An os subfibulare is an ossicle that is located distal to the lateral malleolus near the distal fibular tip and typically at the fibular attachment of the anterior talofibular ligament (ATFL). Although there is debate concerning whether these ossicles are unfused accessory ossification centers versus non-united ATFL avulsion fractures, they are seen frequently in the setting of ankle instability. We present a case of an active patient with an unstable os subfibulare contributing to painless "catching" of the ankle due to talar subluxation and locking. This report details the clinical presentation, radiological findings, including MRI and dynamic ultrasound in the "locked" position, and surgical treatment for this unusual presentation of this unstable ossicle. The case underscores the potential importance of the os subfibulare in a patient with ankle instability and highlights the role of advanced imaging in guiding effective treatment.

PURPOSE:To assess whether causes of moral distress vary by academic institution. Moral distress is experienced when health care providers are unable to provide the right care to patients because of institutional or resource constraints. MATERIALS AND METHODS:A survey was performed based on Moral Distress Scale-Revised for Health Care Professionals for 16 clinical scenarios assessing frequency and severity of moral distress among academic radiologists. The survey was sent to members of the RSNA Quality Improvement Committee for distribution to their department. Measure of Moral Distress for Health Care Professionals (MMD-HP) was calculated for individuals and moral distress index for clinical scenarios. MMD-HP were compared by sex, ethnicity, age, years of practice, weekly work hours, practice setting or type, and consideration of leaving the workplace. Statistical analysis was performed using Kruskal-Wallis test and Kendall ordinal correlation. RESULTS:In all, 126 respondents from five institutions from five different states were included in the analysis. MMD-HP ranged from 24 to 66 (maximum 266). Median MMD-HP was higher in radiologists working >60 hours per week (59 versus 32.5, P = .048). Radiologists across institutions consistently reported four main sources of moral distress: pressure to perform unsafe numbers of studies (108 of 126, 85%), high workloads impeding resident teaching (102 of 126, 81%), lack of administrative support for patient care issues (102 of 126, 81%), and pressure to conduct unnecessary imaging (111 of 126, 88%). Higher MMD-HPs correlated significantly with job turnover intentions or past job changes (P < .001). The average percentage of radiologists with an intention to leave or having left as position was 44% with a range of 26% to 84%. CONCLUSION:Moral distress is pervasive in radiology, with four primary causes consistently identified across academic institutions. Strong association between higher moral distress levels and job turnover intentions highlights its impact on workforce retention.

BACKGROUND AND OBJECTIVE:The 2021-2022 Accreditation Council for Graduate Medical Education (ACGME) survey of radiology residents at our institution showed a level of participation in safety event investigations that was below ACGME compliance standards. We undertook a quality improvement (QI) project that aimed to increase resident participation in safety event root cause analysis (RCA) and action planning, as well as to enhance the QI training experience for radiology residents. METHODS:A team of residents, program leaders, and radiology QI professionals applied the DMAIC (Define, Measure, Analyze, Improve, Control) methodology to identify root causes of low resident participation in safety event investigations. RESULTS:We designed and implemented targeted interventions that aimed to restore compliance with ACGME standards. Interventions included integrating first-year residents into the Radiology Quality Oversight Committee, improving safety event reporting education, clarifying terminology used in ACGME survey questions, and incorporating simulated RCA events. The subsequent ACGME survey showed that our QI initiative led to a 33% increase in resident participation in safety event investigations without compromising the balance between education and patient care. DISCUSSION:Addressing the observed decline through structured QI initiatives not only restored compliance with ACGME standards but also strengthened the overall educational experience for residents. This project underscores the critical role of targeted interventions in maintaining high levels of resident engagement in patient safety activities.

Peripheral spondyloarthritis (pSpA) encompasses multiple entities affecting the musculoskeletal system with classic findings of synovitis, enthesitis, and tenosynovitis. It remains poorly defined when compared with the axial spondyloarthritides due to nonspecific symptoms, ill-defined imaging findings, and lack of specific testable biomarkers. Previous research has tried to distinguish between the two disease entities using clinical presentations, scoring systems, and radiographic findings; however, overlap remains. We summarize the current classification of pSpA, imaging findings, and the distinction between these entities and axial spondyloarthritis.

The Accreditation Council for Graduate Medical Education (ACGME) requires radiology residents to engage in an annual safety event that leads to actionable changes in residency programs. Root cause analysis (RCA) is frequently used to fulfill this requirement. Because actual RCA is rare, simulations are a suitable alternative. We evaluated the feasibility and effectiveness of using simulated RCA curriculum to meet the ACGME safety requirement. During the 2023-2024 academic year, quality improvement staff in the radiology department developed a simulated RCA and invited radiology residents to participate in the training event. Four allied health radiology staff were present to ensure realism. The case scenario involved a computed tomography-guided lung biopsy that resulted in a pneumothorax. During a 1 h session, residents analyzed the scenario, identified root causes, proposed actions, and created an action plan. Before and after the event, participants were asked to complete surveys regarding their knowledge, attitudes, and behaviors related to RCA events by using a 5-point Likert scale, and top box scores were compared. Of 18 residents, 11 (61%) attended. Comparison of presurvey and postsurvey top box scores showed that comfort with RCA event participation significantly increased from 6% to 44% (P = .04). Furthermore, knowledge of what to expect from an RCA event significantly increased from 6% to 56% (P = .01). The ability to identify system issues also significantly increased from 6% to 44% (P = .04). Simulated RCA events are effective for meeting ACGME safety improvement requirements and enhance resident soft skills essential for patient care.

BACKGROUND:The presence of a chimeric gracilis and profunda artery perforator (PAP) flap with a common arterial pedicle has been demonstrated on computed tomography angiography in up to 59% of patients and confirmed in a cadaveric model. Already utilized for head and neck reconstruction by Heredero et al, this novel flap could provide more volume than either flap alone which is advantageous, particularly in patients with sizable defects. The purpose of this study was to determine the average tissue volume that can be utilized from this chimeric flap. METHODS:CT Angiogram imaging studies exhibiting chimeric flap anatomy were reviewed over a 7-year period at a single institution utilizing Visage Version 7.1, a radiology picture archiving and communication system. This software was used to trace the flap pedicles and to capture estimated soft tissue volumes of each respective flap. RESULTS:A total of 31 patients, consisting of 52 lower extremity gracilis and PAP chimeric flaps, underwent tissue volume analysis. The average total volume of soft tissue supplied by the gracilis flap was found to be 70.21 cm3 (standard deviation [SD] = 26.99). The average volume of the PAP flap was 31.73 cm3 (SD = 26.12). The average total volume captured by the chimeric gracilis and PAP flap was 101.94 cm3 (SD = 62.40). CONCLUSION:The potential soft tissue volume that can be harvested from a chimeric gracilis and PAP flap is significantly greater than solitary gracilis or PAP flaps. This chimeric flap may serve as a viable and advantageous reconstructive option for patients requiring large volume soft tissue coverage, particularly if other sizable options are not available.

Contrast extravasation (CEV), also known as intravenous (IV) infiltration, is a known complication of CT imaging. Complications range from dull pain to skin ulceration to compartment syndrome with resultant soft tissue necrosis [1]. Depending on the practice, CEV incidents related to power injection for CT range from 0.1% to 1.2% [1-4]. In our practice, CEV events greater than 50 mL are considered large volume, although other authors have considered CEV events greater than 20 mL to be large volume and previously reported a rate of 0.045% when using power injectors [5].

Acute elbow pain can be the result of traumatic and atraumatic processes. Pathologic processes include osseous, ligamentous, and tendinous etiologies. 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 process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.

Lymphedema is a frequent complication of breast cancer treatment. As the survival rates of breast cancer continue to increase, the number of women with lymphedema will also increase. Surgical treatment of lymphedema has made significant advances during the past 20 years, and our understanding of these procedures continues to evolve. Vascularized lymph node transfer is an increasingly popular option for surgical treatment of lymphedema; however, the mechanism behind symptomatic relief is not fully understood. A proposed theory for improvement in lymphedema symptoms is lymphangiogenesis and spontaneous regeneration of lymphatic vessels, the timing and degree of which are not well defined. We present the case of a 40-year-old woman with a 10-year history of right upper extremity lymphedema secondary to bilateral mastectomy and right axillary lymph node dissection, who subsequently underwent vascularized omental lymph node transfer and lymphovenous bypass with radiographic evidence of spontaneous lymphatic reconnection within 9 months. To our knowledge, this is the earliest reported radiographic evidence of lymphatic regeneration in a human subject to date, adding to the growing body of evidence to support the therapeutic benefits of vascularized lymph node transfers.

Cone-beam CT (CBCT) is a promising tool with increasing applications in musculoskeletal imaging due to its ability to provide thin-section CT images of the appendicular skeleton and introduce weight bearing, which accounts for loading forces that typically interact with and affect this anatomy. CBCT devices include an x-ray source directly opposite a digital silicon detector panel that performs a single rotation around an object of interest, obtaining thin-section images. Currently, the majority of research has been focused on the utility of CBCT with foot and ankle pathologic abnormalities, due to the complex architectural arrangement of the tarsal bones and weight-bearing nature of the lower extremities. Associated software can provide a variety of options for image reconstruction, including metal artifact reduction, three-dimensional biometric measurements, and digitally reconstructed radiographs. Advancements in this technology have allowed imaging of the knee, hip, hand, and elbow. As more data are published, it is becoming evident that CBCT provides many additional benefits, including fast imaging time, low radiation dose, lower cost, and small equipment footprint. These benefits allow placement of CBCT units outside of the traditional radiology department, including the orthopedic clinic setting. These technologic developments have motivated clinicians to define the scope of CBCT for diagnostics, surgical planning, and longitudinal imaging. As efforts are made to create standardized protocol and measurements, the current understanding and surgical approach for various orthopedic pathologic conditions will continue to shift, with the hope of improving outcomes. ©RSNA, 2024 Test Your Knowledge questions for this article are available in the supplemental material.

Colectomy for ulcerative colitis can be followed by ileal pouch formation to enable restoration of bowel continuity. Patients with familial adenomatous polyposis may also undergo pouch formation. The most common long-term problem with pouches is pouchitis, though this can often be treated with antibiotics. Stomas come in many forms but the most common types are ileostomy or colostomy, both of which can be permanent or temporary. The indications and complications of each are discussed. The expertise of a stoma nurse is vital to the management of these patients.

Osteonecrosis is defined as bone death due to inadequate vascular supply. It is sometimes also called "avascular necrosis" and "aseptic necrosis" when involving epiphysis, or "bone infarct" when involving metadiaphysis. Common sites include femoral head, humeral head, tibial metadiaphysis, femoral metadiaphysis, scaphoid, lunate, and talus. Osteonecrosis is thought to be a common condition most commonly affecting adults in third to fifth decades of life. Risk factors for osteonecrosis are numerous and include trauma, corticosteroid therapy, alcohol use, HIV, lymphoma/leukemia, blood dyscrasias, chemotherapy, radiation therapy, Gaucher disease, and Caisson disease. Epiphyseal osteonecrosis can lead to subchondral fracture and secondary osteoarthritis whereas metadiaphyseal cases do not, likely explaining their lack of long-term sequelae. Early diagnosis of osteonecrosis is important: 1) to exclude other causes of patient's pain and 2) to allow for possible early surgical prevention to prevent articular collapse and need for joint replacements. Imaging is also important for preoperative planning. The ACR Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer-reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances in which peer-reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.

PURPOSE: A common arterial pedicle supplying both gracilis and profunda artery perforator (PAP) flap perforasomes is a recently described anatomical variation, favoring the potential harvest of a chimeric gracilis and PAP flap. We sought to characterize this novel flap configuration with three-dimensional (3D) angiography. METHODS: Lower extremity CT angiograms were performed according to standard angiography technique: 5 ml/s contrast injection with bolus tracking. Thin slice (0.6mm) axial reconstructions created multiplanar and volume rendered 3D images. Post-processing (Visage 7.1.15b) consisting of vessel measurements and centerline reconstructions of gracilis and PAP pedicles. Tissues supplied by these vessels were identified by tracing perforator branches, tagging supplied muscle and overlying tissues using semiautomated volume selection. RESULTS: A total of 974 CT angiograms were reviewed, yielding a total of 1,940 lower extremities (RLE= 970, LLE= 970) for evaluation. A chimeric gracilis and PAP flap was found in 51% of patients (N=494/974). Average length of the common arterial pedicle was 31.1 ±16.5 mm (Range = 2.0-95 mm), with an average diameter of 2.8 ±0.7 mm (Range = 1.3-8.8 mm). Average length of downstream gracilis and PAP flap pedicles were 58.0 ±18.7 mm (Range = 9.8-123 mm) and 101.7±27.0 mm (Range = 42.2-183 mm) respectively. 3D rendering yielded an overview of chimeric flap anatomy, allowing for comprehensive volumetric assessment (197.1 ± 29.2 cm3) CONCLUSION: 3D rendering of a chimerically configured gracilis and PAP flap with CT provides an objective assessment of arterial anatomy, flap configuration, and tissue volume for potential use in a clinical setting.

Chaput tubercle is the anterior tubercle of the distal tibia, which serves as the insertion site of the anterior inferior tibiofibular ligament (AITFL). A Chaput tubercle fracture is a rare injury in adults occurring due to an avulsion of the AITFL. The injury has been likened to an adult counterpart of the adolescent Tillaux fracture, which shares a similar mechanism in the immature skeleton. High ankle injuries in adults are substantially less common than low ankle injuries. Their usual mechanism is external rotation in which the talus forces the fibula and tibia apart. Typically, this leads to tearing of the syndesmotic ligaments, with the AITFL being torn first. This pattern of soft tissue injuries occurs in adults because generally bones are stronger than ligaments in the adult skeleton. Less commonly, the bone on either the tibial or fibular side of the AITFL will fail first

This review sets forth an approach to performing and interpreting shoulder ultrasound in patients with prior rotator cuff repair and presents a comprehensive review of normal expected findings, postsurgical complications and common artifacts encountered in clinical practice.

The Kaizen method is an approach to lean process improvement that is based on the idea that small ongoing positive changes can lead to major improvements in efficiency and reduction of waste. The hospital-based CT division at Mayo Clinic Arizona had been receiving numerous concerns of delays in the performance of examinations from inpatients, outpatients, and patients presenting to the emergency department. These concerns, along with a planned hospital expansion, provided the impetus to perform a process improvement project with the goal of reducing inpatient, emergency department, and outpatient turnaround times by 20%. Kaizen process improvement was chosen because of the emphasis on reduction of waste, standardization, and empowerment of frontline staff. The project was led by a process improvement coach who was trained in lean process improvement and A3 thinking. At the end of a weeklong Kaizen event, inpatient turnaround time decreased by 54%, emergency department turnaround time decreased by 29%, and outpatient turnaround time decreased by 45%. These results were achieved and sustained by establishing standardized work, developing frontline problem solvers, instituting visual management, aligning with relevant metrics, emphasizing patient and staff satisfaction, and reducing lead time and non-value-added work. When done properly, a Kaizen event can be an effective tool for process improvement in the health care setting. Online supplemental material is available for this article. ©RSNA, 2022.