Publications by authors named "Megan K Mills"

23 Publications

  • Page 1 of 1

Factors Influential in the Selection of Radiology Residents in the Post-Step 1 World: A Discrete Choice Experiment.

J Am Coll Radiol 2021 Jul 29. Epub 2021 Jul 29.

Department of Radiology, Duke University Medical Center, Durham, North Carolina.

Objectives: Reporting of United States Medical Licensing Examination Step 1 results will transition from a numerical score to a pass-or-fail result. We sought an objective analysis to determine changes in the relative importance of resident application attributes when numerical Step 1 results are replaced.

Methods: A discrete choice experiment was designed to model radiology resident selection and determine the relative weights of various application factors, when paired with a numerical or pass-or-fail Step 1 result. Faculty involved in resident selection at 14 US radiology programs chose between hypothetical pairs of applicant profiles between August and November 2020. A conditional logistic regression model assessed the relative weights of the attributes and odds ratios (ORs) were calculated.

Results: There were 212 participants. When a numerical Step 1 score was provided, the most influential attributes were medical school (OR: 2.35, 95% confidence interval [CI]: 2.07-2.67), Black or Hispanic race or ethnicity (OR: 2.04, 95% CI: 1.79-2.38), and Step 1 score (OR: 1.8, 95% CI: 1.69-1.95). When Step 1 was reported as pass, the applicant's medical school grew in influence (OR: 2.78, 95% CI: 2.42-3.18), and there was a significant increase in influence of Step 2 scores (OR: 1.31, 95% CI: 1.23-1.40 versus OR 1.57, 95% CI: 1.46-1.69). There was little change in the relative influence of race or ethnicity, gender, class rank, or clerkship honors.

Discussion: When Step 1 reporting transitions to pass or fail, medical school prestige gains outsized influence and Step 2 scores partly fill the gap left by Step 1 examination as a single metric of decisive importance in application decisions.
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http://dx.doi.org/10.1016/j.jacr.2021.07.005DOI Listing
July 2021

Comparative assessment of midfoot osteoarthritis diagnostic sensitivity using weightbearing computed tomography vs weightbearing plain radiography.

Eur J Radiol 2021 Jan 21;134:109419. Epub 2020 Nov 21.

Department of Orthopaedics, University of Utah, 590 Wakara Way, Salt Lake City, UT 84108, USA; Department of Orthopaedics, Trauma and Reconstructive Surgery, University of Hamburg, Martinistrasse 52, 20246 Hamburg, Germany. Electronic address:

Purpose: Accuracy in diagnosing osteoarthritis in the midfoot using weightbearing plain radiography (WBPR) remains questionable due to the overlapping osseous architecture present, occluding visualization. Weightbearing computed tomography (WBCT), providing clearer bony landmark identification and joint space visualization, can also be used for evaluation. The aim of this project is to perform a standardized retrospective intra-patient analysis identifying the discrepancy of midfoot osteoarthritis diagnosis and osteoarthritis severity grading between WBPR and WBCT.

Methods And Materials: A cohort of 302 patient feet was acquired from an internal, consecutive patient database using detailed inclusion criteria. The musculoskeletal radiologist interpretation of the WBCT and WBPR of each specimen was then assessed for any direct diagnosis or mention of osteoarthritic signs in specific articulations of 3 midfoot joint groups (Chopart, "central", and tarsometatarsal). WBPR sensitivity and specificity metrics were calculated with WBCT considered the gold standard for comparison.

Results: From the WBPR radiologist interpretation, we found diagnostic sensitivity of 72.5 % and specificity of 87.9 % for Chopart joints; 61.5 % sensitivity, and 96.1 % specificity for central joints; and 68.4 % sensitivity, and 92.9 % specificity for tarsometatarsal joints. The severity of degenerative changes was also consistently underestimated when interpreted from WBPR relative to WBCT.

Conclusions: In this series, midfoot osteoarthritis was often undetected on WBPR. WBCT imaging facilitates an earlier, more reliable diagnosis and grading of midfoot osteoarthritis relative to WBPR.
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http://dx.doi.org/10.1016/j.ejrad.2020.109419DOI Listing
January 2021

MRI of the Wrist Ligaments.

Top Magn Reson Imaging 2020 Oct;29(5):209-220

Department of Radiology and Imaging Sciences, University of Utah, Salt Lake City, UT.

Technological advances in magnetic resonance imaging (MRI) have improved radiologists' ability to evaluate wrist ligaments. MRI interpretation often guides clinical management. This article aims to review the normal and pathologic appearance of intrinsic and extrinsic wrist ligaments with a focus on MRI. Variant anatomy, imaging pearls, and clinical significance are also discussed. Special attention is paid to key wrist ligaments that play a role in carpal stability.
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http://dx.doi.org/10.1097/RMR.0000000000000251DOI Listing
October 2020

Percutaneous image-guided sternal biopsy: a cross-institutional retrospective review of diagnostic yield and safety in 50 cases.

Skeletal Radiol 2021 Mar 19;50(3):495-504. Epub 2020 Aug 19.

Oregon Health and Science University, 3181 SW Sam Jackson Park Rd, Portland, OR, 97239, USA.

Objective: Image-guided sternal biopsy may be technically daunting given the immediately subjacent critical structures. There is a paucity of literature describing technique, safety, and efficacy. This study aims to quantify the diagnostic yield and safety of image-guided sternal biopsies. Secondary aims include (1) describing the preferred approach/technique and (2) identifying imaging features and disease entities associated with higher and lower diagnostic yields.

Materials And Methods: A retrospective review of 50 image-guided sternal biopsies performed at two quaternary care centers from 2000 to 2019 was performed. Recorded lesion-related variables included as follows: location, density, extraosseous extension, and size. Recorded variables from electronic medical records included as follows: patient demographics, histologic or microbiological diagnosis, and complications. Recorded technique-related variables included as follows: needle obliquity, type, and gauge; biopsy core number and length; and modality.

Results: Of the 50 biopsies, 88.0% resulted in a definitive histologic diagnosis. Six biopsies were non-diagnostic. The majority of biopsies were performed under computed tomography (88.0%), followed by ultrasound (12.0%). Tumor was the most common biopsy indication (90.0%), followed by infection (10.0%). Of the diagnostic biopsies indicated for tumor, 88.9% were malignant. Seventy-four percent of the lesions were predominantly lytic. Fifty percent of lesions had extraosseous extension. Lesion locations were as follows: manubrium (48.0%), sternal body (48.0%), and sternomanubrial joint (4.0%). No minor or major, acute, or delayed procedure-related complications were encountered.

Conclusion: Image-guided sternal biopsy is an efficacious and safe method of obtaining a definitive histologic diagnosis regardless of lesion-specific features or location.
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http://dx.doi.org/10.1007/s00256-020-03587-6DOI Listing
March 2021

Septic Arthritis: An Evidence-Based Review of Diagnosis and Image-Guided Aspiration.

AJR Am J Roentgenol 2020 09 12;215(3):568-581. Epub 2020 Aug 12.

Department of Radiology and Imaging Sciences, University of Utah School of Medicine, 30 N 1900 E, Rm 1A071, Salt Lake City, UT 84132-2140.

The purpose of this evidence-based review is to equip radiologists to discuss and interpret findings obtained with various imaging modalities, guide patient selection for percutaneous aspiration, and safely perform arthrocentesis to assess for infection in both native and prosthetic joints. Septic arthritis is an emergency that can lead to rapidly progressive, irreversible joint damage. Despite the urgency associated with this diagnosis, there remains a lack of consensus regarding many aspects of the management of native and periprosthetic joint infections.
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http://dx.doi.org/10.2214/AJR.20.22773DOI Listing
September 2020

Asymmetric lambda sign of the second tarsometatarsal joint on axial weight-bearing cone-beam CT scans of the foot: preliminary investigation for diagnosis of subtle ligamentous Lisfranc injuries in a cadaveric model.

Skeletal Radiol 2020 Oct 11;49(10):1615-1621. Epub 2020 May 11.

Department of Orthopaedics, University of Utah, 590 Wakara Way, Salt Lake City, UT, 84108, USA.

Background: Subtle Lisfranc joint injuries remain challenging to diagnose. Although of questionable accuracy, the current gold standard to assess these injuries is through bilateral weight-bearing radiography. However, weight-bearing cone beam-computed tomography (CBCT), providing clearer visualization of bony landmarks, can also be utilized for evaluation. This study aims to establish the hypothesis that a specific weight-bearing CBCT finding (asymmetric lambda sign) can serve as an independent indicator of a subtle Lisfranc injury.

Methods: Weight-bearing CBCT images of 24 match-paired cadaveric legs were acquired, initially intact, and then following sequential dissection of each aspect (dorsal, interosseous, and plantar ligaments, respectively) of the Lisfranc ligamentous complex (LLC). All scans were taken in non- (NWB, 0 kg), partial- (PWB, 40 kg), and full-weight-bearing (FWB, 80 kg) manners. The lambda sign was then inspected axially for asymmetry (positive sign) by identifying three symmetrical joint spaces created between the medial cuneiform and the second metatarsal base (C1-M2), the medial and middle cuneiform (C1-C2), and the second metatarsal base and middle cuneiform (M2-C2).

Results: A positive sign was observed in 25.6% (221/864) of all studies. Most notably, the fully dissected specimens demonstrated an asymmetric lambda sign in 33.3%, 72.2%, and 83.3% in NWB, PWB, and FWB conditions, respectively. The inter- and intra-observer reliability kappa value was calculated to be 0.843 and 0.912.

Conclusion: An asymmetric lambda sign is a simple and useful indicator for a complete LLC injury in PWB and FWB conditions using a cadaver model.
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http://dx.doi.org/10.1007/s00256-020-03445-5DOI Listing
October 2020

Seeing isn't necessarily believing: Misleading contextual information influences perceptual-cognitive bias in radiologists.

J Exp Psychol Appl 2020 Dec 23;26(4):579-592. Epub 2020 Apr 23.

Department of Health, Kinesiology, and Recreation.

A substantial number of medical errors in radiology are attributed to failures of perception or decision making, although it is believed that experience (or expertise) might buffer diagnosticians from some types of perceptual-cognitive bias. We examined how the quality of contextual information influences decision making and how underlying perceptual-cognitive processes change as a function of experience and diagnostic accuracy. Twenty-one radiologists dictated their findings on 16 deidentified musculoskeletal radiographic cases while wearing a mobile-eye tracking system. Patient histories were mismatched on a subset of cases to be miscued relative to the correct diagnosis. Experienced radiologists outperformed less-experienced participants, but no systematic differences in gaze behaviors emerged between groups. Miscued case notes increased perceptual-cognitive bias in both groups, resulting in an approximate 40% decrease in diagnostic accuracy. Most errors were judgment errors, meaning participants visually fixated on the abnormality for longer than a second yet still failed to make the correct diagnosis. Findings suggest a physician's confidence in their diagnosis might be misplaced after spending insufficient time extracting relevant information from key areas of the visual display, or when decisions are based primarily on a priori expectations derived from patient histories. (PsycInfo Database Record (c) 2020 APA, all rights reserved).
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http://dx.doi.org/10.1037/xap0000274DOI Listing
December 2020

Pearls and Pitfalls for Soft-Tissue and Bone Biopsies: A Cross-Institutional Review.

Radiographics 2020 Jan-Feb;40(1):266-290

From the Department of Diagnostic Radiology, Oregon Health and Science University, 3181 SW Sam Jackson Park Rd, Portland, OR, 97239 (R.D.M., B.R.B., S.S., B.G.H.); Department of Radiology and Imaging Sciences, University of Utah, Salt Lake City, Utah (M.K.M., C.J.H., R.L.L., H.A.); Department of Diagnostic Radiology, University of Pittsburgh Medical Center, Pittsburgh, Pa (D.D.W.); and private practice, Eugene, Ore (M.T.).

Management of soft-tissue and bone neoplasms depends on a definitive histologic diagnosis. Percutaneous image-guided biopsy of bone and soft-tissue tumors is a cost-effective and accurate method to obtain a histopathologic diagnosis. Biopsy requests must be approached thoughtfully to avoid numerous potential pitfalls. Hasty biopsy planning places the patient at increased risk for misdiagnosis, delayed therapy, repeated invasive procedures, and substantial morbidity. Biopsy planning begins with a thorough review of the relevant clinical history and pertinent imaging. The biopsy route must be planned in concert with the referring orthopedic oncologist to preserve limb-sparing options. Carefully selecting the most appropriate imaging modality to guide the biopsy increases the chances of reaching a definitive diagnosis. It is also critical to identify and target with expertise the part of the lesion that is most likely to yield an accurate diagnosis. Percutaneous biopsy is a safe procedure, and familiarity with preprocedural laboratory testing parameters, anticoagulation guidelines, and commonly used sedation medications minimizes the risk of complications while ensuring patient comfort. Nondiagnostic biopsy results are not infrequent and may still have value in guiding patient treatment. Awareness of the imaging manifestations of tumor recurrence is also important. The aim of this article is to provide a comprehensive review of pertinent preprocedural, periprocedural, and postprocedural considerations for bone and soft-tissue musculoskeletal biopsies. RSNA, 2020.
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http://dx.doi.org/10.1148/rg.2020190089DOI Listing
February 2021

Avulsion Injuries of the Hand and Wrist.

Radiographics 2020 Jan-Feb;40(1):163-180

From the Department of Radiology and Imaging Sciences, University of Utah, 30 N 1900 E #1A071, Salt Lake City, UT 84132 (M.D.W., S.E.S., H.A., R.L.L., C.J.H., B.Y.C., M.S., P.K., M.K.M.); and Department of Diagnostic Radiology, Oregon Health and Science University, Portland, Ore (B.G.H.).

Injuries of the hand and wrist are frequently encountered in radiology. Avulsions of the hand and wrist are a heterogeneous group of injuries, but they often have a characteristic imaging appearance that relates to the intricate bone and soft-tissue anatomy and the mechanism of injury. The imaging appearance and this intricate form and function dictate treatment of hand and wrist avulsions. This article reviews frequently and infrequently encountered avulsion injuries and describes abnormalities that may mimic the imaging appearance of avulsions. Specifically discussed entities include the Bennett and reverse Bennett fracture, ulnar collateral ligament avulsion, radial and ulnar styloid process avulsion, triquetral avulsion, mallet and jersey finger, central slip avulsion, and acute and chronic volar plate avulsion injuries. Uncommon avulsion injuries are also described and include avulsions of the scapholunate ligament, extensor carpi radialis longus and brevis tendons, trapeziometacarpal ligament, radial collateral ligament, and flexor digitorum profundus tendon. Emphasis is placed on the relevant anatomy and typical imaging findings for each diagnosis, with pertinent clinical history, pathophysiologic evaluation, and treatment discussed briefly. Understanding the anatomy and expected imaging findings can aid the radiologist in recognizing and characterizing these injuries.RSNA, 2020.
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http://dx.doi.org/10.1148/rg.2020190085DOI Listing
February 2021

Perceptual training: learning versus attentional shift.

J Med Imaging (Bellingham) 2020 Mar 31;7(2):022407. Epub 2019 Dec 31.

University of Utah School of Medicine, Department of Radiology and Imaging Sciences, Salt Lake City, Utah, United States.

Prior research has demonstrated that perceptual training can improve the ability of healthcare trainees in identifying abnormalities on medical images, but it is unclear if the improved performance is due to learning or attentional shift-the diversion of perceptional resources away from other activities to a specified task. Our objective is to determine if research subject performance in perceiving the central venous catheter position on radiographs is improved after perceptional training and if improved performance is due to learning or an attentional shift. Forty-one physician assistant students were educated on the appropriate radiographic position of central venous catheters and then asked to evaluate the catheter position in two sets of radiographic cases. The experimental group was provided perceptional training between case sets one and two. The control group was not. Participants were asked to characterize central venous catheters for appropriate positioning (task of interest) and to assess radiographs for cardiomegaly (our marker for attentional shift). Our results demonstrated increased confidence in localization in the experimental group ( -value ) but not in the control group ( ). The ability of subjects to locate the catheter tip significantly improved in both control and experimental groups. Both the experimental ( ) and control groups ( ) demonstrated equivalent decreased performance in assessing cardiomegaly; the difference between groups was not significant ( ). This suggests the performance improvement was secondary to learning not due to an attentional shift.
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http://dx.doi.org/10.1117/1.JMI.7.2.022407DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6938212PMC
March 2020

Imaging in Lisfranc injury: a systematic literature review.

Skeletal Radiol 2020 Jan 31;49(1):31-53. Epub 2019 Jul 31.

Department of Orthopedics, University of Utah, 590 Wakara Way, Salt Lake City, UT, 84108, USA.

Objectives: To systematically review current diagnostic imaging options for assessment of the Lisfranc joint.

Materials And Methods: PubMed and ScienceDirect were systematically searched. Thirty articles were subdivided by imaging modality: conventional radiography (17 articles), ultrasonography (six articles), computed tomography (CT) (four articles), and magnetic resonance imaging (MRI) (11 articles). Some articles discussed multiple modalities. The following data were extracted: imaging modality, measurement methods, participant number, sensitivity, specificity, and measurement technique accuracy. Methodological quality was assessed by the QUADAS-2 tool.

Results: Conventional radiography commonly assesses Lisfranc injuries by evaluating the distance between either the first and second metatarsal base (M1-M2) or the medial cuneiform and second metatarsal base (C1-M2) and the congruence between each metatarsal base and its connecting tarsal bone. For ultrasonography, C1-M2 distance and dorsal Lisfranc ligament (DLL) length and thickness are evaluated. CT clarifies tarsometatarsal (TMT) joint alignment and occult fractures obscured on radiographs. Most MRI studies assessed Lisfranc ligament integrity. Overall, included studies show low bias for all domains except patient selection and are applicable to daily practice.

Conclusions: While conventional radiography can demonstrate frank diastasis at the TMT joints; applying weightbearing can improve the viewer's capacity to detect subtle Lisfranc injury by radiography. Although ultrasonography can evaluate the DLL, its accuracy for diagnosing Lisfranc instability remains unproven. CT is more beneficial than radiography for detecting non-displaced fractures and minimal osseous subluxation. MRI is clearly the best for detecting ligament abnormalities; however, its utility for detecting subtle Lisfranc instability needs further investigation. Overall, the available studies' methodological quality was satisfactory.
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http://dx.doi.org/10.1007/s00256-019-03282-1DOI Listing
January 2020

Practical Approach and Review of Brachial Plexus Pathology With Operative Correlation: What the Radiologist Needs to Know.

Semin Roentgenol 2019 Apr 13;54(2):92-112. Epub 2018 Oct 13.

Department of Radiology and Imaging Sciences, University of Utah School of Medicine, Salt Lake City, UT. Electronic address:

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http://dx.doi.org/10.1053/j.ro.2018.10.002DOI Listing
April 2019

Pearls and pitfalls of fluoroscopic-guided foot and ankle injections: what the radiologist needs to know.

Skeletal Radiol 2019 Nov 6;48(11):1661-1674. Epub 2019 May 6.

University of Michigan Health System, 1500 E. Medical Center Dr, TC2910Q, Ann Arbor, MI, 48109, USA.

Objective: This article provides a comprehensive, joint-by-joint review of fluoroscopic-guided foot and ankle injections and emphasizes pre-procedural planning, relevant anatomy, appropriate technique, troubleshooting the difficult procedure, and the importance of communicating unexpected findings with the referring clinician. The interrogation of pain generators including variant ossicles, fractures, and post-surgical/traumatic findings is also described.

Conclusions: Even the most challenging foot and ankle injections may be successfully completed with a solid anatomical understanding and thoughtful approach.
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http://dx.doi.org/10.1007/s00256-019-03226-9DOI Listing
November 2019

Spinal Marrow Imaging: Clues to Disease.

Radiol Clin North Am 2019 Mar 17;57(2):359-375. Epub 2018 Nov 17.

Department of Radiology and Imaging Sciences, University of Utah, 30 North 1900 East #1A071, Salt Lake City, UT 84132, USA.

Benign and malignant as well as focal and diffuse disease processes can involve the spinal marrow. This is a review of the commonly encountered spinal marrow abnormalities and the distinguishing magnetic resonance features that may provide clues to disease.
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http://dx.doi.org/10.1016/j.rcl.2018.09.008DOI Listing
March 2019

Naviculocuneiform and Second and Third Tarsometatarsal Articulations: Underappreciated Normal Anatomy and How It May Affect Fluoroscopy-Guided Injections.

AJR Am J Roentgenol 2019 04 23;212(4):874-882. Epub 2019 Jan 23.

2 Department of Radiology and Imaging Sciences, University of Utah, Salt Lake City, UT.

Objective: Because the second and third tarsometatarsal (TMT) and naviculocuneiform joints normally communicate, the least arthritic or technically most straightforward joint was injected when a fluoroscopically guided therapeutic injection was ordered for one or both joints. We hypothesized that pain relief would be equivalent regardless of the joint injected and would result in less radiation and a lower steroid dose compared with patients who had both articulations injected.

Materials And Methods: Seventy-eight patients were divided into four joint groups: naviculocuneiform requested and injected (n = 15), nonrequested naviculocuneiform or second and third TMT injected (n = 25), both injected (n = 23), and TMT requested and injected (n = 15). Variables recorded included patient age and sex, fluoroscopy time, steroid dose, pre- and postprocedural pain, osteoarthrosis (OA) grade, and confidence of intraarticular injection. Statistical analysis compared mean pain level change before and after injection, mean fluoroscopy time, and mean steroid dose between groups. The mean OA grade of the nonrequested joint was compared with that of the requested joint in patients whose injected and requested joints did not match (group 2).

Results: Pre- and postinjection pain reduction (p = 0.630) and postinjection pain (p = 0.935) were not significantly different. Mean steroid dose (p < 0.001) and fluoroscopy time (p = 0.0001) were significantly increased for the both joint injection group. Within the nonrequested naviculocuneiform or second and third TMT injection group, there was a significant difference in OA grade between injected (least arthritic) and requested joints (p = 0.001).

Conclusion: When faced with challenging naviculocuneiform or second and third TMT joint injections, choosing the technically most straightforward joint may result in less radiation and steroid dose without compromising quality of care or pain reduction.
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http://dx.doi.org/10.2214/AJR.18.20347DOI Listing
April 2019

Currently used imaging options cannot accurately predict subtalar joint instability.

Knee Surg Sports Traumatol Arthrosc 2019 Sep 26;27(9):2818-2830. Epub 2018 Oct 26.

Department of Orthopaedics, University of Utah, 590 Wakara Way, Salt Lake City, UT, 84108, USA.

Purpose: To give a systematic overview of current diagnostic imaging options and surgical treatment for chronic subtalar joint instability.

Methods: A systematic literature search across the following sources was performed: PubMed, ScienceDirect, and SpringerLink. Twenty-three imaging studies and 19 outcome studies were included. The Quality Assessment of Diagnostic Accuracy Studies 2 (QUADAS 2) tool was used to assess the methodologic quality of the imaging articles, while the modified Coleman Score was used to assess the methodologic quality of the outcome studies.

Results: Conventional radiographs were most frequently used to assess chronic subtalar joint instability. Talar tilt, anterior talar translation, and subtalar tilt were the three most commonly used measurement methods. Surgery often included calcaneofibular ligament reconstruction.

Conclusion: Current imaging options do not reliably predict subtalar joint instability. Distinction between chronic lateral ankle instability and subtalar joint instability remains challenging. Recognition of subtalar joint instability as an identifiable and treatable cause of ankle pain requires vigilant clinical investigation.

Level Of Evidence: Systematic Review of Level III and Level IV Studies, Level IV.
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http://dx.doi.org/10.1007/s00167-018-5232-8DOI Listing
September 2019

Lymphangiomatosis: a rare entity presenting with involvement of the sacral plexus.

Skeletal Radiol 2018 Sep 21;47(9):1293-1297. Epub 2018 Feb 21.

Department of Radiology, University of Utah Health Sciences Center, 30 North 1900 East #1A071, Salt Lake City, UT, 84132-2140, USA.

Lymphangiomatosis is an uncommon disease process characterized by multisystem lymphatic malformations that can involve numerous body systems, including organs, muscles, soft tissues, and bones. Involvement of the nervous system is rare and has even been previously described as a site of sparing. We present a case of a 24-year-old female with known lymphangiomatosis, presenting with acute onset of lower extremity paresthesias, weakness, and new urinary retention. MRI of the pelvis revealed lymphangiomatosis of the sacral plexus, which has not been previously reported. We will review the clinical and imaging manifestations of lymphangiomatosis and provide a differential diagnosis for masses of the lumbosacral plexus. Although lower extremity pain and weakness encountered in the emergency department or outpatient setting is most frequently caused by lumbar spine pathology, occasionally, abnormalities of the lumbosacral plexus may prove to be the cause. While peripheral nerve sheath tumors lead the differential diagnosis of tumor or tumor-like entities involving the lumbosacral plexus, lymphangiomatosis is a rare differential consideration.
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http://dx.doi.org/10.1007/s00256-018-2903-yDOI Listing
September 2018

Imaging in syndesmotic injury: a systematic literature review.

Skeletal Radiol 2018 May 30;47(5):631-648. Epub 2017 Nov 30.

Department of Orthopaedics, University of Utah, 590 Wakara Way, Salt Lake City, UT, 84108, USA.

Objectives: To give a systematic overview of current diagnostic imaging options for assessment of the distal tibio-fibular syndesmosis.

Materials And Methods: A systematic literature search across the following sources was performed: PubMed, ScienceDirect, Google Scholar, and SpringerLink. Forty-two articles were included and subdivided into three groups: group one consists of studies using conventional radiographs (22 articles), group two includes studies using computed tomography (CT) scans (15 articles), and group three comprises studies using magnet resonance imaging (MRI, 9 articles).The following data were extracted: imaging modality, measurement method, number of participants and ankles included, average age of participants, sensitivity, specificity, and accuracy of the measurement technique. The Quality Assessment of Diagnostic Accuracy Studies 2 (QUADAS-2) tool was used to assess the methodological quality.

Results: The three most common techniques used for assessment of the syndesmosis in conventional radiographs are the tibio-fibular clear space (TFCS), the tibio-fibular overlap (TFO), and the medial clear space (MCS). Regarding CT scans, the tibio-fibular width (axial images) was most commonly used. Most of the MRI studies used direct assessment of syndesmotic integrity. Overall, the included studies show low probability of bias and are applicable in daily practice.

Conclusions: Conventional radiographs cannot predict syndesmotic injuries reliably. CT scans outperform plain radiographs in detecting syndesmotic mal-reduction. Additionally, the syndesmotic interval can be assessed in greater detail by CT. MRI measurements achieve a sensitivity and specificity of nearly 100%; however, correlating MRI findings with patients' complaints is difficult, and utility with subtle syndesmotic instability needs further investigation. Overall, the methodological quality of these studies was satisfactory.
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http://dx.doi.org/10.1007/s00256-017-2823-2DOI Listing
May 2018

Less Is More: Efficacy of Rapid 3D-T2 SPACE in ED Patients with Acute Atypical Low Back Pain.

Acad Radiol 2017 08 3;24(8):988-994. Epub 2017 Apr 3.

Department of Radiology, University of Utah Health Sciences Center, 30 North 1900 East #1A071, Salt Lake City, UT 84132-2140.

Rationale And Objectives: Emergency department (ED) patients with acute low back pain (LBP) may present with ambiguous clinical findings that pose diagnostic challenges to exclude cauda equina syndrome (CES). As a proof of concept, we aimed to determine the efficacy of a rapid lumbar spine (LS) magnetic resonance imaging (MRI) screening protocol consisting of a single 3D-T2 SPACE FS (3D-T2 Sampling Perfection with Application optimized Contrasts using different flip angle Evolution fat saturated) sequence relative to conventional LS MRI to exclude emergently treatable pathologies in this complex patient population.

Materials And Methods: LS MRI protocol including a sagittal 3D-T2 SPACE FS pulse sequence was added to the routine for ED patients presenting with acute atypical LBP over a 12-month period. Imaging findings were categorically scored on the 3D-T2 SPACE FS sequence and separately on the reference standard conventional LS MRI sequences. Patients' symptoms were obtained from review of the electronic medical record. Descriptive test statistics were performed.

Results: Of the 206 ED patients who obtained MRI for acute atypical LBP, 118 (43.3 ± 13.5 years of age; 61 female) were included. Specific pathologies detected on reference standard conventional MRI included disc herniation (n = 30), acute fracture (n = 3), synovial cyst (n = 3), epidural hematoma (n = 2), cerebrospinal fluid leak (n = 1), and leptomeningeal metastases (n = 1), and on multiple occasions these pathologies resulted in nerve root impingement (n = 36), severe spinal canal stenosis (n = 13), cord/conus compression (n = 2), and cord signal abnormality (n = 2). The 3D-T2 SPACE FS sequence was an effective screen for fracture (sensitivity [sens] = 100%, specificity [spec] = 100%), cord signal abnormality (sens = 100%, spec = 99%), and severe spinal canal stenosis (sens = 100%, spec = 96%), and identified cord compression not seen on reference standard. Motion artifact was not seen on the 3D-T2 SPACE FS but noted on 8.5% of conventional LS MRI.

Conclusions: The 3D-T2 SPACE FS sequence MRI is a rapid, effective screen for emergently actionable pathologies that might be a cause of CES in ED patients presenting with acute atypical LBP. As this abbreviated, highly sensitive sequence requires a fraction of the acquisition time of conventional LS MRI, it has the potential of contributing to increased efficiencies in the radiology department and improved ED throughput.
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http://dx.doi.org/10.1016/j.acra.2017.02.011DOI Listing
August 2017

Postoperative Imaging in the Setting of Hip Preservation Surgery.

Radiographics 2016 Oct;36(6):1746-1758

From the Department of Musculoskeletal Imaging and Intervention (M.K.M., C.D.S., M.K.J., P.A.L., J.A.F.) and Department of Sports Medicine (O.M.D.), University of Colorado School of Medicine, Aurora, Colo.

Osteoarthritis of the hip remains a prevalent disease condition that influences ever-changing treatment options. Procedures performed to correct anatomic variations, and, in turn, prevent or slow the progression of osteoarthritis, are aptly referred to as types of hip preservation surgery (HPS). Conditions that predispose individuals to femoroacetabular impingement (FAI), including pincer- and cam-type morphology, and hip dysplasia are specifically targeted in HPS. Common surgical interventions include acetabuloplasty, osteochondroplasty, periacetabular osteotomy (PAO), and derotational femoral osteotomy (DFO). The radiologist's understanding of the surgical approach, pre- and postoperative imaging findings, and common complications of HPS are paramount to providing value to the patient and surgeon. Acetabuloplasty and osteochondroplasty are performed to address pincer- and cam-type morphology in patients with FAI. With both of these HPS techniques, the goal is to restore the normal morphology by resecting excess bone in the acetabulum or femoral head or neck. As a result, a frequently encountered complication is incomplete or excessive resection. Excessive resection can predispose the patient to dislocation in the case of acetabuloplasty and fracture in the case of osteochondroplasty. Iatrogenic injury to adjacent structures such as the ischiofemoral ligament and acetabular cartilage also may occur. Although rare, especially when an arthroscopic approach is used, avascular necrosis remains a risk. Femoral head undercoverage in hip dysplasia is corrected by using PAO, which may be performed as the sole procedure or in conjunction with DFO. Incomplete or excessive rotation during surgery can result in postprocedural complications. As with any orthopedic procedure involving osteotomy, nonhealing is a risk. Iatrogenic injury in the form of fracture or hardware failure also may be seen. RSNA, 2016.
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http://dx.doi.org/10.1148/rg.2016160021DOI Listing
October 2016

Imaging of the perivertebral space.

Radiol Clin North Am 2015 Jan 11;53(1):163-80. Epub 2014 Oct 11.

Department of Radiology, University of Utah, 30 North 1900 East #1A071, Salt Lake City, UT 84132, USA.

The perivertebral space extends from the skull base to the mediastinum and is delineated by the deep layer of the deep cervical fascia. The different tissue types, including muscles, bones, nerves, and vascular structures, give rise to the various disorders that can be seen in this space. This article defines the anatomy of the perivertebral space, guides lesion localization, discusses different disease processes arising within this space, and reviews the best imaging approaches.
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http://dx.doi.org/10.1016/j.rcl.2014.09.008DOI Listing
January 2015

Outcomes from treatment of necrotizing soft-tissue infections: results from the National Surgical Quality Improvement Program database.

Am J Surg 2010 Dec;200(6):790-6; discussion 796-7

Department of Surgery, 3B-306, University of Utah, Health Center, Salt Lake City, UT 84132, USA.

Background: Necrotizing soft-tissue infections (NSTIs) are a group of uncommon, rapidly progressive, potentially fatal disorders. The National Surgical Quality Improvement Program (NSQIP) Registry was used to determine current data on the incidence, treatment, and outcomes of NSTIs.

Methods: There were 688 NSTI cases identified for years 2005 to 2008. Ten control patients for each NSTI patient were also selected. Demographic, laboratory, and outcome data were collected to compare both groups.

Results: Evidence of systemic inflammatory response syndrome (SIRS), sepsis, or septic shock occurred in 83% of NSTI cases. Mortality was 12% for NSTI patients versus 2% for controls. Regression analysis showed that age, emergent surgery, transfer from an outside hospital, sepsis, and several comorbid diseases correlated with mortality but not sex or diabetes. Direct admission was associated with reduced mortality.

Conclusions: NSTIs are seen regularly in academic centers, and their incidence may be increasing. Despite a high incidence of comorbid conditions and frequent presentation with sepsis, mortality is lower than previously reported, reflecting ongoing progress in the treatment of these disorders at NSQIP hospitals.
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http://dx.doi.org/10.1016/j.amjsurg.2010.06.008DOI Listing
December 2010

Decompressive laparotomy for abdominal compartment syndrome in children: before it is too late.

J Pediatr Surg 2010 Jun;45(6):1324-9

Department of Surgery, University of Utah, Salt Lake City, UT 84113, USA.

Purpose: Abdominal compartment syndrome (ACS) in children is an infrequently reported, rapidly progressive, and often lethal condition underappreciated in the pediatric population. This underrecognition can result in a critical delay in diagnosis causing increased morbidity and mortality. This study examines the clinical course of patients treated for ACS at our institution.

Methods: A review of children requiring an emergency laparotomy (n = 264) identified 26 patients with a diagnosis of ACS. ACS was defined as sustained intraabdominal hypertension (bladder pressure >12 mm Hg) that was associated with new onset organ dysfunction or failure.

Results: Patients ranged in age from 3 months to 17 years old and were cared for in the pediatric intensive care unit (PICU). Twenty-seven percent (n = 7) were transferred from referring hospitals, 50% (n = 13) were admitted directly from the emergency department, and 23% (n = 6) were inpatients before being transferred to PICU. Admission diagnoses included infectious enterocolitis (n = 12), postsurgical procedure (n = 10), and others (n = 4). Patients progressed to ACS rapidly, with most requiring decompressive laparotomy within 8 hours of PICU admission (range, <1-96 hours). Preoperatively, all patients had maximum ventilatory support and oliguria, 85% (n = 22) required vasopressors/inotropes, and 31% (n = 8) required hemodialysis. Mean bladder pressure was 25 mm Hg (range, 12-44 mm Hg). In 42% (n = 11), cardiac arrest preceeded decompressive laparotomy. All patients showed evidence of tissue ischemia before decompressive laparotomy with an average preoperative lactate of 8 (range, 1.2-20). Decompressive laparotomy was done at the bedside in the PICU in 13 patients and in the operating room in 14 patients. Abdominal wounds were managed with open vacuum pack or silastic silo dressings. Physiologic data including fluid resuscitation, oxygen index, mean airway pressure, vasopressor score, and urine output were recorded at 6-hour intervals beginning 12 hours before decompressive laparotomy and extending 12 hours after operation. The data demonstrate improvement of all physiologic parameters after decompressive laparotomy except for urine output, which continued to be minimal 12 hours post intervention. Mortality was 58% (n = 15) overall. The only significant factor related to increased mortality was bladder pressure (P = .046; odds ratio, 1.258). Cardiac arrest before decompressive laparotomy, need for hemodialysis, and transfer from referring hospital also trended toward increased mortality but did not reach significance.

Conclusion: Abdominal compartment syndrome in children carries a high mortality and may be a consequence of common childhood diseases such as enterocolitis. The diagnosis of ACS and the potential need for emergent decompressive laparotomy may be infrequently discussed in the pediatric literature. Increased awareness of ACS may promote earlier diagnosis, treatment, and possibly improve outcomes.
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http://dx.doi.org/10.1016/j.jpedsurg.2010.02.107DOI Listing
June 2010
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