roots were, on average, 37.9 ± 5.2 mm and 39.3 ± 3.8 mm medial to the edge of the lateral tibial plateau, respectively. On lateral radiographs, the anteromedial and anterolateral roots were, on average, 4.8 ± 3.7 mm and 20.5 ± 4.3 mm posterior to the anterior margin of the tibial plateau, respectively. The posteromedial and posterolateral roots were, on average, 18.0 ± 2.8 mm and 19.8 ± 3.5 mm anterior to the posterior margin of the tibial plateau, respectively. The intrarater and interrater intraclass correlation coefficients (ICCs) were >0.958, demonstrating excellent reliability. Conclusion: The meniscal root attachment sites were quantitatively and reproducibly defined with respect to anatomic landmarks and superimposed radiographic reference lines. The high ICCs indicate that the measured radiographic relationships are a consistent means for evaluating meniscal root positions. Clinical Relevance: This study demonstrated consistent and reproducible radiographic guidelines for the location of the meniscal roots. These measurements may be used to assess root positions on intraoperative fluoroscopy and postoperative radiographs.

Anatomic and Radiographic Comparison of Arthroscopic Suprapectoral and Open Subpectoral Biceps Tenodesis Sites

Background: Arthroscopic suprapectoral and open subpectoral surgical techniques are both commonly utilized approaches for proximal biceps tenodesis of the long head of the biceps brachii. A central limitation to the widespread use of an arthroscopic approach for biceps tenodesis is that the tendon may be tenodesed too proximally in the bicipital groove, leading to persistent pain and tendinopathy. Purpose/Hypothesis: The purpose of this study was to determine the in vivo tenodesis location using arthroscopic suprapectoral and open subpectoral techniques for proximal biceps tenodesis in relation to clinically pertinent anatomic and radiographic landmarks. The null hypothesis was that arthroscopic suprapectoral biceps tenodesis would not be significantly different in terms of the location from open subpectoral biceps tenodesis. Study Design: Controlled laboratory study. Methods: A total of 20 matched pairs of cadaveric shoulder specimens were randomized such that within each pair, 1 shoulder underwent a standard open subpectoral biceps tenodesis and the other underwent an arthroscopic suprapectoral tenodesis. Limited dissection and exposure of the surgical tunnel site and reference landmarks were subsequently performed, and anteroposterior and lateral radiographs were obtained. Direct measurements were performed anatomically using a digital caliper and radiographically using picture archiving and communication system (PACS) software from the proximal lip of the humeral tunnel to regional landmarks. Results: Both techniques were able to place the humeral tunnel distal to the bicipital groove in all specimens. On average, the open subpectoral approach placed the tunnel 2.2 cm distal to the arthroscopic suprapectoral approach. Conclusion: The arthroscopic suprapectoral biceps tenodesis technique used in this study consistently placed the tenodesis tunnel distal to the bicipital groove, which may allay concerns about the bicipital groove as a pain source after this procedure. Clinical Relevance: This anatomic study provides new information on tunnel placement in 2 biceps tenodesis techniques. In addition, it provides clinically relevant anatomic and radiographic guidelines using clinically pertinent landmarks. This information may be useful in preoperative planning, intraoperative technique, and postoperative assessment of both open subpectoral and arthroscopic suprapectoral biceps tenodesis.