Peh WCG

Three excellent instructional cases from Dr. Lawrence Wells and colleagues from
the Children’s Hospital of Philadelphia follow in this E-Focus on Imaging in Pediatric Orthopedics of the February issue of The American Journal of Orthopedics (AJO). These cases highlight the important role of imaging in the practice of pediatric orthopedics, particularly its usefulness in problem solving for conditions that are difficult to diagnose clinically. Given the wide array of imaging techniques currently available, there is a tendency for surgeons to over-investigate. But more isn’t always better.

For example, while magnetic resonance (MR) imaging has the well-known advantages of avoidance of the potential hazards of ionizing radiation, multiplanar imaging capability, and superior soft-tissue contrast and resolution, the relatively long time period for acquisition of MR images make it relatively user-unfriendly for imaging in children. Movement artifacts can be a big problem, leading to image degradation and interpretation difficulties. For young children, having to administer heavy sedation or general anesthesia often negates the benefits of this diagnostic technique. Multidetector computed tomography (CT) produces images of excellent quality and resolution, particularly of bone. However, the price to pay for the thinner contiguous slices that enable production of the beautiful reformatted 2-dimensional sagittal and coronal images, and the stunning 3-dimensional
(3D) images, is a markedly increased radiation dose to the young patient.

It appears that the solution lies in a return to basic principles of good clinical practice. As illustrated by these 3 pediatric orthopedic cases in this month’s AJO, formulating a provisional diagnosis and short list of differential diagnoses starts with a well-taken and detailed clinical history and a meticulous physical examination. Simple hematologic investigations should be interpreted in light of the clinical findings. Imaging should be reserved for problem solving and should not be considered as a screening tool. There must be an imaging plan that aims to
address the following questions: Is there a lesion? If so, what and where exactly is it? And how can I best treat this patient’s condition—in this respect, is imaging really necessary?

For orthopedic problems, the time-honored radiograph still remains the initial imaging investigation in today’s practice. Too often, more expensive and advanced imaging modalities are requested first, even when the diagnosis can be made on
the basis of the plain film. This is poor clinical practice, and it reflects a lack of training and common sense. Radiographs are readily available, technically easy to perform, and give an overview of bone and joint lesions. It is the imaging investigation of choice for the detection of fractures and dislocations and also for the diagnosis of bone tumors and many other bone conditions. CT should be considered a supplementary examination to radiographs and is helpful when radiographs are equivocal or findings are subtle. CT is particularly suited for complex skeletal anatomy, for example, the spine, scapula, pelvis, and hindfoot.
In pediatric patients, reconstructed 3D CT images are useful for sorting out congenital spinal deformities.

For children and adolescents, ultrasonography can be used in place of MR imaging for many indications, particularly for assessing superficial structures such as tendons, muscles, ligaments, blood vessels, and other soft tissues. However, performing musculoskeletal ultrasonography well entails a rather long and steep
learning curve before technical expertise can be achieved. More advanced techniques such as MR imaging, nuclear medicine imaging, and imaging-guided interventional procedures should be used sparingly.

In fact, less may be better. If in doubt, pause before asking for more imaging and do consult your friendly neighborhood musculoskeletal radiologist.

Three excellent instructional cases from Dr. Lawrence Wells and colleagues from
the Children’s Hospital of Philadelphia follow in this E-Focus on Imaging in Pediatric Orthopedics of the February issue of The American Journal of Orthopedics (AJO). These cases highlight the important role of imaging in the practice of pediatric orthopedics, particularly its usefulness in problem solving for conditions that are difficult to diagnose clinically. Given the wide array of imaging techniques currently available, there is a tendency for surgeons to over-investigate. But more isn’t always better.

For example, while magnetic resonance (MR) imaging has the well-known advantages of avoidance of the potential hazards of ionizing radiation, multiplanar imaging capability, and superior soft-tissue contrast and resolution, the relatively long time period for acquisition of MR images make it relatively user-unfriendly for imaging in children. Movement artifacts can be a big problem, leading to image degradation and interpretation difficulties. For young children, having to administer heavy sedation or general anesthesia often negates the benefits of this diagnostic technique. Multidetector computed tomography (CT) produces images of excellent quality and resolution, particularly of bone. However, the price to pay for the thinner contiguous slices that enable production of the beautiful reformatted 2-dimensional sagittal and coronal images, and the stunning 3-dimensional
(3D) images, is a markedly increased radiation dose to the young patient.

It appears that the solution lies in a return to basic principles of good clinical practice. As illustrated by these 3 pediatric orthopedic cases in this month’s AJO, formulating a provisional diagnosis and short list of differential diagnoses starts with a well-taken and detailed clinical history and a meticulous physical examination. Simple hematologic investigations should be interpreted in light of the clinical findings. Imaging should be reserved for problem solving and should not be considered as a screening tool. There must be an imaging plan that aims to
address the following questions: Is there a lesion? If so, what and where exactly is it? And how can I best treat this patient’s condition—in this respect, is imaging really necessary?

For orthopedic problems, the time-honored radiograph still remains the initial imaging investigation in today’s practice. Too often, more expensive and advanced imaging modalities are requested first, even when the diagnosis can be made on
the basis of the plain film. This is poor clinical practice, and it reflects a lack of training and common sense. Radiographs are readily available, technically easy to perform, and give an overview of bone and joint lesions. It is the imaging investigation of choice for the detection of fractures and dislocations and also for the diagnosis of bone tumors and many other bone conditions. CT should be considered a supplementary examination to radiographs and is helpful when radiographs are equivocal or findings are subtle. CT is particularly suited for complex skeletal anatomy, for example, the spine, scapula, pelvis, and hindfoot.
In pediatric patients, reconstructed 3D CT images are useful for sorting out congenital spinal deformities.

For children and adolescents, ultrasonography can be used in place of MR imaging for many indications, particularly for assessing superficial structures such as tendons, muscles, ligaments, blood vessels, and other soft tissues. However, performing musculoskeletal ultrasonography well entails a rather long and steep
learning curve before technical expertise can be achieved. More advanced techniques such as MR imaging, nuclear medicine imaging, and imaging-guided interventional procedures should be used sparingly.

In fact, less may be better. If in doubt, pause before asking for more imaging and do consult your friendly neighborhood musculoskeletal radiologist.

Three excellent instructional cases from Dr. Lawrence Wells and colleagues from
the Children’s Hospital of Philadelphia follow in this E-Focus on Imaging in Pediatric Orthopedics of the February issue of The American Journal of Orthopedics (AJO). These cases highlight the important role of imaging in the practice of pediatric orthopedics, particularly its usefulness in problem solving for conditions that are difficult to diagnose clinically. Given the wide array of imaging techniques currently available, there is a tendency for surgeons to over-investigate. But more isn’t always better.

For example, while magnetic resonance (MR) imaging has the well-known advantages of avoidance of the potential hazards of ionizing radiation, multiplanar imaging capability, and superior soft-tissue contrast and resolution, the relatively long time period for acquisition of MR images make it relatively user-unfriendly for imaging in children. Movement artifacts can be a big problem, leading to image degradation and interpretation difficulties. For young children, having to administer heavy sedation or general anesthesia often negates the benefits of this diagnostic technique. Multidetector computed tomography (CT) produces images of excellent quality and resolution, particularly of bone. However, the price to pay for the thinner contiguous slices that enable production of the beautiful reformatted 2-dimensional sagittal and coronal images, and the stunning 3-dimensional
(3D) images, is a markedly increased radiation dose to the young patient.

It appears that the solution lies in a return to basic principles of good clinical practice. As illustrated by these 3 pediatric orthopedic cases in this month’s AJO, formulating a provisional diagnosis and short list of differential diagnoses starts with a well-taken and detailed clinical history and a meticulous physical examination. Simple hematologic investigations should be interpreted in light of the clinical findings. Imaging should be reserved for problem solving and should not be considered as a screening tool. There must be an imaging plan that aims to
address the following questions: Is there a lesion? If so, what and where exactly is it? And how can I best treat this patient’s condition—in this respect, is imaging really necessary?

For orthopedic problems, the time-honored radiograph still remains the initial imaging investigation in today’s practice. Too often, more expensive and advanced imaging modalities are requested first, even when the diagnosis can be made on
the basis of the plain film. This is poor clinical practice, and it reflects a lack of training and common sense. Radiographs are readily available, technically easy to perform, and give an overview of bone and joint lesions. It is the imaging investigation of choice for the detection of fractures and dislocations and also for the diagnosis of bone tumors and many other bone conditions. CT should be considered a supplementary examination to radiographs and is helpful when radiographs are equivocal or findings are subtle. CT is particularly suited for complex skeletal anatomy, for example, the spine, scapula, pelvis, and hindfoot.
In pediatric patients, reconstructed 3D CT images are useful for sorting out congenital spinal deformities.

For children and adolescents, ultrasonography can be used in place of MR imaging for many indications, particularly for assessing superficial structures such as tendons, muscles, ligaments, blood vessels, and other soft tissues. However, performing musculoskeletal ultrasonography well entails a rather long and steep
learning curve before technical expertise can be achieved. More advanced techniques such as MR imaging, nuclear medicine imaging, and imaging-guided interventional procedures should be used sparingly.

In fact, less may be better. If in doubt, pause before asking for more imaging and do consult your friendly neighborhood musculoskeletal radiologist.

The idiom “penny wise, pound foolish” certainly applies in this report of 2 cases of missed bone tumors that were present but not recognized on preoperative imaging prior to placement of patient-specific knee arthroplasties. The case report appeared in the December 2013 issue of The American Journal of Orthopedics. The term “non-diagnostic imaging,” itself a paradox, used in the context of preoperative imaging performed solely for the purpose of component templating for patient-specific instrumentation (PSI) and not intended to be diagnostic in purpose, would be anathematic to most radiologists and should be discarded as a concept.

Bearing in mind the costs incurred by the patient undergoing a total knee arthroplasty (TKA), such as professional consultation, preoperative magnetic resonance imaging, customized manufacture of the components, surgery and associated costs, and postoperative rehabilitation, the fee for a formal report by a musculoskeletal radiologist is comparatively minuscule. As correctly pointed out by the authors, the price associated with bypassing any assessment and missing malignant disease is far greater.

It is well recognized that unreported radiologic examinations can lead to misdiagnosis, compromised patient care, and liability concerns. As PSI is relatively new and has good potential to increase the accuracy, precision and efficiency of TKA, it is even more vital that this promising technology not be marred by disrepute due to possible devastating outcomes resulting from lack of a radiologic report. From the professional point of view of a radiologist, the issuance of a formal report is part and parcel of any radiological examination. I would argue that obtaining radiologic images without an accompanying report constitutes an incomplete study, and will not be in the best interest of patients.

Let the lessons learned from these 2 cases be a springboard to establish protocols for proper utilization of technologies involved in PSI for TKA and other orthopedic procedures. It is imperative to put into place mandatory reporting of all diagnostic images obtained for preoperative evaluation, particularly those that are meant to be sent directly to implant manufacturers for component design.

Menge TJ, Hartley KG, Holt GE. Patient-Specific Imaging and Missed Tumors: A Catastrophic Outcome. Am J Orthop. 2013;42(12):553-556.

The idiom “penny wise, pound foolish” certainly applies in this report of 2 cases of missed bone tumors that were present but not recognized on preoperative imaging prior to placement of patient-specific knee arthroplasties. The case report appeared in the December 2013 issue of The American Journal of Orthopedics. The term “non-diagnostic imaging,” itself a paradox, used in the context of preoperative imaging performed solely for the purpose of component templating for patient-specific instrumentation (PSI) and not intended to be diagnostic in purpose, would be anathematic to most radiologists and should be discarded as a concept.

Bearing in mind the costs incurred by the patient undergoing a total knee arthroplasty (TKA), such as professional consultation, preoperative magnetic resonance imaging, customized manufacture of the components, surgery and associated costs, and postoperative rehabilitation, the fee for a formal report by a musculoskeletal radiologist is comparatively minuscule. As correctly pointed out by the authors, the price associated with bypassing any assessment and missing malignant disease is far greater.

It is well recognized that unreported radiologic examinations can lead to misdiagnosis, compromised patient care, and liability concerns. As PSI is relatively new and has good potential to increase the accuracy, precision and efficiency of TKA, it is even more vital that this promising technology not be marred by disrepute due to possible devastating outcomes resulting from lack of a radiologic report. From the professional point of view of a radiologist, the issuance of a formal report is part and parcel of any radiological examination. I would argue that obtaining radiologic images without an accompanying report constitutes an incomplete study, and will not be in the best interest of patients.

Let the lessons learned from these 2 cases be a springboard to establish protocols for proper utilization of technologies involved in PSI for TKA and other orthopedic procedures. It is imperative to put into place mandatory reporting of all diagnostic images obtained for preoperative evaluation, particularly those that are meant to be sent directly to implant manufacturers for component design.

Menge TJ, Hartley KG, Holt GE. Patient-Specific Imaging and Missed Tumors: A Catastrophic Outcome. Am J Orthop. 2013;42(12):553-556.

The idiom “penny wise, pound foolish” certainly applies in this report of 2 cases of missed bone tumors that were present but not recognized on preoperative imaging prior to placement of patient-specific knee arthroplasties. The case report appeared in the December 2013 issue of The American Journal of Orthopedics. The term “non-diagnostic imaging,” itself a paradox, used in the context of preoperative imaging performed solely for the purpose of component templating for patient-specific instrumentation (PSI) and not intended to be diagnostic in purpose, would be anathematic to most radiologists and should be discarded as a concept.

Bearing in mind the costs incurred by the patient undergoing a total knee arthroplasty (TKA), such as professional consultation, preoperative magnetic resonance imaging, customized manufacture of the components, surgery and associated costs, and postoperative rehabilitation, the fee for a formal report by a musculoskeletal radiologist is comparatively minuscule. As correctly pointed out by the authors, the price associated with bypassing any assessment and missing malignant disease is far greater.

It is well recognized that unreported radiologic examinations can lead to misdiagnosis, compromised patient care, and liability concerns. As PSI is relatively new and has good potential to increase the accuracy, precision and efficiency of TKA, it is even more vital that this promising technology not be marred by disrepute due to possible devastating outcomes resulting from lack of a radiologic report. From the professional point of view of a radiologist, the issuance of a formal report is part and parcel of any radiological examination. I would argue that obtaining radiologic images without an accompanying report constitutes an incomplete study, and will not be in the best interest of patients.

Let the lessons learned from these 2 cases be a springboard to establish protocols for proper utilization of technologies involved in PSI for TKA and other orthopedic procedures. It is imperative to put into place mandatory reporting of all diagnostic images obtained for preoperative evaluation, particularly those that are meant to be sent directly to implant manufacturers for component design.

Menge TJ, Hartley KG, Holt GE. Patient-Specific Imaging and Missed Tumors: A Catastrophic Outcome. Am J Orthop. 2013;42(12):553-556.