Metal artefact reduction (MAR) MRI is now widely considered to be the standard for imaging metal-on-metal (MoM) hip implants. The Medicines and Healthcare Products Regulatory Agency (MHRA) has recommended cross-sectional imaging for all patients with symptomatic MoM bearings. This paper describes the natural history of MoM disease in a 28 mm MoM total hip replacement (THR) using MAR MRI. Inclusion criteria were patients with MoM THRs who had not been revised and had at least two serial MAR MRI scans. All examinations were reported by an experienced observer and classified as A (normal), B (infection) or C1–C3 (mild, moderate, severe MoM-related abnormalities). Between 2002 and 2011 a total of 239 MRIs were performed on 80 patients (two to four scans per THR); 63 initial MRIs (61%) were normal. On subsequent MRIs, six initially normal scans (9.5%) showed progression to a disease state; 15 (15%) of 103 THRs with sequential scans demonstrated worsening disease on subsequent imaging. Most patients with a MoM THR who do not undergo early revision have normal MRI scans. Late progression (from normal to abnormal, or from mild to more severe MoM disease) is not common and takes place over several years. Cite this article: Bone Joint J 2013;95-B:1035–9

Background. Back pain is a common orthopaedic problem which results in hospital admissions in severe cases. The aim of our study was to identify the reasons for back pain admissions and role of further investigations in the treatment of severe back pain. Methods. We collected data prospectively for all admissions between January and March 2011. Demographic details were recorded along with the reasons for admissions, time of admission, further investigations and treatment offered. Results. Total admissions were 850 and 58 (6.8%) had severe back pain.13 patients (22%) had fractures (Group-A); 16 patients (27%) did not require MRI scan (Group-B); 27 patients (50%) needed MRI scan of the lumbosacral spine (Group-C). The mean age of Group-A was 67 years (15–93). 3 were male and 10 females. 10 patients had lumbar and 3 had thoracic spine fractures. The mean age of Group-B was 59 years (32–87). 8 were male and 8 females. The mean age of Group-C was 47 years (23–79). 9 were male and 18 females. The mean hospital stay for Group-C was 5days (0–29). 16 patients (59%) were referred by GP, 5(18%) by emergency department and 3(11%) by physiotherapist. 9(43%) were admitted for pain control, 8(38%) with suspected Cauda Equina syndrome and 2(9%) for further investigations. 20 patients (83%) were admitted during the day, 3(12%) in the evening and 1(4%) during the night. No patient had Cauda equina syndrome on clinical and radiological examination. 12 patients(44%) had nerve root compression on the MRI scan and 7(58%) were offered surgery. Conclusions. Patients were older in group-A with a mean age of 67 years. 27% did not require MRI scan. 67% females admitted with back pain required an MRI scan. No patient had Cauda Equina Syndrome. 55% patients had no nerve root compression. MRI scan was performed to reassure the patients and clinicians with negative results in the presence of severe back pain and unclear neurological signs. Conflicts of interest. None. Sources of funding. None

Abstract. Introduction. MRI scanning is the establish method of defining intra- and extra-articular diagnoses of patients with non-arthritic knee problems. Discrepancies in reporting have been noted in previous historic studies and anecdotally. The aim of this study was to analyse the reporting of intra-articular pathology and discrepancies in knee MRI reports by two clinician groups, consultant radiologists and consultant knee surgeons in a district hospital setting. Methods. A retrospective case-controlled cohort study was conducted using data collected from an outpatient physiotherapy-led knee clinic. Seventy-four patients in the cohort were referred for an MRI scan of their knee(s) following a clinical examination and history. MRI reports from both the consultant knee surgeon and the radiologist were entered into a database with other clinical details. Reports were analysed to determine number of diagnoses and degree of agreement. Each report was deemed to either completely agree, completely disagree or partially agree. Results. 87 knees were scanned in total. Of the 87 reports, 14% (n=12) completely agreed. 45% of the reports (n=39) partially agreed and 41% (n=36) completely disagreed. Of the reports which partially agreed 79% (n=31) had a percentage agreement of ≤ 50%. Conclusions. This study reveals major discrepancies in knee MRI reporting by two clinician groups. This has greatest clinical impact on non-surgical clinicians and those with limited MRI reviewing experience who are reliant on reports to describe diagnoses to patients and determining management plans. More research is required to determine the reasons for these differences and measures to mitigate them

MRI scan for the knee joint has often been regarded to be the non invasive alternative to a diagnostic arthroscopy. MRI scan is routinely used to support the diagnosis for meniscal or ACL injuries prior to recommending arthroscopic examination and surgery. Identification of meniscal tears can be difficult to interpret and can be observer dependent as well as dependent upon the sensitivity of the scanner. Similar difficulties may exists in clinical examination as well. Our aim was to compare and correlate clinical, MRI and arthroscopic findings in the diagnosis of meniscal and Anterior Cruciate Ligament (ACL) Injuries. This was an observational study of 131 patients over 36 months who had both MRI and arthroscopic surgery. Our study showed clinical examination had better sensitivity (0.86 vs 0.76)and specificity(0.73 v/s 0.52) in comparing to MRI in diagnosis of medial menisceal injuries. similarly +predictive value and −predictive value were higher for clinical examination. whereas for lateral menisceal and ACL injuries there were marginal differences in sensitivity, specificity and predictive values. We conclude that carefully performed clinically examination can give equally or better diagnosis of meniscal and ACL injuries in comparison to MRI scan. MRI scan may be used to rule out such injuries rather than to diagnose them. MRI scan has much better negative predictive value than positive predictive value in both meniscal and ACL injuries diagnosis. When clinical signs and symptoms are inconclusive, performing MRI scan is likely to be more beneficial in avoiding unnecessary arthroscopic surgery. When clinical diagnosis is in favour of either meniscal or ACL injuries, performing MRI scan prior to Arthroscopic examination is unlikely to be of significance. MRI scan should not be used as a primary diagnostic tool in meniscal and ACL injuries

Purpose and background. Whether to order an MRI scan or not for patients with low back and leg pain (LBP). Resources are limited. Waiting for diagnostic imaging impacts time to treatment and may be critical to the “18 week target”. We have looked into devising a system in which we can ordered MRI scans for patients with LBP pre-clinical assessment based on questionnaire and accessing their referral letter. Methods and results. 49 patient's referrals were looked into (randomly picked). 23 had a questionnaire filled by either themselves or their GPs. the rests had MRI scans ordered based on their referral letters. MRI scans were requested pre-clinical assessment for patients with symptoms spreading beyond their knees and willing to consider interventional treatments (injections or operations). We considered MRI positive if the report mentioned stenosis or disc prolapse causing nerve root or cauda compression. 7 out of the 23 fitted the criteria for MRI. 6 (85%) of them had positive results. 26 of the GP referrals letters had MRI out of those 16 (61%) had positive results. In total out of 33 MRI, 22 (66.7%) were positive. Conclusion. Our study showed that pre-clinic MRI scanning for patients with LBP is an effective method to find surgically treatable pathology. Using the questionnaire was more advantageous than the referral letter in order to identify patients who would benefit from pre-clinic MRI scanning. With the small numbers this is not statistically significant. We propose that rather than a blanket scanning, it would be reasonable to scan patients based on their referral letter. No Conflict of interest. No funding obtained. This abstract has not been previously published in whole or substantial part nor has it been presented previously at a national meeting

Introduction. MRI imaging is carried out to identify levels of degenerative disc disease, and in some cases to identify a definite surgical target at which decompression should take place. We wanted to see if repeat MRI scans due to a prolonged time between the initial diagnostic MRI scan of the lumbar sacral spine, and the MRI scan immediately pre-operatively, due for the desire for a ‘fresh’ MRI scan pre-operatively, altered the level or type of procedure that they would have. Methods. This was a retrospective observational cohort study. Inclusion criteria- all patients with more than one MRI scan before their surgical procedure on the lumbar sacral spine, these were limited to patients that had either, discectomy, microdiscectomy, laminotomy decompression, laminectomy decompression and fusion, and posterior lumbar interbody fusion. Exclusion criteria- all patients with anterior approaches, all patients without decompression and all non lumbar sacral patients. Outcome measures were if there was a change between the pre-operative MRI scans, which would have changed the operative level of decompression, added other levels of decompression or type of surgery than primarily decided. Results. 84 patients were identified with our inclusion criteria with two or more pre-operative MRI scans. The repeat MRI did not change the surgical target for all 84 patients. Conclusion. Repeat MRI scanning does not alter the surgical target level, and therefore does not change management. It can delay the initial primary procedure which can lead to progressive neurology, which may be irreversible and should be avoided unless the distribution of neurology has changed

Forty-eight images using magnetic resonance imaging (MRI) in 16 hips with Perthes' disease were evaluated over a mean period of two years. MRI depicted exactly the infarcted zone in the femoral head before typical radiological changes were evident. Early determination of the extent of the infarcted bone on MRI benefits those patients who require treatment. Follow-up MRI scans at six-monthly intervals, reflected the chronological stages of the repair process in each group classified according to Catterall

Aims

Intra-articular (IA) tumours around the knee are treated with extra-articular (EA) resection, which is associated with poor functional outcomes. We aim to evaluate the accuracy of MRI in predicting IA involvement around the knee.

Aims and objectives. Our aim was to evaluate the indications for patients undergoing magnetic resonance imaging (MRI) of the knee prior to referral to an orthopaedic specialist, and ascertain whether these scans altered initial management. Materials and Method. We retrospectively reviewed all referrals received by a single specialist knee surgeon over a 1-year period. Patient demographics, relevant history, examination findings and past surgical procedures were documented. Patients having undergone MRI prior to referral were identified and indications for the scans recorded. These were reviewed against The NHS guidelines for Primary Care Physicians to identify if the imaging performed was appropriate in each case. Results. A total of 261 patients were referred between 1. st. July 2018 and 30. th. June 2019. 87/261 patients underwent MRI of the knee joint prior to referral. The mean patient age was 53 years with predominance of male patients (52 verses 35 females). 21/87 patients (24%) underwent the appropriate imaging prior to referral with only 13% of patients undergoing x-ray imaging before their MRI. In cases where MRI was not indicated, patients waited an average of 12 weeks between their scan and a referral being sent to the specialist knee surgeon. Conclusion. 76% of patients referred to orthopaedics had inappropriate MRI imaging arranged by their primary care physician. For a single consultant's referrals over 1 year these unnecessary MRI scans cost the NHS £13,200. Closer adherence to the guidelines by primary care physicians would result in a financial saving for the NHS, faster referral times and a more effective use of NHS resources

Objective: To determine whether extended scope physiotherapists (ESP’s) in spinal clinics are able to accurately assess and diagnose patient pathology as verified by MRI findings. Methods: This is a prospective study of 318 new spinal outpatients assessed and examined by one of two spinal ESP’s. 76 patients (24%) were referred for an MRI scan. At the time of request for MRI scan the likelihood of specific spinal pathology correlating with the MRI scan was noted on a four point scale dividing the patients into 4 groups:. Group 4 = Very high suspicion of pathology (n=41). Group 3 = Moderate suspicion of pathology (n=21). Group 2 = Some suspicion of pathology (n=10). Group 1 = Pathology unlikely but scan indicated eg thoracic pain (n=4). Results: Of the 76 patients referred for an MRI scan, 54 (71%) had an MRI scan result that would correlate with the clinical picture. Looking at the percentage of scans correlating with the clinical picture for each of the 4 groups:. Group 4: 88%. Group 3: 67%. Group 2: 40%. Group 1: 0%. Conclusion: Dividing the patients into groups by clinical suspicion is essential for evaluating a clinician’s ability in spinal assessment. Further evaluation of Consultants, Fellows and Specialist Registrars is on going. This type of study could form a basis for competency measures for staff development and training if they are undertaking extended roles

Introduction. Occult hip fractures occur in 3% of cases. Delay in treatment results in significantly increased morbidity and mortality. NICE guidelines recommend cross-sectional imaging within 24 hours and surgery on the day of, or day after, admission. MRI was the standard imaging modality for suspected occult hip fractures in our institution, but since January 2013, we have switched to multi-detector CT (MDCT) scan. Our aims were to investigate whether MDCT has improved the times to diagnosis and surgery; and whether it resulted in missed hip fractures. Patients/Materials & Methods. Retrospective review of a consecutive series of patients between 01/01/2013 and 31/08/2014 who had MDCT scan for suspected occult hip fracture. Missed fracture was defined as a patient re-presenting with hip fracture within six weeks of a negative scan. A comparative group of consecutive MRI scans from 01/01/2011 to 31/12/2012 was used. Results. Seventy-three MDCTs and 70 MRIs were included. MDCT identified nine hip fractures and other fractures in 27 patients. Mean time to scan for MDCT was 13 hours 37 minutes compared with 53 hours 36 minutes for MRI scan (p<0.001). 88.5% of MDCTs were performed within 24 hours compared with 33.3% of MRIs. Nine and 16 patients required surgery in the MDCT and MRI groups, respectively. Mean time to surgery for MDCT was 50 hours 41 minutes compared with 223 hours 21 minutes for MRI scan (p = 0.25). There were no missed hip fractures in the patients with negative MDCT scan. Discussion. MDCT scan has led to a significant reduction in time to diagnosis, and a large reduction in time to surgery. MDCT did not miss any hip fractures. Conclusion. We advocate the use of MDCT over MRI in suspected occult hip fractures as it is cheaper, quicker, and more readily available; and does not result in missed hip fractures

Purpose: To investigate the value of various clinical signs to identify occult hip fracture. Methodology: MRI register was searched to identify all patients who had MRI scan between July 2000–June 2006 for suspected occult hip fracture. 64 patients were identified. 33 patients had occult proximal femoral fractures. 27 patients had no fracture. Results: 19 patients with fracture were not independently mobile compared to 6 patients without fracture. 7 patients with fracture and 2 patients without fracture were able to weight bear. 13 patients with fracture and 10 patients without fracture had unrestricted straight leg raise ability. 7 patients with fracture and 16 patients without fracture had no pain on axial loading. Fisher exact and chi square analysis was performed; with Bonferroni correction for multiple comparisons (10 tests) p< 0.005 was deemed significant. Pain on axial loading of limb and pre-fracture patient mobility were associated with fracture (p< 0.005). Both factors had positive predictive value = 0.76 and post-test probability of disease given a negative test = .30. Predictive values remained the same when both factors were considered together. Discussion: These data indicate that although patients who were independently mobile before the fall and who do not have pain on axial compression of the limb are less likely to have a fracture, these signs alone or in combination will not exclude a fracture. It is essential to perform MRI scanning of patients with severe hip pain but normal x rays after fall as it does not seem possible to clinically exclude fracture

Aims. Early cases of cauda equina syndrome (CES) often present with nonspecific symptoms and signs, and it is recommended that patients undergo emergency MRI regardless of the time since presentation. This creates substantial pressure on resources, with many scans performed to rule out cauda equina rather than confirm it. We propose that compression of the cauda equina should be apparent with a limited sequence (LS) scan that takes significantly less time to perform. Methods. In all, 188 patients with suspected CES underwent a LS lumbosacral MRI between the beginning of September 2017 and the end of July 2018. These images were read by a consultant musculoskeletal radiologist. All images took place on a 3T or 1.5T MRI scanner at Stoke Mandeville Hospital, Aylesbury, UK, and Royal Berkshire Hospital, Reading, UK. Results. The 188 patients, all under the age of 55 years, underwent 196 LS lumbosacral MRI scans for suspected CES. Of these patients, 14 had cauda equina compression and underwent emergency decompression. No cases of CES were missed. Patients spent a mean 9.9 minutes (8 to 10) in the MRI scanner. Conclusion. Our results suggest that a LS lumbosacral MRI could be used to diagnose CES safely in patients under the age of 55 years, but that further research is needed to assess safety and efficacy of this technique before changes to existing protocols can be recommended. In addition, work is needed to assess if LS MRIs can be used throughout the spine and if alternative pathology is being considered. Cite this article: Bone Joint J 2020;102-B(4):501–505

Introduction: The possibility of occult hip fracture in older patients after a fall is a common problem. The value of various clinical signs to determine which patients require further investigation has not been reported. Methodology: MRI register was hand searched to identify all patients who had MRI scan between July 2000–June 2006 for suspected occult hip fracture. 64 patients were identified. 33 patients had occult proximal femoral fractures. 27 patients had no fracture. Results: More patients with fracture were living in their own home (20/26), were independent for daily living (20/26) and were not independently mobile(19/26) compared to patients without a fracture (14/22, 11/22 and 6/22 respectively). 7 patients with fracture and 2 patients without fracture were able to weight bear. 13 patients with fracture and 10 patients without fracture had unrestricted straight leg raise ability. 7 patients with fracture and 16 patients without fracture had no pain on axial loading. The value of individual tests was evaluated using Fisher exact and chi square analysis; with Bonferroni correction for multiple comparisons (10 tests) p< 0.005 was deemed significant. Pain on axial loading of the limb and pre-fracture patient mobility were both associated with the presence of a fracture (p< 0.005). Discussion: These data indicate that although patients who were independently mobile before the fall and who do not have pain on axial compression of the limb are less likely to have a fracture, these signs alone or in combination will not exclude a fracture. Other widely used signs (eg ability to straight leg raise) appear of little predictive value. On the basis of our data, we believe it is essential to have a policy of MRI scanning of patients with severe hip pain but normal x rays after a fall as it does not seem possible to clinically exclude a fracture

The aim of this study was to determine the accuracy of Magnetic Resonance Imaging (MRI) scanning compared to arthroscopic findings in patients presenting with chronic ankle pain and/or instability. We reviewed all patients who underwent arthroscopy of the ankle between December 2005 to July 2008 in our institution. A total of 105 patients underwent arthroscopy for chronic ankle pain and/or instability. Twenty-four patients underwent MRI prior to the procedure. We compared the MRI findings with arthroscopic findings. We specifically examined for the anterior talofibular ligament (ATFL), calcaneofibular cigament (CFL) and osteochondral lesions(OCD). Arthroscopic findings were considered as a gold standard. There were 12 female and 12 male patients with an average age 39 years (11–65). The time interval between the MRI scan and arthroscopy was 7 months (2–18). In our study MRI had 100% specificity for the diagnosis of ATFL and CFL tears and osteochondral lesions. However sensitivity was low particularly for CFL tears. The accuracy of MRI in detecting ATFL tear was 91.7%, CFL tear was 87.5% and osteochondral lesion was 83.3%. We conclude that MRI scanning has a very high specificity and positive predictive value in diagnosing tears of ATFT, CFL and osteochondral lesions. However sensitivity was low with MRI. In a symptomatic patient negative results on MRI must be viewed with caution and an arthroscopy is advisable for a definitive diagnosis and treatment

Magnetic resonance imaging (MRI) was used to compare the appearance of the spine in 20 adolescents with proven symptomatic intervertebral disc herniations with that in 20 asymptomatic patients who acted as controls. Abnormality in the signal from the nucleus pulposus of one or more discs was present in all patients, while only four of the 20 controls had any abnormal signals. In all the patients the symptomatic disc produced an abnormal signal and in most a herniated fragment of the nucleus pulposus was identified. Fifteen of the 20 patients had multiple-disc abnormality: six had three abnormal discs and nine had two. This suggests there was an underlying diathesis in patients who later developed disc herniation

NHS Patients can wait up to 15 months for non-urgent spine surgery. The intended procedure is determined by the outpatient MRI scan. Do changes occur within the spine during the wait for surgery? Would the changes affect the operative decision?. In a prospective study, 105 patients listed for elective lumbar spine surgery at a district general hospital If the MRI scan is over 6 months old, a second scan is performed prior to surgery. Changes that alter the operative decision are noted. 44% Discectomy, 17% decompression, and 19% fusion plus decompression patients cancelled surgery due to improvement in symptoms. None of the spinal fusion patients cancelled. 14% discectomy; 12.5% decompression; 25% fusion; 19% fusion plus decompression and 65% fusion plus discectomy patients had different procedures after the second MRI. Changes seen include disc resolution, prolapse at a new level, progressive modic changes and compression at other levels. We do not support the fact that patients may have to wait upto 18 months before having elective spinal surgery. However, we found that significant numbers of discectomy and decompression patients found that their symptoms improved enough to decline surgery. No patient that had been listed for fusion alone got better. Due to changes seen on the second MRI scan, 1 in 6 operations were different to the initial planned procedure. Could a surgeon failing to request a further up to date scan prior to surgery therefore be considered negligent?

Aims. For paediatric and adolescent patients with growth potential, preservation of the physiological joint by transepiphyseal resection (TER) of the femur confers definite advantages over arthroplasty procedures. We hypothesized that the extent of the tumour and changes in its extent after neoadjuvant chemotherapy are essential factors in the selection of this procedure, and can be assessed with MRI. The oncological and functional outcomes of the procedure were reviewed to confirm its safety and efficacy. Methods. We retrospectively reviewed 16 patients (seven male and nine female, mean age 12.2 years (7 to 16)) with osteosarcoma of the knee who had been treated by TER. We evaluated the MRI scans before and after neoadjuvant chemotherapy for all patients to assess the extent of the disease and the response to treatment. Results. The mean follow-up period was 64.3 months (25 to 148) after surgery and no patients were lost to follow-up. On MRI evaluation, 13 tumours were near but not in contact with the physes and three tumours were partially in contact with the physes before neoadjuvant chemotherapy. Bone oedema in the epiphysis was observed in eight patients. After neoadjuvant chemotherapy, bone oedema in the epiphysis disappeared in all patients. In total, 11 tumours were not in contact and five tumours were in partial contact with the physes. The postoperative pathological margin was negative in all patients. At the last follow-up, 12 patients were continuously disease-free and three had no evidence of disease. One patient died due to the disease. Functionally, the patients with retained allograft or recycled autograft had a mean knee range of flexion of 126° (90° to 150°). The mean Musculoskeletal Tumor Society functional score was 27.6 (23 to 30). Conclusion. TER is an effective limb-salvage technique for treating malignant metaphyseal bone tumours in paediatric and young osteosarcoma patients with open physes when a good response to chemotherapy and no progression of the tumour to the epiphysis have been confirmed by MRI. Cite this article: Bone Joint J 2020;102-B(6):772–778

Objective: NHS Patients can wait up to 18 months for non-urgent spine surgery. The intended procedure is determined by the outpatient MRI scan. Do changes occur within the spine during the wait for surgery? Would the changes affect the operative decision?. Design: A Prospective study. Subjects: 105 patients listed for elective lumbar spine surgery at a district general hospital. Outcome Measures: If the MRI scan is over six months old, a second scan is performed prior to surgery. Changes that alter the operative decision are noted. Results: Forty-four percent discectomy, 17% decompression, and 19% fusion plus decompression patients cancelled surgery due to improvement in symptoms. None of the spinal fusion patients cancelled. Fourteen percent discectomy; 12.5% decompression; 25% fusion; 19% fusion plus decompression and 65% fusion plus discectomy patients had different procedures after the second MRI. Changes seen include disc resolution, pro-lapse at a new level, progressive modic changes and compression at different levels. Conclusions: We do not support the fact that patients may have to wait up to 18 months before having elective spinal surgery. However, a significant numbers of discectomy and decompression patients found that their symptoms improved enough to decline surgery. No patient who had been listed for fusion alone got better. Due to changes seen on the second MRI scan, one in six operations were different to the initial planned procedure. Could a surgeon failing to request a further up to date scan prior to surgery therefore be considered negligent?

A study of structures which obstruct reduction of hip dislocation was performed on 15 hips by magnetic resonance imaging (MRI). Before treatment started, MRI studies were performed on 10 patients, six of whom were treated conservatively, after which further MRI studies helped to establish a concentric reduction. In the other four conservative treatment failed and they were operated on; in them the MRI studies were compared with arthrographic and surgical findings. In all but one of these 10 patients, MRI enabled us to differentiate between an everted and an inverted limbus. In five other patients with unsatisfactory development of the hip following closed reduction, MRI was compared with earlier arthrographic studies. MRI provided accurate anatomical information which would not have been obtained by arthrography. It clearly has great potential in assisting the surgeon to select the appropriate form of treatment