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Gaulrapp H, Schoof P, Schönecker G. Transient Hip Synovitis, 146 Cases, Origin and Duration. ZEITSCHRIFT FUR ORTHOPADIE UND UNFALLCHIRURGIE 2025. [PMID: 40179943 DOI: 10.1055/a-2533-4972] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/05/2025]
Abstract
Transient hip synovitis is one of the most common paediatric orthopaedic diseases. This non-controlled interventional study investigated the origin, clinical findings, imaging and the duration of symptoms. 146 affected patients out of the total of 27659 patients under 18 years result in an incidence of 0.53%. 76.7% boys outweighed 23.3% girls (1.8-12.9 years [Ø 6.3 y, boys Ø 6.5 y, girls Ø 6.2 y]). Diagnoses were defined by ultrasound and the absence of concurrent diseases. In 60.5% of patients, the right hip was affected, in 39.5% the left. A single patient had CF on both sides but not at the same time. No simultaneous incidence was recorded. There were two singular recurrences. Within the study period, we counted 11 cases of Perthes' disease, 2 juvenile hip arthritis and one septic hip. Patients' history showed 41.0% viral infections, 21.6% physical exertion and 15.1% singular trauma. In 22.3% no origin could be named. Clinical aspects included pain in inward rotation (51.5%), in hip flexion (49.3%) and limping (37.5%). Ultrasound depicted medium joint effusion in 53.4%, marked effusion in 46.6% and synovial thickening in 17.1% of patients. 119 patients could be followed up weekly. Joint effusion vanished after 3-36 days (Ø 13.3 d), clinical symptoms Ø 1.6 days earlier. Total duration in terms of sonographic appearance of effusion was 3 to 37 days (Ø 19.1 d).
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Affiliation(s)
- Hartmut Gaulrapp
- Facharztpraxis für Orthopädie und Kinderorthopädie München-Schwabing, München, Germany
| | - Philipp Schoof
- Gemeinschaftspraxis Kinder- und Jugendmedizin, Kinderrheumatologie, Neuropädiatrie, München, Germany
| | - Gregor Schönecker
- Gemeinschaftspraxis für Orthopädie, Unfallchirurgie und Kinderorthopädie, Landshut, Germany
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2
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Restrepo R, Park HJ, Karakas SP, Cervantes LF, Rodriguez-Ruiz FG, Zahrah AM, Inarejos-Clemente EJ, Laufer M, Shreiber VM. Bacterial osteomyelitis in pediatric patients: a comprehensive review. Skeletal Radiol 2024; 53:2195-2210. [PMID: 38504031 DOI: 10.1007/s00256-024-04639-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Revised: 02/24/2024] [Accepted: 02/27/2024] [Indexed: 03/21/2024]
Abstract
Bacterial osteomyelitis, an inflammatory response in the bone caused by microorganisms, typically affects the metaphysis in the skeletally immature. Bacterial osteomyelitis possesses a significant diagnostic challenge in pediatric patients due to its nonspecific clinical presentation. Because the metaphysis is the primary focus of infection in skeletally immature patients, understanding the normal physiologic, maturation process of bones throughout childhood allows to understand the pathophysiology of osteomyelitis. Timely and accurate diagnosis is crucial to initiate appropriate treatment, and prevent long-term sequelae and efforts must be made to isolate the causative organism. The potential causative organism changes according to the age of the patient and underlying medical conditions. Staphylococcus Aureus is the most common isolated bacteria in pediatric pyogenic osteomyelitis whereas Kingella Kingae is the most common causative agent in children aged 6 months to 4 years. Imaging plays a pivotal role in the diagnosis, characterization, evaluation of complications, and follow up of bacterial osteomyelitis. Imaging also plays a pivotal role in the evaluation of potential neoplastic and non-neoplastic mimickers of osteomyelitis. In children, MRI is currently the gold standard imaging modality when suspecting bacterial osteomyelitis, whereas surgical intervention may be required in order to isolate the microorganism, treat complications, and exclude mimickers.
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Affiliation(s)
- Ricardo Restrepo
- Radiology Department, Nicklaus Children's Hospital, 3100 SW 62nd Ave, Miami, FL, 33155, USA.
| | - Halley J Park
- Radiology Department, Nicklaus Children's Hospital, 3100 SW 62nd Ave, Miami, FL, 33155, USA
| | - S Pinar Karakas
- Radiology Department, Nicklaus Children's Hospital, 3100 SW 62nd Ave, Miami, FL, 33155, USA
| | - Luisa F Cervantes
- Radiology Department, Nicklaus Children's Hospital, 3100 SW 62nd Ave, Miami, FL, 33155, USA
| | | | - Anna Maria Zahrah
- Krieger School of Arts and Sciences, Johns Hopkins University, Baltimore, MD, USA
| | | | - Marcelo Laufer
- Infectious Disease Department, Nicklaus Children's Hospital, Miami, USA
| | - Verena M Shreiber
- Orthopedic, Sports Medicine, and Spine Institute, Nicklaus Children's Hospital, Miami, USA
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Griffith JF, Yip SWY, van der Heijden RA, Valenzuela RF, Yeung DKW. Perfusion Imaging of the Musculoskeletal System. Magn Reson Imaging Clin N Am 2024; 32:181-206. [PMID: 38007280 DOI: 10.1016/j.mric.2023.07.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2023]
Abstract
Perfusion imaging is the aspect of functional imaging, which is most applicable to the musculoskeletal system. In this review, the anatomy and physiology of bone perfusion is briefly outlined as are the methods of acquiring perfusion data on MR imaging. The current clinical indications of perfusion related to the assessment of soft tissue and bone tumors, synovitis, osteoarthritis, avascular necrosis, Keinbock's disease, diabetic foot, osteochondritis dissecans, and Paget's disease of bone are reviewed. Challenges and opportunities related to perfusion imaging of the musculoskeletal system are also briefly addressed.
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Affiliation(s)
- James F Griffith
- Department of Imaging and Interventional Radiology, Prince of Wales Hospital, The Chinese University of Hong Kong.
| | - Stefanie W Y Yip
- Department of Imaging and Interventional Radiology, Prince of Wales Hospital, The Chinese University of Hong Kong
| | - Rianne A van der Heijden
- Department of Radiology and Nuclear Medicine, Erasmus University Medical Center, Rotterdam, The Netherlands; Department of Radiology, University of Wisconsin-Madison, Madison, WI, USA
| | - Raul F Valenzuela
- Department of Musculoskeletal Imaging, The University of Texas, MD Anderson Cancer Center, USA
| | - David K W Yeung
- Department of Imaging and Interventional Radiology, Prince of Wales Hospital, The Chinese University of Hong Kong
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Yun SY, Choo HJ, Jeong HW, Lee SJ. Comparison of MR Findings between Patients with Septic Arthritis and Acute Gouty Arthritis of the Knee. JOURNAL OF THE KOREAN SOCIETY OF RADIOLOGY 2022; 83:1071-1080. [PMID: 36276224 PMCID: PMC9574278 DOI: 10.3348/jksr.2021.0147] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/27/2021] [Revised: 01/17/2022] [Accepted: 02/23/2022] [Indexed: 11/15/2022]
Abstract
Purpose To compare the MR findings of septic and acute gouty arthritis of the knee joint. Materials and Methods This retrospective study included patients who underwent knee MRI for septic or gouty arthritis at our hospital between October 2012 and October 2018. The MR findings were analyzed for the presence of bone marrow edema, soft tissue edema, abscess, pattern of synovial thickening (frondlike, lamellated, diffuse linear), maximum thickness of the synovium, and joint effusion volume. The gouty (n = 5) and septic arthritis (n = 10) groups were compared using the Wilcoxon rank-sum test and Fisher's exact test. Results No statistically significant differences were observed for each item. One patient in the gouty arthritis group and seven in the septic arthritis group had bone marrow edema. Soft tissue abscess formation was only observed in the septic group. The incidence of each synovial thickening pattern was as follows: 100% (diffuse linear) in the gouty arthritis group and 20% (frondlike), 50% (lamellated), and 30% (diffuse linear) in the septic arthritis group. Conclusion Differentiation of gouty arthritis and septic arthritis based on imaging findings is difficult. However, lamellated synovial thickening patterns, bone marrow edema, and soft tissue abscess formation are more commonly observed in patients with septic arthritis than in those with gouty arthritis.
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Habre C, Botti P, Laurent M, Ceroni D, Toso S, Hanquinet S. Benefits of diffusion-weighted imaging in pediatric acute osteoarticular infections. Pediatr Radiol 2022; 52:1086-1094. [PMID: 35376979 PMCID: PMC9107444 DOI: 10.1007/s00247-022-05329-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2021] [Revised: 12/08/2021] [Accepted: 12/21/2021] [Indexed: 11/18/2022]
Abstract
BACKGROUND Contrast-enhanced magnetic resonance imaging (MRI) is recommended for the diagnosis of acute osteoarticular infections in children. Diffusion-weighted imaging (DWI) may be an alternative to the injection of gadolinium. OBJECTIVE To evaluate unenhanced MRI with DWI in comparison to contrast-enhanced MRI for the diagnostic work-up of acute osteoarticular infections in children. MATERIALS AND METHODS This retrospective study included 36 children (age range: 7 months-12 years) with extra-spinal osteoarticular infections and MRI performed within 24 h of admission. MRI protocol included short tau inversion recovery (STIR), water-only T2 Dixon, T1, DWI, and gadolinium-enhanced T1 sequences. Two readers reviewed three sets of images: 1) unenhanced sequences, 2) unenhanced sequences with DWI and 3) unenhanced followed by contrast-enhanced sequences (reference standard). Sensitivity and specificity of sets 1 and 2 were compared to set 3 and assessed to identify osteoarticular infections: osteomyelitis (long bones, metaphyseal equivalents), septic arthritis and abscess (soft tissues, bone). RESULTS All 14 cases of osteomyelitis in the metaphyses and diaphyses of long bones and all 27 cases of septic arthritis were identified by unenhanced sequences, but 4/16 abscesses were missed. For the diagnosis of abscess, DWI increased sensitivity to 100%. Among the 18 osteomyelitis in metaphyseal equivalents, 4 femoral head chondroepiphyses were identified by contrast-enhanced sequences only. CONCLUSION MRI for suspected pediatric acute osteoarticular infections is the best diagnostic modality to guide patient management. An unenhanced protocol with DWI may be an alternative to a contrast-based protocol, even in the presence of an abscess. However, gadolinium remains necessary to assess for chondroepiphyseal involvement of the femoral head.
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Affiliation(s)
- Céline Habre
- Pediatric Radiology Unit, Radiology Division, Diagnostic Department, Children's Hospital, University Hospitals of Geneva, CH-1211, Geneva 14, Switzerland.
| | - Paul Botti
- Pediatric Radiology Unit, Radiology Division, Diagnostic Department, Children's Hospital, University Hospitals of Geneva, CH-1211, Geneva 14, Switzerland
| | - Méryle Laurent
- Pediatric Radiology Unit, Radiology Division, Diagnostic Department, Children's Hospital, University Hospitals of Geneva, CH-1211, Geneva 14, Switzerland
| | - Dimitri Ceroni
- Pediatric Orthopedics Unit, Surgery Division, Department of Women-Children-Teenagers, Children's Hospital, University Hospitals of Geneva, Geneva, Switzerland
| | - Seema Toso
- Pediatric Radiology Unit, Radiology Division, Diagnostic Department, Children's Hospital, University Hospitals of Geneva, CH-1211, Geneva 14, Switzerland
| | - Sylviane Hanquinet
- Pediatric Radiology Unit, Radiology Division, Diagnostic Department, Children's Hospital, University Hospitals of Geneva, CH-1211, Geneva 14, Switzerland
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Shet NS, Iyer RS, Chan SS, Baldwin K, Chandra T, Chen J, Cooper ML, Creech CB, Gill AE, Levin TL, Moore MM, Nadel HR, Saidinejad M, Schooler GR, Squires JH, Swenson DW, Rigsby CK. ACR Appropriateness Criteria® Osteomyelitis or Septic Arthritis-Child (Excluding Axial Skeleton). J Am Coll Radiol 2022; 19:S121-S136. [PMID: 35550797 DOI: 10.1016/j.jacr.2022.02.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2022] [Accepted: 02/19/2022] [Indexed: 10/18/2022]
Abstract
Imaging plays an integral role in the evaluation of suspected musculoskeletal infections in children, not only in the accurate identification of infection such as osteomyelitis or septic arthritis, but also in guiding management. Various diagnostic modalities serve different purposes in the assessment of suspected pediatric musculoskeletal infections. The purpose of this document is to provide imaging guidance in the most frequently encountered clinical scenarios in which osteomyelitis and/or septic arthritis are suspected, outside of the axial skeleton. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion.
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Affiliation(s)
- Narendra S Shet
- Children's National Hospital, Washington, District of Columbia.
| | - Ramesh S Iyer
- Panel Chair, Seattle Children's Hospital, Seattle, Washington; and Chair, SPCC (CoPLL)
| | - Sherwin S Chan
- Panel Vice-Chair, Vice Chair of Radiology, Children's Mercy Hospital, Kansas City, Missouri
| | - Keith Baldwin
- Associate Professor, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; American Academy of Orthopaedic Surgeons
| | - Tushar Chandra
- Magnetic Resonance Medical Director, Chief of Research, Chief of Medical Education, Co-director of 3D and Advanced Imaging Lab, Nemours Children's Hospital, Orlando, Florida
| | - Jimmy Chen
- University of Florida College of Medicine Jacksonville, Jacksonville, Florida; American Academy of Pediatrics
| | - Matthew L Cooper
- Pediatric Radiology Division Chief, Radiology Medical Director, Riley Hospital for Children, Indianapolis, Indiana
| | - C Buddy Creech
- Vanderbilt University Medical Center, Nashville, Tennessee; Infectious Diseases Society of America; and President, Pediatric Infectious Diseases Society
| | - Anne E Gill
- Children's Healthcare of Atlanta and Emory University, Atlanta, Georgia
| | - Terry L Levin
- The Children's Hospital at Montefiore, Albert Einstein College of Medicine, Bronx, New York; Chair ACR Pediatric Practice Parameters
| | - Michael M Moore
- Co-director, Division of Radiology Innovation and Value Enhancement (DRIVE), Penn State Health Children's Hospital, Hershey, Pennsylvania
| | - Helen R Nadel
- Lucile Packard Children's Hospital at Stanford, Stanford, California; Member Committee on Practice Parameters-Pediatric ACR; and Alternate to Senate Stanford University School of Medicine
| | - Mohsen Saidinejad
- UCLA Medical Center, Los Angeles, California; American College of Emergency Physicians; and Director, Institute for Health Services and Outcomes Research-The Lundquist Institute for Biomedical Innovation at Harbor UCLA
| | | | - Judy H Squires
- Chief of Ultrasound; Associate Program Director for Diagnostic Radiology, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania
| | - David W Swenson
- Alpert Medical School of Brown University, Providence, Rhode Island
| | - Cynthia K Rigsby
- Specialty Chair, Department of Medical Imaging, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
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Adam M, Ibrahim B, Khidir R, Elmahdi E, Ahmed S, Ahmed A. Usefulness of MRI findings in differentiating between septic arthritis and transient synovitis of hip joint in children: A systematic review and meta-analysis. Eur J Radiol Open 2022; 9:100439. [PMID: 36061257 PMCID: PMC9436746 DOI: 10.1016/j.ejro.2022.100439] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Revised: 08/19/2022] [Accepted: 08/23/2022] [Indexed: 11/10/2022] Open
Abstract
Purpose Septic arthritis (SA) of the hip joint is a serious infection which can lead to more irreversible complications. Differentiating Septic arthritis from Transient synovitis (which is the most common cause of painful hip in children) is difficult and very important to prevent serious complications which can occur with Septic arthritis. The aim of this study was to find out the MRI findings which can differentiate between these two conditions. Methods Systematic literature search was conducted according to the PRISMA guidelines on MEDLINE(PubMed), Google Scholar, ScienceDirect, and world Health Organization Virtual Health Library, up to April 2022. Studies that compared MRI findings between Septic Arthritis and Transient Synovitis of hip joint in children were included. The pooled sensitivity and specificity estimates of these findings were calculated using MetaDTA version 2.0. Results Six studies were included in qualitative analysis and five were included in quantitative analysis. Pooled sensitivity and specificity of synovial enhancement were 94.2 % (95 % CI, 45.2–99.7 %) and 60.6 % (95% CI, 6–97.4 %) respectively. Soft tissue changes had pooled sensitivity and specificity of 75 % (95% CI, 57.5–86.9 %) and 69.9 % (95 % CI, 46.5–86.2 %) respectively. Pooled sensitivity and specificity of femoral head changes were 41.5 % (95 % CI, 15.9–72.7 %) and 87.3 % (95 % CI, 75.5–93.8 %) respectively. Bone marrow changes had pooled sensitivity and specificity of 70 % (95 % CI, 26.8–93.7 %) and 99.9 % (95 % CI, 28.7–100 %) respectively. Conclusion MRI findings especially bone marrow changes were found to be useful in differentiating septic arthritis from transient synovitis among children presented with painful hip after exclusion of other causes.
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8
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Butt FE, Lee EY, Chaturvedi A. Pediatric Musculoskeletal Infections: Imaging Guidelines and Recommendations. Radiol Clin North Am 2021; 60:165-177. [PMID: 34836563 DOI: 10.1016/j.rcl.2021.08.012] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Pediatric musculoskeletal infections often pose a diagnostic challenge due to their frequently vague and nonspecific clinical presentation. Imaging evaluation is a crucial component to diagnostic workup of these entities. Changed epidemiology of these infections over the past 2 decades has resulted in increases in both disease incidence and severity in the pediatric population. Prompt and accurate diagnosis is essential in order to reduce the risk of morbid sequelae, and to optimize patient management. In this article, the unique pathophysiology of musculoskeletal infections and characteristic imaging findings in children compared with adults are reviewed.
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Affiliation(s)
- Frederick E Butt
- Department of Radiology, Dartmouth-Hitchcock Medical Center, One Medical Center Drive, Lebanon, NH 03756, USA.
| | - Edward Y Lee
- Department of Radiology, Boston Children's Hospital, Harvard Medical School, 300 Longwood Avenue, Boston, MA 02115, USA
| | - Apeksha Chaturvedi
- Department of Imaging Sciences, University of Rochester Medical Center, School of Medicine and Dentistry, 601 Elmwood Avenue, Rochester, NY 14642, USA
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El-Sobky T, Mahmoud S. Acute osteoarticular infections in children are frequently forgotten multidiscipline emergencies: beyond the technical skills. EFORT Open Rev 2021; 6:584-592. [PMID: 34377550 PMCID: PMC8335954 DOI: 10.1302/2058-5241.6.200155] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Acute osteoarticular infections (AOI) should be treated as top emergencies. The first few days following the inception of infection are ultra-critical to long-term prognosis.A comprehensive road map for management of childhood AOI is still lacking despite recent advances in microbiology and imaging (magnetic resonance imaging). The many faces of childhood AOI warrant a multidiscipline approach to management.Laboratory and imaging findings of are still debatable and should not overshadow or delay a management plan based on the experienced physician's clinical judgment.Ample evidence-based practice supports the use of a few days of intravenous antibiotic administration followed by oral therapy until correlative clinical and basic laboratory (acute phase reactants) results improve.The growing body of evidence on 'high-risk' children/neonates of AOI warrants continual clinical extra-vigilance in identifying these patient subsets.Open drainage and debridement remain the mainstay of treatment of septic hips, whereas for other joints the use of alternative surgical techniques should be individualized or on case-by-case basis.Because the consequences of misdiagnosis of AOI are usually grave and permanent, proactive treatment/overtreatment is justified in the event of unconfirmed but suspicious diagnosis. Cite this article: EFORT Open Rev 2021;6:584-592. DOI: 10.1302/2058-5241.6.200155.
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Affiliation(s)
- Tamer El-Sobky
- Division of Paediatric Orthopaedics, Department of Orthopaedic Surgery, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Shady Mahmoud
- Division of Paediatric Orthopaedics, Department of Orthopaedic Surgery, Faculty of Medicine, Ain Shams University, Cairo, Egypt
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10
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Abstract
The Society of Skeletal Radiology (SSR) Practice Guidelines and Technical Standards Committee identified musculoskeletal infection as a White Paper topic, and selected a Committee, tasked with developing a consensus on nomenclature for MRI of musculoskeletal infection outside the spine. The objective of the White Paper was to critically assess the literature and propose standardized terminology for imaging findings of infection on MRI, in order to improve both communication with clinical colleagues and patient care.A definition was proposed for each term; debate followed, and the committee reached consensus. Potential controversies were raised, with formulated recommendations. The committee arrived at consensus definitions for cellulitis, soft tissue abscess, and necrotizing infection, while discouraging the nonspecific term phlegmon. For bone infection, the term osteitis is not useful; the panel recommends using terms that describe the likelihood of osteomyelitis in cases where definitive signal changes are lacking. The work was presented virtually to SSR members, who had the opportunity for review and modification prior to submission for publication.
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11
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Differential MRI findings of transient synovitis of the hip in children when septic arthritis is suspected according to symptom duration. J Pediatr Orthop B 2020; 29:297-303. [PMID: 31503109 DOI: 10.1097/bpb.0000000000000671] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/10/2023]
Abstract
We investigated the differential MRI findings in children with transient synovitis of the hip in whom septic arthritis was suspected. Under the hypothesis that disease progression can alter representative MRI findings, we stratified these findings in accordance with symptom duration as this can correlate with disease progression. We analyzed 65 children who underwent MRI for acute hip pain and who were suspected of having a septic condition (i.e. presented with fever or increased inflammatory markers) when the imaging was performed. Symptom duration was defined as the interval from the first presentation of hip pain to the MRI scan. We divided the patients into two subgroups according to symptom duration: patients with short symptom duration (≤2 days, short-term subgroup, n = 30) and those with long symptom duration (≥3 days, long-term subgroup, n = 35). Twenty-eight (43.1%) of the study subjects were diagnosed with septic arthritis. Whereas only a high-grade joint effusion was a significant MRI finding differentiating septic arthritis from transient synovitis in the whole cohort, the presence of contralateral joint effusion in the short-term subgroup (P = 0.024) and the absence of a change/enhancement of the signal intensity of soft tissue in the long-term subgroup (P < 0.001) were significant predictors of transient synovitis. The significances of differential MRI findings for septic arthritis and transient synovitis seem to change according to symptom duration. We suggest that symptom duration, which may correlate with disease progression, should also be considered when interpreting MRIs of children under suspicion of septic arthritis.
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12
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Safdar NM, Rigsby CK, Iyer RS, Alazraki AL, Anupindi SA, Bardo DME, Brown BP, Chan SS, Chandra T, Dillman JR, Dorfman SR, Garber MD, Lam HFS, Nguyen JC, Siegel A, Widmann RF, Karmazyn B. ACR Appropriateness Criteria ® Acutely Limping Child Up To Age 5. J Am Coll Radiol 2018; 15:S252-S262. [PMID: 30392594 DOI: 10.1016/j.jacr.2018.09.030] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2018] [Accepted: 09/07/2018] [Indexed: 11/19/2022]
Abstract
Imaging plays in important role in the evaluation of the acutely limping child. The decision-making process about initial imaging must consider the level of suspicion for infection and whether symptoms can be localized. The appropriateness of specific imaging examinations in the acutely limping child to age 5 years is discussed with attention in each clinical scenario to the role of radiography, ultrasound, nuclear medicine, computed tomography, and magnetic resonance imaging. Common causes of limping such as toddler's fracture, septic arthritis, transient synovitis, and osteomyelitis are discussed. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.
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Affiliation(s)
| | - Cynthia K Rigsby
- Panel Chair, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Ramesh S Iyer
- Panel Vice-Chair, Seattle Children's Hospital, Seattle, Washington
| | | | | | | | - Brandon P Brown
- Riley Hospital for Children Indiana University, Indianapolis, Indiana
| | | | | | | | | | - Matthew D Garber
- Wolfson Children's Hospital, Jacksonville, Florida; American Academy of Pediatrics
| | - H F Samuel Lam
- Sutter Medical Center Sacramento, Sacramento, California; American College of Emergency Physicians
| | - Jie C Nguyen
- Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Alan Siegel
- Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - Roger F Widmann
- Hospital for Special Surgery, New York, New York; American Academy of Orthopaedic Surgeons
| | - Boaz Karmazyn
- Specialty Chair, Riley Hospital for Children Indiana University, Indianapolis, Indiana
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13
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Boesen M, Kubassova O, Sudoł-Szopińska I, Maas M, Hansen P, Nybing JD, Oei EH, Hemke R, Guermazi A. MR Imaging of Joint Infection and Inflammation with Emphasis on Dynamic Contrast-Enhanced MR Imaging. PET Clin 2018; 13:523-550. [PMID: 30219186 DOI: 10.1016/j.cpet.2018.05.007] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
Contrast-enhanced MR imaging (CE-MR imaging) is recommended for diagnosis and monitoring of infectious and most inflammatory joint diseases. CE-MR imaging clearly differentiates soft and bony tissue from fluid collections and infectious debris. To improve imaging information, a dynamic CE-MR imaging sequence (DCE-MR imaging) sequence can be applied using fast T1-weighted sequential image acquisition during contrast injection. Use of DCE-MR imaging allows robust extraction of quantitative information regarding blood flow and capillary permeability, especially when dedicated analysis methods and software are used to analyze contrast kinetics. This article describes principles of DCE-MR imaging for the assessment of infectious and inflammatory joint diseases.
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Affiliation(s)
- Mikael Boesen
- Department of Radiology, Bispebjerg and Frederiksberg Hospital, Bispebjerg Bakke 23, 2400, Copenhagen Nv, Denmark; Parker Institute, Bispebjerg and Frederiksberg Hospital, Nordrefasanvej 57, 2000 Copenhagen F, Denmark.
| | - Olga Kubassova
- Image Analysis Group (IAG), AQBC Minster House, 272-274 Vauxhall Bridge Road, SW1V 1BA, London, UK
| | - Iwona Sudoł-Szopińska
- Department of Radiology, National Institute of Geriatrics, Rheumatology and Rehabilitation, Warsaw, Poland; Department of Diagnostic Imaging, Warsaw Medical University, Warsaw, Poland
| | - Mario Maas
- Department of Radiology, Faculty of Medicine, Academic Medical Center (AMC) Amsterdam, University of Amsterdam, Amsterdam, The Netherlands; Department of Nuclear Medicine, Faculty of Medicine, Academic Medical Center (AMC) Amsterdam, University of Amsterdam, Amsterdam, The Netherlands
| | - Philip Hansen
- Department of Radiology, Bispebjerg and Frederiksberg Hospital, Bispebjerg Bakke 23, 2400, Copenhagen Nv, Denmark
| | - Janus Damm Nybing
- Department of Radiology, Bispebjerg and Frederiksberg Hospital, Bispebjerg Bakke 23, 2400, Copenhagen Nv, Denmark
| | - Edwin H Oei
- Department of Radiology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands; Department of Nuclear Medicine, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Robert Hemke
- Department of Radiology, Faculty of Medicine, Academic Medical Center (AMC) Amsterdam, University of Amsterdam, Amsterdam, The Netherlands; Department of Nuclear Medicine, Faculty of Medicine, Academic Medical Center (AMC) Amsterdam, University of Amsterdam, Amsterdam, The Netherlands
| | - Ali Guermazi
- Department of Radiology, Boston University School of Medicine, Boston, MA, USA
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Kobayashi Y, Kamishima T, Sugimori H, Ichikawa S, Noguchi A, Kono M, Iiyama T, Sutherland K, Atsumi T. Quantification of hand synovitis in rheumatoid arthritis: Arterial mask subtraction reinforced with mutual information can improve accuracy of pixel-by-pixel time-intensity curve shape analysis in dynamic MRI. J Magn Reson Imaging 2018; 48:687-694. [PMID: 29493823 DOI: 10.1002/jmri.25995] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2017] [Accepted: 02/13/2018] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND Synovitis, which is a hallmark of rheumatoid arthritis (RA), needs to be precisely quantified to determine the treatment plan. Time-intensity curve (TIC) shape analysis is an objective assessment method for characterizing the pixels as artery, inflamed synovium, or other tissues using dynamic contrast-enhanced MRI (DCE-MRI). PURPOSE/HYPOTHESIS To assess the feasibility of our original arterial mask subtraction method (AMSM) with mutual information (MI) for quantification of synovitis in RA. STUDY TYPE Prospective study. SUBJECTS Ten RA patients (nine women and one man; mean age, 56.8 years; range, 38-67 years). FIELD STRENGTH/SEQUENCE 3T/DCE-MRI. ASSESSMENT After optimization of TIC shape analysis to the hand region, a combination of TIC shape analysis and AMSM was applied to synovial quantification. The MI between pre- and postcontrast images was utilized to determine the arterial mask phase objectively, which was compared with human subjective selection. The volume of objectively measured synovitis by software was compared with that of manual outlining by an experienced radiologist. Simple TIC shape analysis and TIC shape analysis combined with AMSM were compared in slices without synovitis according to subjective evaluation. STATISTICAL TESTS Pearson's correlation coefficient, paired t-test and intraclass correlation coefficient (ICC). RESULTS TIC shape analysis was successfully optimized in the hand region with a correlation coefficient of 0.725 (P < 0.01) with the results of manual assessment regarded as ground truth. Objective selection utilizing MI had substantial agreement (ICC = 0.734) with subjective selection. Correlation of synovial volumetry in combination with TIC shape analysis and AMSM with manual assessment was excellent (r = 0.922, P < 0.01). In addition, negative predictive ability in slices without synovitis pixels was significantly increased (P < 0.01). DATA CONCLUSIONS The combination of TIC shape analysis and image subtraction reinforced with MI can accurately quantify synovitis of RA in the hand by eliminating arterial pixels. LEVEL OF EVIDENCE 2 Technical Efficacy: Stage 2 J. Magn. Reson. Imaging 2018.
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Affiliation(s)
- Yuto Kobayashi
- Graduate School of Health Sciences, Hokkaido University, Sapporo, Japan
| | | | | | - Shota Ichikawa
- Department of Radiological Technology, Kurashiki Central Hospital, Kurashiki, Japan
| | - Atsushi Noguchi
- Department of Rheumatology, Endocrinology and Nephrology, Graduate School of Medicine and Faculty of Medicine, Hokkaido University, Sapporo, Japan
| | - Michihito Kono
- Department of Rheumatology, Endocrinology and Nephrology, Graduate School of Medicine and Faculty of Medicine, Hokkaido University, Sapporo, Japan
| | | | - Kenneth Sutherland
- Global Station for Medical Science and Engineering, Global Institution for Collaborative Research and Education (GI-CoRE), Hokkaido University, Japan
| | - Tatsuya Atsumi
- Department of Radiological Technology, Kurashiki Central Hospital, Kurashiki, Japan
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Welling BD, Haruno LS, Rosenfeld SB. Validating an Algorithm to Predict Adjacent Musculoskeletal Infections in Pediatric Patients With Septic Arthritis. Clin Orthop Relat Res 2018; 476:153-159. [PMID: 29389760 PMCID: PMC5919251 DOI: 10.1007/s11999.0000000000000019] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Septic arthritis is frequently associated with adjacent infections including osteomyelitis and subperiosteal and intramuscular abscesses. While often clinically indiscernible from isolated septic arthritis, the diagnosis of adjacent infections is important in determining the need for additional surgical intervention. MRI has been used as the diagnostic gold standard for assessing adjacent infection. Routine MRI, however, can be resource-intensive and delay surgical treatment. In this context, there is need for additional diagnostic tools to assist clinicians in determining when to obtain preoperative MRI in children with septic arthritis. In a previous investigation by Rosenfeld et al., an algorithm, based on presenting laboratory values and symptoms, was derived to predict adjacent infections in septic arthritis. The clinical applicability of the algorithm was limited, however, in that it was built from and applied on the same population. The current study was done to address this criticism by evaluating the predictive power of the algorithm on a new patient population. QUESTIONS/PURPOSES (1) Can a previously created algorithm used for predicting adjacent infection in septic arthritis among pediatric patients be validated in a separate population? METHODS Records for all pediatric patients (1-18 years old) surgically treated for suspected septic arthritis during a 3-year period were retrospectively reviewed (109 patients). Of these patients, only those with a diagnosis of septic arthritis confirmed by synovial fluid analysis were included in the study population. Patients without confirmation of septic arthritis via synovial fluid analysis, Gram stain, or culture were excluded (34 patients). Patients with absence of MRI, younger than 1 year, insufficient laboratory tests, or confounding concurrent illnesses also were excluded (18 patients), resulting in a total of 57 patients in the study population. Five variables which previously were shown to be associated with risk of adjacent infection were collected: patient age (older than 4 years), duration of symptoms (> 3 days), C-reactive protein (> 8.9 mg/L), platelet count (< 310 x 10 cells/µL), and absolute neutrophil count (> 7.2 x 10 cells/µL). Adjacent infections were determined exclusively by preoperative MRI, with all patients in this study undergoing preoperative MRI. MR images were read by pediatric musculoskeletal radiologists and reviewed by the senior author. According to the algorithm we considered the presence of three or more threshold-level variables as a "positive" result, meaning the patient was predicted to have an adjacent infection. Comparing against the gold standard of MRI, the algorithm's accuracy was evaluated in terms of sensitivity, specificity, positive predictive value, and negative predictive value. RESULTS In the new population, the sensitivity and specificity of the algorithm were 86% (95% CI, 0.70-0.95) and 85% (95% CI, 0.64-0.97), respectively. The positive predictive value was determined to be 91% (95% CI, 0.78-0.97), with a negative predictive value of 77% (95% CI, 0.61-0.89). All patients meeting four or more algorithm criteria were found to have septic arthritis with adjacent infection on MRI. CONCLUSIONS Critical to the clinical applicability of the above-mentioned algorithm was its validation on a separate population different from the one from which it was built. In this study, the algorithm showed reproducible predictive power when tested on a new population. This model potentially can serve as a useful tool to guide patient risk stratification when determining the likelihood of adjacent infection and need of MRI. This better-informed clinical judgement regarding the need for MRI may yield improvements in patient outcomes, resource allocation, and cost. LEVEL OF EVIDENCE Level II, diagnostic study.
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Affiliation(s)
- Benjamin D Welling
- B. D. WellingBaylor College of Medicine, Department of Orthopedic Surgery, Houston, TX, USA L. S. Haruno, S. B. RosenfeldTexas Children's Hospital, Division of Orthopedic Surgery, Houston, TX, USA
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Martín Noguerol T, Luna A, Gómez Cabrera M, Riofrio AD. Clinical applications of advanced magnetic resonance imaging techniques for arthritis evaluation. World J Orthop 2017; 8:660-673. [PMID: 28979849 PMCID: PMC5605351 DOI: 10.5312/wjo.v8.i9.660] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2017] [Revised: 04/18/2017] [Accepted: 05/05/2017] [Indexed: 02/06/2023] Open
Abstract
Magnetic resonance imaging (MRI) has allowed a comprehensive evaluation of articular disease, increasing the detection of early cartilage involvement, bone erosions, and edema in soft tissue and bone marrow compared to other imaging techniques. In the era of functional imaging, new advanced MRI sequences are being successfully applied for articular evaluation in cases of inflammatory, infectious, and degenerative arthropathies. Diffusion weighted imaging, new fat suppression techniques such as DIXON, dynamic contrast enhanced-MRI, and specific T2 mapping cartilage sequences allow a better understanding of the physiopathological processes that underlie these different arthropathies. They provide valuable quantitative information that aids in their differentiation and can be used as potential biomarkers of articular disease course and treatment response.
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Affiliation(s)
| | - Antonio Luna
- MRI Unit, Clínica Las Nieves, SERCOSA, Health Time, 23007 Jaén, Spain
- Department of Radiology, University Hospitals of Cleveland, Case Western Reserve University, Cleveland, OH 44106, United States
| | | | - Alexie D Riofrio
- Department of Radiology, Duke Regional Hospital, Durham, NC 27710, United States
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Martín Noguerol T, Luna Alcalá A, Beltrán LS, Gómez Cabrera M, Broncano Cabrero J, Vilanova JC. Advanced MR Imaging Techniques for Differentiation of Neuropathic Arthropathy and Osteomyelitis in the Diabetic Foot. Radiographics 2017; 37:1161-1180. [DOI: 10.1148/rg.2017160101] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Affiliation(s)
- Teodoro Martín Noguerol
- From the MRI Section, Department of Radiology, SERCOSA, Health Time, Calle Carmelo Torres 2, 23007 Jaén, Spain (T.M.N., A.L.A.); Department of Radiology, University Hospitals of Cleveland, Case Western Reserve University, Cleveland, Ohio (A.L.A.); Department of Radiology, NYU Langone Medical Center, New York, NY (L.S.B.); MRI Section, Department of Radiology, DADISA, Health Time, Cádiz, Spain (M.G.C.); MRI Section, Department of Radiology, RESSALTA, Health Time, Córdoba, Spain (J.B.C.); and Department of
| | - Antonio Luna Alcalá
- From the MRI Section, Department of Radiology, SERCOSA, Health Time, Calle Carmelo Torres 2, 23007 Jaén, Spain (T.M.N., A.L.A.); Department of Radiology, University Hospitals of Cleveland, Case Western Reserve University, Cleveland, Ohio (A.L.A.); Department of Radiology, NYU Langone Medical Center, New York, NY (L.S.B.); MRI Section, Department of Radiology, DADISA, Health Time, Cádiz, Spain (M.G.C.); MRI Section, Department of Radiology, RESSALTA, Health Time, Córdoba, Spain (J.B.C.); and Department of
| | - Luis S. Beltrán
- From the MRI Section, Department of Radiology, SERCOSA, Health Time, Calle Carmelo Torres 2, 23007 Jaén, Spain (T.M.N., A.L.A.); Department of Radiology, University Hospitals of Cleveland, Case Western Reserve University, Cleveland, Ohio (A.L.A.); Department of Radiology, NYU Langone Medical Center, New York, NY (L.S.B.); MRI Section, Department of Radiology, DADISA, Health Time, Cádiz, Spain (M.G.C.); MRI Section, Department of Radiology, RESSALTA, Health Time, Córdoba, Spain (J.B.C.); and Department of
| | - Marta Gómez Cabrera
- From the MRI Section, Department of Radiology, SERCOSA, Health Time, Calle Carmelo Torres 2, 23007 Jaén, Spain (T.M.N., A.L.A.); Department of Radiology, University Hospitals of Cleveland, Case Western Reserve University, Cleveland, Ohio (A.L.A.); Department of Radiology, NYU Langone Medical Center, New York, NY (L.S.B.); MRI Section, Department of Radiology, DADISA, Health Time, Cádiz, Spain (M.G.C.); MRI Section, Department of Radiology, RESSALTA, Health Time, Córdoba, Spain (J.B.C.); and Department of
| | - Jordi Broncano Cabrero
- From the MRI Section, Department of Radiology, SERCOSA, Health Time, Calle Carmelo Torres 2, 23007 Jaén, Spain (T.M.N., A.L.A.); Department of Radiology, University Hospitals of Cleveland, Case Western Reserve University, Cleveland, Ohio (A.L.A.); Department of Radiology, NYU Langone Medical Center, New York, NY (L.S.B.); MRI Section, Department of Radiology, DADISA, Health Time, Cádiz, Spain (M.G.C.); MRI Section, Department of Radiology, RESSALTA, Health Time, Córdoba, Spain (J.B.C.); and Department of
| | - Joan C. Vilanova
- From the MRI Section, Department of Radiology, SERCOSA, Health Time, Calle Carmelo Torres 2, 23007 Jaén, Spain (T.M.N., A.L.A.); Department of Radiology, University Hospitals of Cleveland, Case Western Reserve University, Cleveland, Ohio (A.L.A.); Department of Radiology, NYU Langone Medical Center, New York, NY (L.S.B.); MRI Section, Department of Radiology, DADISA, Health Time, Cádiz, Spain (M.G.C.); MRI Section, Department of Radiology, RESSALTA, Health Time, Córdoba, Spain (J.B.C.); and Department of
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Jaramillo D, Dormans JP, Delgado J, Laor T, St Geme JW. Hematogenous Osteomyelitis in Infants and Children: Imaging of a Changing Disease. Radiology 2017; 283:629-643. [DOI: 10.1148/radiol.2017151929] [Citation(s) in RCA: 88] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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de Bodman C, Ceroni D, Dufour J, Crisinel PA, Bregou-Bourgeois A, Zambelli PY. Obturator externus abscess in a 9-year-old child: A case report and literature review. Medicine (Baltimore) 2017; 96:e6203. [PMID: 28248876 PMCID: PMC5340449 DOI: 10.1097/md.0000000000006203] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
RATIONALE Obturator pyomyositis is a rare condition in children. Diagnosis is often delayed because of its rarity, and the vagaries of its presentation cause it to be easily be missed. Physicians should therefore familiarize themselves with this condition and consider it as a possible differential diagnosis in patients presenting with an acutely painful hip. Inflammatory syndrome is also frequent among sufferers and the MRI is a very sensitive diagnostic tool for obturator pyomyositis. Additionally, joint fluid aspirations and blood cultures are also useful in identifying the pathogen. The appropriate antibiotic therapy provides a rapid regression of symptoms during the early stage of pyomyositis. In cases of MRI-confirmed abscess, surgical treatment is indicated. PATIENT CONCERNS Our report focuses on a case of obturator pyomyositis in a 9-year-old boy. The child was febrile for 5 days and could only manage to walk a few steps. His hip range of motion was restricted in all directions. In addition, the patient had presented pain and swelling of his right elbow for a day, with a restriction of motion in the joint. There was a clear inflammatory syndrome. A diagnosis of hip and elbow septic arthritis was suspected, and the child underwent joint aspiration of the both cited joints. The aspiration of the elbow returned pus. Conversely, no effusion was found in the hip aspiration. The administration of empiric intravenous antibiotherapy was started. DIAGNOSES An MRI revealed an osteomyelitis of the ischio-pubic area associated with a subperiosteal abscess. INTERVENTIONS Subsequently, 3 days after elbow arthrotomy, a surgical treatment was performed on the patient's right hip in order to evacuate the subperiosteal abscess and muscular collection because of the persistence of the patient's symptoms and inflammatory syndrome despite susceptible intravenous antibiotics. Postsurgery the patient showed steady improvement. LESSONS Such cases demonstrate how diagnosis can be difficult because pelvic pyomyositis is often mistaken for more common pathologies such as septic arthritis, osteomyelitis, or appendicitis. This may delay the diagnosis or refer misdiagnosis. We discuss this rare infection in light of the literature with particular reference to its incidence, clinical features, bacteriological etiology, biological, and radiological presentation, and above all, its treatment.
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Affiliation(s)
- Charlotte de Bodman
- Pediatric Orthopedics and Traumatology Unit, Lausanne University Hospital, Lausanne
| | - Dimitri Ceroni
- Pediatric Orthopedic Service, University Hospitals of Geneva, Geneva
| | - Justine Dufour
- Pediatric Orthopedics and Traumatology Unit, Lausanne University Hospital, Lausanne
| | - Pierre-Alex Crisinel
- Unit of Paediatric Infectious Diseases, Department of Paediatrics, Lausanne University Hospital, Lausanne, Switzerland
| | | | - Pierre-Yves Zambelli
- Pediatric Orthopedics and Traumatology Unit, Lausanne University Hospital, Lausanne
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Abstract
BACKGROUND The gold standard for treatment of septic arthritis is urgent surgical debridement. Preoperative magnetic resonance imaging (MRI) may identify osteomyelitis, subperiosteal abscesses, and intramuscular abscesses, which frequently occur with septic arthritis. If these adjacent infections are not recognized, initial treatment may be inadequate. The purpose of this study is to develop a prediction algorithm to distinguish septic arthritis with adjacent infections from isolated septic arthritis to determine which patients should undergo preoperative MRI. METHODS An IRB-approved retrospective review of 87 children treated for septic arthritis was performed. All patients underwent MRI. Sixteen variables (age, sex, temperature, WBC, CRP, ESR, ANC, hematocrit, platelet count, heart rate, systolic blood pressure, diastolic blood pressure, symptom duration, weight-bearing status, prior antibiotic therapy, and prior hospitalization) from admission were reviewed. Graphical and logistical regression analysis was used to determine variables independently predictive of adjacent infection. Optimal cutoff values were determined for each variable and a prediction algorithm was created. Finally, the model was applied to our patient database and each patient with isolated septic arthritis or adjacent infection was stratified based upon the number of positive predictive factors. RESULTS A total of 36 (41%) patients had isolated septic arthritis and 51 (59%) had septic arthritis with adjacent foci. Five variables (age above 3.6 y, CRP>13.8 mg/L, duration of symptoms >3 d, platelets <314×10 cells/μL, and ANC>8.6×10 cells/μL) were found to be predictive of adjacent infection and were included in the algorithm. Patients with ≥3 risk factors were classified as high risk for septic arthritis with adjacent infection (sensitivity: 90%, specificity: 67%, positive predictive value: 80%, negative predictive value: 83%). CONCLUSIONS Age, CRP, duration of symptoms, platelet count, and ANC were predictive of adjacent infections. Patients who met ≥3 criteria are at high risk for adjacent infection and may benefit from preoperative MRI. LEVEL OF EVIDENCE Level III—retrospective comparative study.
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Metaphyseal osteomyelitis in children: how often does MRI-documented joint effusion or epiphyseal extension of edema indicate coexisting septic arthritis? Pediatr Radiol 2015; 45:1174-81. [PMID: 25698366 DOI: 10.1007/s00247-015-3293-0] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2014] [Revised: 11/25/2014] [Accepted: 01/23/2015] [Indexed: 01/08/2023]
Abstract
BACKGROUND Joint effusions identified by MRI may accompany osteomyelitis and determining whether the joint effusion is septic or reactive has important implications on patient care. OBJECTIVE Determine the incidence of epiphyseal marrow edema, joint effusions, perisynovial edema and epiphyseal non-enhancement in the setting of pediatric metaphyseal osteomyelitis and whether this may be used to predict coexisting septic arthritis. MATERIALS AND METHODS Following IRB approval, we retrospectively evaluated children who underwent MRI and orthopedic surgical consultation for suspected musculoskeletal infection between January 2011 and September 2013. Criteria for inclusion in the study were microbiologically/pathologically proven infection, MRI prior to surgical intervention, long bone involvement and age 0-18 years. MRI exams were independently reviewed by two faculty pediatric radiologists to confirm the presence of appendicular metaphyseal osteomyelitis, to evaluate extent of edema, to determine subjective presence of a joint effusion and to assess perisynovial edema and epiphyseal non-enhancement. Any discrepant readings were reviewed in consensus. Charts and operative notes were reviewed to confirm the diagnosis of osteomyelitis and septic arthritis. RESULTS One hundred and three joints with metaphyseal osteomyelitis were identified (mean age: 7.1 years; M:F 1.3:1), of whom 53% (55/103) had joint effusions, and of those, 75% (41/55) had surgically confirmed septic arthritis. The incidence of coexisting septic arthritis was 40% in the setting of epiphyseal edema, 74% in epiphyseal edema and effusion, 75% with perisynovial edema, 76% with epiphyseal non-enhancement and 77% when all four variables were present. Of these, the only statistically significant variable, however, was the presence of a joint effusion with a P-value of <0.0001 via Fisher exact test. Statistical significance for coexisting septic arthritis was also encountered when cases were subdivided into intra-articular vs. extra-articular metaphyses (P-value = 0.0499). No statistically significant difference was found between patients younger than 24 months and those older than 24 months. CONCLUSION Patients with joint effusions identified by MRI, in the setting of metaphyseal osteomyelitis, should be presumed to have septic arthritis until proven otherwise. Epiphyseal extension of edema, perisynovial edema and epiphyseal non-enhancement in the setting of metaphyseal osteomyelitis are not helpful predictors in differentiating reactive and pyogenic joint effusions. Osteomyelitis at a site with an intra-articular metaphyses, however, is more likely to have concurrent septic arthritis.
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OARSI Clinical Trials Recommendations: Hip imaging in clinical trials in osteoarthritis. Osteoarthritis Cartilage 2015; 23:716-31. [PMID: 25952344 PMCID: PMC4430132 DOI: 10.1016/j.joca.2015.03.004] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2014] [Revised: 03/01/2015] [Accepted: 03/09/2015] [Indexed: 02/02/2023]
Abstract
Imaging of hip in osteoarthritis (OA) has seen considerable progress in the past decade, with the introduction of new techniques that may be more sensitive to structural disease changes. The purpose of this expert opinion, consensus driven recommendation is to provide detail on how to apply hip imaging in disease modifying clinical trials. It includes information on acquisition methods/techniques (including guidance on positioning for radiography, sequence/protocol recommendations/hardware for magnetic resonance imaging (MRI)); commonly encountered problems (including positioning, hardware and coil failures, artifacts associated with various MRI sequences); quality assurance/control procedures; measurement methods; measurement performance (reliability, responsiveness, and validity); recommendations for trials; and research recommendations.
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Dynamic gadolinium-enhanced MRI of the proximal femur: preliminary experience in healthy children. AJR Am J Roentgenol 2014; 203:W440-6. [PMID: 25247974 DOI: 10.2214/ajr.13.12341] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
OBJECTIVE The purpose of this study is to use dynamic contrast-enhanced MRI to evaluate the perfusion characteristics of the proximal femur in the growing skeleton. MATERIALS AND METHODS We evaluated 159 subjects (mean age, 5.67 years) who underwent a well-controlled protocol of contrast-enhanced MRI of the abdomen and hips. Perfusion and permeability parameters (enhancement ratio peak, AUC, time to peak, and rate of extraction) for six regions of the proximal femur were calculated. RESULTS A decrease with age was found for all contrast kinetics parameters in all regions (p < 0.001). Perfusion parameters differed between the regions (p < 0.001). The highest perfusion and permeability parameters were found in the metaphyseal spongiosa, metaphyseal marrow, and periosteum. The metaphyseal spongiosa had a highly vascular pattern of enhancement and showed the highest enhancement ratio peak, AUC, and rate of extraction and the lowest time to peak. The metaphyseal marrow showed a vascular pattern of enhancement with a lower peak compared with the metaphyseal spongiosa. The periosteum showed prompt nonvascular contrast enhancement that reached a plateau that remained elevated. CONCLUSION The highest enhancement was seen in areas involved with growth: the metaphyseal spongiosa, which is related to endochondral ossification, and the periosteal cambium, which is related to membranous ossification. The enhancement characteristics are radically different: in the spongiosa; enhancement is brisk and declines, with a vascular pattern, whereas contrast uptake increases with time in the periosteum. Recognition of normal enhancement patterns of the proximal femur is important for distinguishing normal development from pathologic processes.
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Budzik JF, Lefebvre G, Forzy G, El Rafei M, Chechin D, Cotten A. Study of proximal femoral bone perfusion with 3D T1 dynamic contrast-enhanced MRI: a feasibility study. Eur Radiol 2014; 24:3217-23. [PMID: 25120203 DOI: 10.1007/s00330-014-3340-5] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2013] [Revised: 05/28/2014] [Accepted: 07/10/2014] [Indexed: 12/17/2022]
Abstract
OBJECTIVE The objective of this study was to compare measurements of semi-quantitative and pharmacokinetic parameters in areas of red (RBM) and yellow bone marrow (YBM) of the hip, using an in-house high-resolution DCE T1 sequence, and to assess intra- and inter-observer reproducibility of these measurements. METHODS The right hips of 21 adult patients under 50 years of age were studied. Spatial resolution was 1.8 × 1.8 × 1.8 mm(3), and temporal resolution was 13.5 seconds. Two musculoskeletal radiologists independently processed DCE images and measured semi-quantitative and pharmacokinetic parameters in areas of YBM and RBM. Signal-to-noise (SNR) and contrast-to-noise (CNR) ratios were calculated. Intra- and inter-observer reproducibility was assessed. RESULTS Area under the curve (AUC) and initial slope (IS) were significantly greater for RBM than for YBM (p < 0.05). K(trans) and kep were also significantly greater for RBM (p < 0.05). There was no significant difference in time to peak between the regions (p < 0.05). SNR, CNR, and intra- and inter-observer reproducibility were all good. CONCLUSIONS DCE study of the whole hip is feasible with high spatial resolution using a 3D T1 sequence. Measures were possible even in low vascularized areas of the femoral head. K(trans), kep, AUC, and IS values were significantly different between red and yellow marrow, whereas TTP values were not. KEY POINTS High-spatial-resolution dynamic contrast-enhanced MRI of hip structures is feasible. Intra- and inter-observer reproducibility is good. Red and yellow bone marrow have different perfusion patterns.
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Affiliation(s)
- Jean-François Budzik
- Service d'Imagerie Médicale, Groupe Hospitalier de l'Institut Catholique de Lille / Faculté Libre de Médecine, 59000, Lille, France,
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Sarwar ZU, DeFlorio R, Catanzano TM. Imaging of Nontraumatic Acute Hip Pain in Children: Multimodality Approach With Attention to the Reduction of Medical Radiation Exposure. Semin Ultrasound CT MR 2014; 35:394-408. [DOI: 10.1053/j.sult.2014.05.001] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Magnetic resonance imaging of the hip: poor cost utility for treatment of adult patients with hip pain. Clin Orthop Relat Res 2014; 472:787-92. [PMID: 24363186 PMCID: PMC3916585 DOI: 10.1007/s11999-013-3431-7] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2013] [Accepted: 12/11/2013] [Indexed: 01/31/2023]
Abstract
BACKGROUND Although MRI is frequently used to diagnose conditions affecting the hip, its cost-effectiveness has not been defined. QUESTIONS/PURPOSES We performed this retrospective study to determine for patients 40 to 80 years old: (1) the differences in hip MRI indications between orthopaedic and nonorthopaedic practitioners; (2) the clinical indications that most commonly influence treatment decisions; (3) the likelihood that hip MRI influences treatment decisions separate from plain radiographs; and (4) the cost of obtaining hip MRI studies that influence treatment decisions (impact studies). METHODS We retrospectively assessed 218 consecutive hip MRI studies (213 patients) at one institution over a 5-year interval. Medical records, plain radiographs, and MRI studies were reviewed to determine how frequently individual MRI findings determined treatment recommendations (impact study). The cost estimate of an impact study was calculated from the product of institutional MRI unit cost (USD 436) and the proportion of impact studies relative to all studies obtained either for a specific indication or by an orthopaedic/nonorthopaedic clinician. RESULTS Nonorthopaedic clinicians more frequently ordered hip MRI without a clinical diagnosis (72% versus 30%, p < 0.01), before plain radiographs (29% versus 3%, p < 0.001), and with less frequent impact on treatment (6% versus 15%, p < 0.05). Hip MRI most frequently influenced treatment when assessing for a tumor (58%, p < 0.001) or infection (40%, p < 0.001) and least frequently when assessing for pain (1%, p < 0.002). Hip MRI impacted a treatment decision independent of plain radiographic findings in only 7% of studies (3% surgical, 4% nonsurgical). Hip MRI cost was least when assessing for a neoplasm (USD 750) and greatest when assessing undefined hip pain (USD 59,000). The cost of obtaining an impact study was also less when the ordering clinician was an orthopaedic clinician (USD 2800) than a nonorthopaedic clinician (USD 7800). CONCLUSIONS Although MRI can be valuable for diagnosing or staging specific conditions, it is not cost-effective as a screening tool for hip pain that is not supported by history, clinical examination, and plain radiographic findings in patients between 40 and 80 years of age. LEVEL OF EVIDENCE Level IV, economic and decision analysis study. See Instructions for Authors for a complete description of levels of evidence.
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Abstract
Transient synovitis is a benign, self-limiting condition that is diagnosed after the exclusion of more serious causes of acute hip pain in children. Although its etiology remains unclear, it is largely believed to be viral in nature. Transient synovitis typically presents as an acute onset of thigh pain with a limp or an unwillingness to bear weight. It can be distinguished from similar conditions by the absence of fever, as well as unremarkable bloodwork (WBC, CRP, ESR), radiographs, and hip aspiration. Conservative treatment and observation are the mainstay of management. Resolution of symptoms generally occurs by 1 week and may be accelerated by NSAIDs. Although numerous papers have emerged over the years with an effort to advance our understanding, many questions remain about its pathomechanics, etiology, and how to exclude other more serious conditions that present similarly.
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Radiological approach to a child with hip pain. Clin Radiol 2013; 68:1167-78. [DOI: 10.1016/j.crad.2013.06.016] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2013] [Revised: 06/11/2013] [Accepted: 06/18/2013] [Indexed: 11/17/2022]
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