Radiological Signs Research Articles

I saw the “sea anemone” sign: Puffy face of borderline ovarian tumors

The sea anemone sign is a radiologic sign seen on magnetic resonance imaging (MRI) studies that indicates the morphological development of serous borderline ovarian tumors (SBOTs), as papillary projections originating from the wall of the cystic lesion. The presence of T2 hypointense fibrous stroma in the center of the papilla is a helpful tip in the diagnosis of SBOTs. Those projections might also be assumed to have a frond-like appearance which can be seen as branching papillary projections, especially on T2-weighted imaging.The term “sea anemone” sign is described by Tanaka et al. who deemed it as a “hallmark” feature of surface SBOTs.

Measuring outcomes when odontogenic sinusitis is treated with endoscopic sinus surgery: A systematic review

AbstractAimTo determine outcome measurement when odontogenic sinusitis (ODS) is treated by Endoscopic Sinus Surgery (ESS).Materials and MethodsA PRISMA compliant systematic review using MeSH headings on Pubmed, Ovid and Embase. Inclusion criteria: Adults with odontogenic maxillary sinus disease undergoing ESS. Exclusion criteria: Adolescents, odontogenic disease related to; trauma, neoplasia, tumour resection, palatal cleft or fungal infection, previous sinus surgery, endoscopic surgery not involving the middle meatus.ResultsA total of 1462 papers were identified, 68 eligible for review. No randomised controlled trials were identified. Twenty‐three papers (34%) reported a successful outcome as no disease at endoscopy and reduced sinonasal symptoms; 14 papers (21%) based outcomes on endoscopy, reduced symptoms and resolution of sinus opacification or reduced mucosal thickness; 1 paper established success on reduced symptoms only and 7 papers (10%) based outcomes on radiographic findings only. Other primary measures of success were excision and closure of oro‐antral fistula, 6 (9%), removal of odontogenic cysts, 5 (7%), removal of displaced dental implants, 4 (6%), removal of displaced root of tooth, 3 (4%). Five papers (7%) reported no outcome measure. Additional measures of outcome were; retention of dental implants perforating the sinus floor, survival of sinus floor grafting with subsequent implant placement and retention of teeth with persistent apical periodontitis.ConclusionReported outcome measures were very heterogeneous. In consideration of the weak evidence base for the role of ESS in ODS management, more consistent measurement and reporting of patient symptoms, clinical and radiological signs with endoscopic findings is recommended to enable meta‐analysis.

Clinical, genetic, and orthopedic characteristics of large group of patients with diastrophic dysplasia

BACKGROUND: Diastrophic dysplasia (OMIM #222600) is a rare congenital autosomal recessive skeletal dysplasia associated with homozygous or compound-heterozygous variants in the sulfate transporter gene SLC26A2. Clinical and radiological descriptions of diastrophic dysplasia in patients of different ages will help improve the diagnosis and orthopedic treatment.
 AIM: To describe clinical and genetic characteristics of Russian patients with diastrophic dysplasia caused by previously described and newly identified pathogenic SLC26A2 variants.
 MATERIALS AND METHODS: A comprehensive examination of 28 Russian patients from 28 unrelated families aged 3 months to 34 years with clinical and radiological signs of diastrophic dysplasia was performed. To confirm the diagnosis, genealogical analysis, clinical examination, radiography, and targeted research of SLC26A2 using direct Sanger sequencing were performed.
 RESULTS: Typical clinical and radiological signs sufficient for diagnosing diastrophic dysplasia in newborns have been identified, which included rhizo/mesomelic shortening of the upper and lower extremities, congenital clubfoot, hand anomalies, multiple dislocations, and joint contractures. In our patients, 14 SLC26A2 variants were identified, 9 of which were first discovered. The most common variant identified in Russian patients with diastrophic dysplasia was c.1957TA (p.Cys653Ser), which accounted for 50% of the alleles.
 CONCLUSIONS: Clinical and genetic analyses of Russian patients with diastrophic dysplasia made it possible to identify the core clinical and radiological signs and evaluate the polymorphism of the clinical manifestations of the disease. In contrast to previously examined patients from European populations (including Finland with the largest number of patients with diastrophic dysplasia), 50% of the cases in the Russian population are caused by the c.1957TA (p.Cys653Ser) homozygous or compound-heterozygous variant.

High-risk coronary plaque of sudden cardiac death victims: postmortem CT angiographic features and histopathologic findings

High-risk coronary plaques (HRP) are characterized in clinical radiological imaging by the presence of low plaque attenuation, a napkin-ring sign (NRS), spotty calcifications (SC) and a positive remodeling index (RI). To evaluate if these signs are detectable in postmortem imaging by a multi-phase postmortem CT angiography (MPMCTA), a retrospective study of a series of autopsy well-documented coronary plaques related to sudden cardiac death (SCD) was performed. Then correlations between histological and radiological findings were described. Fourty SCD cases due to acute coronary syndrome based on clinical history and confirmed at autopsy were selected (28 men and 12 women, age 53.3 ± 10.9). The culprit lesion was mainly situated in the proximal segments of coronary arteries, in the right coronary artery in 23 cases (57.5%), the left anterior descending artery in 13 cases (32.5%), the circumflex artery in 3 cases (7.5%) and in one case in the left main stem. MPMCTA showed a positive RI (≥ 1.1) in 75% of cases with a mean RI 1.39 ± 0.71. RI values were lower in cases with fibrotic plaques. NRS was observed in 40% of cases, low attenuation plaque in 46.3%, and SC in 48.7% of cases. There were significant correlations of the radiological presence of NRS for fibrolipid composition of the plaque (p-value 0.007), severe intraplaque inflammation (p-value 0.017), severe adventitial inflammation (p-value 0.021) and an increased vasa vasorum (p-value 0.012). A significant correlation (p-value 0.002) was observed between the presence of SC at radiological examination and the presence of punctuate/fragmented calcification at histology. In addition, in 58.3% of cases, plaque enhancement was observed, which correlated with plaque inflammation and the fibrolipid composition of the plaque. The coronary artery calcium score was 314 (± 455). There was a poor agreement between stenosis of the lumen at histology versus radiology. Our study shows that the various radiological signs of HRP can be detected in all plaques by MPMCTA, but individually only to a variable extent; plaque enhancement appeared as a new sign of vulnerability. In the postmortem approach, these radiological markers of HRP, should always be applied in combination, which can be useful for developing a predictive model for diagnosing coronary SCD.

Apparent Diffusion Coefficient of the Optic Nerve Head in Idiopathic Intracranial Hypertension

ABSTRACT Idiopathic Intracranial Hypertension (IIH) is a condition in which patients have elevated intracranial pressure which does not have an apparent cause. To diagnose IIH, evaluation excluding other causes of elevated pressure must be performed. This typically includes magnetic resonance imaging (MRI) of the brain and venous sinuses. Despite there being known radiographic signs suggestive of IIH on MRI, there currently are no established correlations between radiographic findings and visual outcomes. Previous work revealed diffusion weighted imaging (DWI), a qualitative measurement on MRI, correlated with clinical findings (i.e presence and grade of papilloedema), but not visual outcomes. We hypothesized that the apparent diffusion coefficient (ADC), a quantitative value obtained during clinical MRI, may correlate with visual outcomes. We conducted a retrospective chart review to correlate findings on the ADC sequence on routine brain MRIs in patients with papilloedema with visual outcomes. In 49 patients with IIH, this study shows the ADC in the retrobulbar optic nerve to be 1,487 ± 559 × 10−6 mm2 /s, 15% lower than reported value of 1744 ± 413 in healthy controls. This suggests that there is true restricted diffusion in patients with IIH and papilloedema, as previously reported visually by MRI. However, there was no significant correlation with clinical outcomes of papilloedema grade, mean deviation on standard perimetry, and retinal nerve fibre layer (RNFL) on optical coherence tomography (OCT). We discuss reasons why the ADC measurement may be confounded by motion and partial volume and propose methods that may reduce these confounders for future studies.

Intimomedial tears of the aorta heal by smooth muscle cell-mediated fibrosis without atherosclerosis.

BACKGROUNDDisease of the aorta varies from atherosclerosis to aneurysms, with complications including rupture, dissection, and poorly characterized limited tears. We studied limited tears without any mural hematoma, termed intimomedial tears, to gain insight into aortic vulnerability to excessive wall stresses. Our premise is that minimal injuries in aortas with sufficient medial resilience to prevent tear progression correspond to initial mechanisms leading to complete structural failure in aortas with significantly compromised medial resilience.METHODSIntimomedial tears were macroscopically identified in 9 of 108 ascending aortas after surgery and analyzed by histology and immunofluorescence confocal microscopy.RESULTSNonhemorrhagic, nonatheromatous tears correlated with advanced aneurysmal disease and most lacked distinctive symptoms or radiological signs. Tears traversed the intima and part of the subjacent media, while the resultant defects were partially or completely filled with neointima characterized by differentiated smooth muscle cells, scattered leukocytes, dense fibrosis, and absent elastic laminae despite tropoelastin synthesis. Healed lesions contained organized fibrin at tear edges without evidence of plasma and erythrocyte extravasation or lipid accumulation.CONCLUSIONThese findings suggest a multiphasic model of aortic wall failure in which primary lesions of intimomedial tears either heal if the media is sufficiently resilient or progress as dissection or rupture by medial delamination and tear completion, respectively. Moreover, mural incorporation of thrombus and cellular responses to injury, two historically important concepts in atheroma pathogenesis, contribute to vessel wall repair with adequate conduit function, but even together are not sufficient to induce atherosclerosis.FUNDINGNIH (R01-HL146723, R01-HL168473) and Yale Department of Surgery.

Can the metabolic characteristics of diffuse glioma on <sup>11</sup>C-methionine PET/CT serve as a marker of its IDH status? Cross sectional study

INTRODUCTION: Since 2016, molecular markers, in particular, mutations in isocitrate dehydrogenase (IDH) 1 and 2, have been introduced as a classifying feature of cerebral gliomas that provided superior prognostication. The search for non-invasive biomarkers of the molecular profile of gliomas is necessary to improve the quality of preoperative diagnostics, identify patients with good and poor prognosis and determine treatment tactics.OBJECTIVE: Was to study the relationship between the IDH genotype of diffuse cerebral gliomas and metabolic biomarkers according to the results of PET/CT with [11C]methionine.MATERIALS AND METHOD: The results of PET/CT with 11C-methionine were identified to a retrospective analysis of 260 patients aged 18 to 75 years (median 40 years) with untreated cerebral glioma. Based on histological and molecular genetic studies of the surgical material including the determination of a mutation in the isocitrate dehydrogenase 1 (IDH1132H) gene, diffuse gliomas were classified according to the 2016 WHO classification of CNS tumors. Metabolic biomarkers included the calculation of tumor-to-brain ratio of 11С-methionine (TBRmax, TBRpeak and TBRmean) as well as the metabolic tumor volume (MTV). Statistics. Non-parametric tests were performed to compare the differences among patient groups. ROC curve analysis was performed to screen the optimal parameter and its best cutoff value for the discrimination of glioma genotype. All data analyses were performed using “Statistica 10,0” and “MedCalc” ststistical software. p-values less than 0.05 were considered statistically significant.RESULTS: According to the 2016 WHO classification astrocytic and oligodendroglial tumors of the adult type were divided into three groups: astrocytic gliomas with a mutation in the IDH1 gene (IDH1 mut) (n=95), astrocytic gliomas without a mutation in the IDH1 gene (IDH1 wild type — IDH1 wt) (n=103), and IDH1-mutant oligodendrogliomas (n=62). Significant differences in all ratios between the three molecular groups of gliomas were established. TBRmax cutoff of 2.27 differentiated between IDH1 wt and IDH1 mut gliomas with a sensitivity of 61% and a specificity of 77% (area under curve — AUC 0.752). When considering subgroups of gliomas that are homogeneous in terms of the IDH1 status or Grade, the dependence of TBR on the glioma histotype and grading was additionally established. In IDH1 mut oligodendrogliomas, TBR was significantly higher than in mutant astrocytomas, and in IDH1 wt astrocytomas, significant differences in TBR were established between Grade 2 and Grade 3–4. TBRmax was not a predictor of glioma type according to the WHO 2016 classification due to significant overlap of individual of TBR values. But TBRmax allowed diagnosing a cluster of malignant gliomas, including glioblastoma and astrocytoma Grade 3 IDH wt, as well as oligodendroglioma Grade 3 IDH1 mut, with a sensitivity of 65% and a specificity of 89% (AUC 0.848) at a cutoff of TBR=2.7. A strong correlation between the three tumor-to-brain ratios allows any ratio to be used in diagnostics. There were no significant differences in MTV between molecular types of gliomas.DISCUSSION: Distinguishing glioma types based on the 2016 WHO classification of the CNS tumors on the basis of 11Cmethionine uptake seems to be not reliable due to many factors that affect its uptake. In astrocytomas high TBR is associated with malignant grade and wild type IDH1 gene. However, the lack of differences in TBR between these astrocytomas and Grade 3 IDH1-mutant oligodendrogliomas does not allow one to predict the IDH1 status of the tumor in the absence of other radiological signs of the glioma histotype. The absence of differences in TBR between Grade 2 and Grade 3 astrocytomas IDH1 mut supports the view that they are considered as a single subgroup of lower grade gliomas. CONCLUSION: PET/CT with 11C-methionine has limited potential to assess the IDH status of diffuse gliomas. High TBR is associated with malignant glioma with wild-type IDH1 gene or oligodendroglial structure.

HPV-Related Multiphenotypic Sinonasal Carcinoma: A Clinicoradiological Series of 3 Cases With Full Endoscopic Surgical Outcome.

Context: Human papillomavirus (HPV)-related multiphenotypic sinonasal carcinoma (HMSC), formerly known as HPV-related carcinoma with adenoid cystic like features, is a rare tumor subtype with unusual correlation between radiological, histopathological, and surgical findings. The shared histological characteristics with other sinonasal tumors make the diagnosis challenging. Optimal surgical and oncological treatments for this rare condition remains to be clearly defined. Methods: The objective of the study was to describe the unique characteristics and endoscopic surgical treatment of this rare tumor. In this retrospective case series, all patients with an HMSC diagnosis treated in our tertiary center were selected. Results: Three HMSC cases were identified, including 2 male and 1 female patients. All cases originated from the posterior nasal cavity. One case presented with a tumor of 8.9 cm × 6.4 cm × 8.7 cm, which is the largest tumor volume described to date. All patients received exclusively endoscopic surgical treatment, followed by adjuvant radiation therapy. No patient showed clinical or radiological sign of disease recurrence, or regional or distant metastasis, with a follow-up ranging from 9 months to 4 years. In 2 cases, initial diagnoses incorrectly suggested adenoid cystic or basaloid squamous cell carcinoma. HPV-DNA testing confirmed the presence of HPV in all cases, with identification of strains 16 and 18. Conclusion and Relevance: HMSC represents a newly identified diagnosis that constitutes a significant challenge for both clinicians and pathologists. It is crucial to acknowledge its indolent clinical course and the apparent contradiction between aggressive radiological features and the noninvasive nature of surgical findings. Skull base surgeons should be aware that, despite these complexities, endoscopic treatment is achievable in the majority of cases. This understanding is essential for the effective management of HMSC.

Associated patellofemoral osteoarthritis is not a contraindication for unicompartmental knee replacement. Report of one hundred ten prostheses with an average 6-year follow-up

IntroductionAssociated patellofemoral joint osteoarthritis (APFJ-OA) has typically been considered a contraindication for unicompartmental knee arthroplasty (UKA) in the treatment of femorotibial joint osteoarthritis. However, this contraindication is being challenged. The aim of this study was to assess clinical and functional outcomes, complications, and implant survival in medial or lateral UKA, regardless of clinical symptoms or radiographic signs of APFJ-OA. MethodsThis retrospective, comparative study included patients treated with medial or lateral UKA regardless of preoperative symptoms or signs of APFJ-OA, with a minimum 2-year follow-up. Intraoperatively, knees were subdivided based on APFJ-OA grade, according to the Outerbridge classification. Clinical and functional outcomes were analyzed using the 2011 Knee Society Score (KSS) at the last follow-up control. APFJ-OA was treated systematically, in a tailored, stepwise fashion according to its severity. Complications and implant survival rates were evaluated. Two-sided paired T-test, ANOVA, and Kruskal–Wallis tests were used with a significance level of 5%. ResultsFinally, 110 UKAs were assessed 81 (73.6%) medial and 29 (26.4%) laterals. The average follow-up was 6 years (2–19.5). According to Outerbridge, 22 knees (20%) were in grade 2, 59 (53.6%) were in grade 3, and 29 (26.4%) were in grade 4. All three groups showed a statistically significant increase in KSS scores and range of motion. There were no significant differences in clinical KSS improvement and flexion contracture between Outerbridge groups (average 35.7 and −4.9, respectively). Group 3 showed statistically significant improvement in functional KSS when compared to group 2 (68.8 vs 61.2). In maximum flexion, groups 3 and 4 did significantly better than group 2 (20° vs 15°). Three prostheses (2.7%) needed revision after 7, 8.6, and 12 years due to aseptic tibial loosening. Implant survival was 100% at 5 (64 of 64), 97% at 7 (30 of 31), 93% at 9 (14 of 15), and 89% at 12 years, respectively (8 of 9). ConclusionClinical and functional results, complications, and survival of medial or lateral UKA were not negatively affected by APFJ-OA assessed intraoperatively using the Outerbridge classification after an average follow-up of 6 years. We consider that APFJ-OA is not a contraindication for UKA when treated systematically according to its severity. Level of evidenceIV.

Organ involvement in newly diagnosed sarcoidosis patients in the Netherlands: The first large European multicentre prospective study

BackgroundClinical presentation and prevalence of organ involvement is highly variable in sarcoidosis and depends on ethnic, genetic and geographical factors. These data are not extensively studied in a Dutch population. AimTo determine the prevalence of organ involvement and the indication for systemic immunosuppressive therapy in newly diagnosed sarcoidosis patients in the Netherlands. MethodsTwo large Dutch teaching hospitals participated in this prospective cohort study. All adult patients with newly diagnosed sarcoidosis were prospectively included and a standardized work-up was performed. Organ involvement was defined using the WASOG instrument. ResultsBetween 2015 and 2020, a total of 330 patients were included, 55% were male, mean age was 46 (SD 14) years. Most of them were white (76%). Pulmonary involvement including thoracic lymph node enlargement was present in 316 patients (96%). Pulmonary parenchymal disease was present in 156 patients (47%). Ten patients (3%) had radiological signs of pulmonary fibrosis. Cutaneous sarcoidosis was present in 74 patients (23%). Routine ophthalmological screening revealed uveitis in 29 patients (12%, n = 256)). Cardiac and neurosarcoidosis were diagnosed in respectively five (2%) and six patients (2%). Renal involvement was observed in 11 (3%) patients. Hypercalcaemia and hypercalciuria were observed in 29 (10%) and 48 (26%, n = 182) patients, respectively. Hepatic involvement was found in 6 patients (2%). In 30% of the patients, systemic immunosuppressive treatment was started at diagnosis. ConclusionsHigh–risk organ involvement in sarcoidosis is uncommon at diagnosis. Indication for systemic immunosuppressive therapy was present in a minority of patients.

Retrospective analysis of scaphoid trapezium pyrocarbon implant intervention in STT arthritis: a 3-year follow-up study.

The purpose of this study was to evaluate clinical, patient rated and radiological outcome of the scaphoid trapezium pyrocarbon implant (STPI) at a minimum of three years follow-up. Consecutive patients operated with the STPI due to scaphotrapeziotrapezoidal (STT) arthritis between 2012 and 2019 were included. Patients were evaluated preoperatively and annually after surgery for range of motion, grip strength, key pinch, quick-DASH, pain, and satisfaction. Radiographs were evaluated for implant position, signs of dorsal intercalated segment instability (DISI), capitolunate (CL) angle, scapholunate (SL) distance, and presence of osteophytes. Twenty-six patients (29 implants) were included. Seven implants were revised during the follow up, mainly due to pain: three implants were removed, four patients received a new STPI of a different size, leaving 22 implants in 20 patients available for follow up, 9 males and 11 females. Median age was 61.7 years (51-78 years). Median follow-up time was 68 months (37-105 months). Comparing preoperative status to the last follow-up, wrist extension and deviation, thumb abduction, and grip strength did not change. Key Pinch, quick DASH, pain, and patient satisfaction improved significantly at last follow-up. Radiographic signs of DISI were seen in six cases preoperatively and in 12 cases at last follow-up. At a minimum of three years follow-up, the STPI used for STT-arthritis improve pain, quick-DASH result, and patient satisfaction significantly. ROM and grip strength did not change compared to preoperative values. Radiographic signs of carpal instability were common at the follow-up and the revision rate was high.

Practical Tips for Successful Bitewing Radiographs in Children

Bitewings are a fundamental tool for treatment decision-making in young patients as they provide essential information on caries depth, the presence of a dentine bridge and pulp retraction, radiographic signs of pulp necrosis and presence of a permanent successor. The article updates the practitioner on the use of bitewing radiographs for primary molars and provides hints and tips for maximizing success in children. CPD/Clinical Relevance: The correct use of bitewing radiographs is essential for clinical decision-making in children.

Isolated Gastric Perforation following Blunt Trauma Abdomen not to be Missed: A Case Series

Abdominal trauma is a commonly encountered emergency which may be because of roadside accidents, assaults, or falls from height. Blunt injury to the abdomen is far more common than penetrating injury. Gastric perforation commonly occurs following penetrating abdominal trauma. However, gastric rupture is an uncommon entity following blunt trauma abdomen (BTA). Here, we are presenting three cases of isolated gastric perforation after BTA, two were due to a roadside accident, and one was a result of a fall from height. History suggests of a full stomach is usually found in traumatic gastric rupture. This condition usually presents with insignificant clinical or radiological signs. Isolated gastric rupture due to trauma is rare as it is usually associated with other injuries such as splenic and liver injuries. Early suspicion plays an important role in diagnosing this entity which carries higher morbidity and mortality if not managed timely. As isolated gastric perforation because of trauma leads to high morbidity and mortality, hence thorough lavage of the peritoneal cavity followed by double-layer closure after adequate debridement will reduce chances of intraperitoneal contamination thus improving outcome. Presentation after the last meal, the severity of gastric rupture, and other associated injuries play an important role in the prognosis of the patient.

Construction of Composite Correlation Index Matrix and Analysis of Cultural Properties of Representatives of Mycobacterium abscessus Complex Isolated from Patients with Cystic Fibrosis.

Microbiological diagnosis of mycobacteriosis is often difficult, as it is necessary to differentiate between transient colonization and active infection. We studied the cultural properties of Mycobacterium abscessus complex (MABSc) strains obtained from cystic fibrosis patients, and also analyzed composite correlation index (CCI) values in patients with repeated MABSc inoculation and their correlation with the presence of clinical and radiological manifestations of mycobacteriosis. As a result, MABSc more often grew in S-form colonies in patients without clinical manifestations of chronic infection, while R-form colonies were characteristic of patients with chronic infection and clinical symptoms. At the same time, in patients examined once, no growth of colonies in the R-form was recorded, and all strains produced growth in the form of either S-colonies or in the S- and R-forms simultaneously. Statistically significant results were obtained for the relationship of the CCI with the clinical and radiological picture. In addition, a heterogeneous MABSc population with low CCI score values correlated with the development of mycobacteriosis in patients. In patients with high CCI score values (homogeneity of isolated strains), on the contrary, there were no radiological or clinical signs of the disease. These data make it possible to build a strategy for monitoring patients depending on changes in CCI score values. The use of CCI matrix to evaluate microorganisms' identification results is a potentially new method that expands the use of matrix-assisted laser desorption ionization time-of-flight mass spectrometry.

Central Giant Cell Granuloma: Negotiating the Diagnostic and Management Dilemmas.

Giant cell lesions of orofacial region although rare in presentation, have diagnostic and treatment challenges due to overlapping clinical, radiological, and histopathological signs. We happened to come across a case, which presented to us with an aggressive jaw lesion of nonodontogenic origin, mimicking a malignancy and putting us in a conundrum with regard to work up and treatment. The sequential work up not only helped us reach a definitive diagnosis but also led us the draw algorithms for diagnosis of Giant cell lesions and management of Central giant cell granuloma. Meticulous planning along with molecular studies helps in better delineating one giant cell lesion from other.

Nonoperative Treatment as an Option for Isolated Anterior Cruciate Ligament Injury: A Systematic Review and Meta-analysis.

An anterior cruciate ligament (ACL) tear is a risk factor for early osteoarthritis (OA) onset. Generally, ACL reconstruction (ACLR) is associated with better outcomes. However, there is a lack of evidence regarding the effect of operative versus nonoperative treatment for preventing premature knee OA in isolated ACL tears while achieving good functional outcomes. The purpose of the study was to compare the outcomes of ACLR to primarily nonoperative management of isolated ACL tears. It was hypothesized that the outcomes between treatment types would be similar. Systematic review; Level of evidence, 3. This systematic review was registered on the International Prospective Register of Systematic Reviews (PROSPERO) (registration No. CRD42021285901) and was conducted according to the Cochrane Handbook guidelines. We systematically searched for randomized and nonrandomized studies that compared ACLR with nonoperative treatments in isolated ACL tears in 3 databases until October 25, 2021. The risk of bias and quality of evidence of the included studies was assessed in accordance with the Cochrane guidelines. The primary outcome was radiologic signs of OA, and the secondary outcomes were functional parameters. Using the common effects model, we calculated pooled mean differences (MDs) and odds ratios (ORs) with 95% CIs. Five studies-2 randomized controlled trials (RCTs) and 3 retrospective non-RCTs-were included. There was a moderate risk of bias in 2 studies and a serious risk of bias in 1 study. The quality of evidence was rated low because of the higher risk of bias and inconsistency. Nonoperatively treated knees showed a trend toward lower odds of developing radiological signs of OA (OR, 1.84 [95% CI, 0.90 to 3.75]); however, surgically reconstructed knees had significantly better stability (MD, -2.44 [95% CI, -3.21 to -1.66 ]) and a trend toward better but clinically not meaningful Lysholm scores (MD, 2.88 [95% CI, -1.09 to 6.85]). The qualitative synthesis showed that surgical reconstruction was protective against subsequent injuries but not superior when returning to previous activity levels or various functional tests. Findings indicated that there is no certain evidence that ACLR for an isolated ACL tear is superior to nonoperative treatment. Clinicians should consider nonoperative treatments with a well-designed rehabilitative program as a primary option. However, these findings must be interpreted with caution because of low study quality and high risk of bias.

How modular porous metal augments have changed the management of acetabular bone loss at primary or revision total hip arthroplasty.

The advent of modular porous metal augments has ushered in a new form of treatment for acetabular bone loss. The function of an augment can be seen as reducing the size of a defect or reconstituting the anterosuperior/posteroinferior columns and/or allowing supplementary fixation. Depending on the function of the augment, the surgeon can decide on the sequence of introduction of the hemispherical shell, before or after the augment. Augments should always, however, be used with cement to form a unit with the acetabular component. Given their versatility, augments also allow the use of a hemispherical shell in a position that restores the centre of rotation and biomechanics of the hip. Progressive shedding or the appearance of metal debris is a particular finding with augments and, with other radiological signs of failure, should be recognized on serial radiographs. Mid- to long-term outcomes in studies reporting the use of augments with hemispherical shells in revision total hip arthroplasty have shown rates of survival of > 90%. However, a higher risk of failure has been reported when augments have been used for patients with chronic pelvic discontinuity.

869 Early Signs of Elevated Intracranial Pressure (ICP) on Computed Tomography Correlate With Measured ICP in the Intensive Care Unit and Six-month Outcome Following Moderate to Severe TBI

INTRODUCTION: Identifying patients at risk for increased intracranial pressure (ICP) followingTBI via baseline computed tomography (CT) has not previously been validated in a prospective dataset. METHODS: Data were obtained from the Progesterone for Traumatic Brain Injury, Experimental Clinical Treatment (ProTECTIII) multicenter clinical trial. Baseline CT scans for 881 participants were individually reviewed by a blinded central neuroradiologist. Five signs of elevated ICP were measured (sulcal obliteration, lateral ventricle compression, 3rd ventricle compression, midline shift, and herniation). Associations between signs of increased ICP and outcomes (6-month functional outcome and mortality) were assessed. RESULTS: Sulcal obliteration (p = 0.029) and third ventricular compression (p = 0.039) were associated with elevated ICP. Univariate regression analyses indicated that increasing combinations of the five defined signs of elevated ICP were associated with mortality, poor functional outcome, and time to death. There was also an increased likelihood of mortality if patients required craniotomy (OR = 4.318, 95% Confidence Interval [1.330-16.030]) or hemicraniectomy (OR = 2.993 [1.109-8.482]). On multivariate regression analyses, hemorrhage location was associated with mortality (posterior fossa, OR = 3.208 [1.120-9.188] and basal ganglia, OR = 3.079 [1.178-8.077]). Volume of hemorrhage >30cc was also associated with increased mortality, OR = 3.702 [1.575-8.956]). The proportion of patient hours with sustained ICP = 20 mmHg, and maximum ICP = 20 mmHg, were also directly correlated with increased mortality (OR = 64.99 [7.731-635.51]; and OR = 1.025 [1.004-1.047]). Poor functional outcome was predicted by concurrent presence of all five radiographic signs of elevated ICP (OR = 4.44 [1.514-14.183]) and presence of frontal lobe (OR = 2.951 [1.265-7.067]), subarachnoid (OR = 2.231 [1.067-4.717]), or intraventricular (OR = 2.249 [1.159-4.508]) hemorrhage. Time to death was modulated by total patient days of elevated ICP = 20 mmHg (Effect Size = 3.424 [1.500, 5.439]) in the first two weeks of hospitalization. CONCLUSIONS: ICP-related imaging variables can be prognosticate for moderate-severe TBI.

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

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

Survival and Lung Function Changes in Hypersensitivity Pneumonitis According to Radiological Phenotypes Compared With Idiopathic Pulmonary Fibrosis.

The main objective of this study was to estimate survival and changes in lung function in patients with chronic hypersensitivity pneumonitis (HP), both fibrotic (f-HP) and nonfibrotic (nf-HP), and to compare them with those in patients with idiopathic pulmonary fibrosis (IPF). HP was diagnosed based on antigen exposure, HRCT (high-resolution CT scan), BAL (bronchoalveolar lavage), and histology. According to HRCT, HP was classified into fibrotic and non-fibrotic phenotypes. In most cases, IPF was diagnosed based on HRCT findings. We identified 84 patients: 46 with IPF, 18 with f-HP, and 20 with nf-HP. Five-year survival was 23.9% in IPF, 72% in f-HP, and 100% in nf-HP (p <0.0001). Honeycombing was associated with decreased survival in IPF (p <0.001) and in f-HP (p <0.0001). The mean loss of FVC (forced vital capacity) % pred. (percent predicted) was -18.3% in IPF (p =0.001), -4.8% in f-HP, and -6.0% in nf-HP. The mean change in DLCO (diffusion capacity for carbon monoxide) % pred. was -10.2% in IPF (p <0.002), -0.5% in f-HP, and +1.9% in nf-HP. The agreement between radiological phenotypes and histology in HP was 89.6%. We found shorter survival in IPF, followed by f-HP, and nf-HP. Over time, we did not find significant changes in FVC% pred. or DLCO% pred. in HP, while a significant decline in IPF was noted. In HP, we found strong agreement between radiological phenotypes and histology. Radiological signs suggestive of lung fibrosis in HP were reliable for the diagnosis of f-HP and seem to have intrinsic prognostic value.