http://www.medscape.com/viewarticle/769156
Tibial Stress Injury: Relationship of Radiographic, Nuclear Medicine Bone Scanning, MR Imaging, and CT Severity Grades to Clinical Severity and Time to Healing
Beck BR, Bergman AG, Miner M, et al
Radiology. 2012;263:811-818
Radiology. 2012;263:811-818
Tibial stress injury: relationship of radiographic, nuclear medicine bone scanning, MR imaging, and CT Severity grades to clinical severity and time to healing.
Radiology. 2012; 263(3):811-8 (ISSN: 1527-1315)
Beck BR; Bergman AG; Miner M; Arendt EA; Klevansky AB; Matheson GO; Norling TL; Marcus R
School of Physiotherapy and Exercise Science, Centre for Musculoskeletal Research, Griffith University, Gold Coast campus, Griffth, QLD 4222, Australia. b.beck@griffith.edu.au
PURPOSE: To examine the relationship between severity grade for radiography, triple-phase technetium 99m nuclear medicine bone scanning, magnetic resonance (MR) imaging, and computed tomography (CT); clinical severity; and recovery time from a tibial stress injury (TSI), as well as to evaluate interassessor grading reliability.
MATERIALS AND METHODS: This protocol was approved by the Griffith University Human Research Ethics Committee, the Stanford University Panel on Human Subjects in Medical Research, the U.S. Army Human Subjects Research Review Board, and the Australian Defense Human Research Ethics Committee. Informed consent was obtained from all subjects. Forty subjects (17 men, 23 women; mean age, 26.2 years ± 6.9 [standard deviation]) with TSI were enrolled. Subjects were examined acutely with standard anteroposterior and lateral radiography, nuclear medicine scanning, MR imaging, and CT. Each modality was graded by four blinded clinicians. Mixed-effects models were used to examine associations between image severity, clinical severity, and time to healing, with adjustments for image modality and assessor. Grading reliability was evaluated with the Cronbach α coefficient.
RESULTS: Image assessment reliability was high for all grading systems except radiography, which was moderate (α = 0.565-0.895). Clinical severity was negatively associated with MR imaging severity (P ≤ .001). There was no significant relationship between time to healing and severity score for any imaging modality, although a positive trend existed for MR imaging (P = .07).
CONCLUSION: TSI clinical severity was negatively related to MR imaging severity. Radiographic, bone scan, and CT severity were not related to time to healing, but there was a positive trend for MR imaging.
- PreMedline Identifier: 22623695
From MEDLINE®/PubMed®, a database of the U.S. National Library of Medicine.
Tibial stress injury: relationship of radiographic, nuclear medicine bone scanning, MR imaging, and CT Severity grades to clinical severity and time to healing.
Radiology. 2012; 263(3):811-8 (ISSN: 1527-1315)
Beck BR; Bergman AG; Miner M; Arendt EA; Klevansky AB; Matheson GO; Norling TL; Marcus R
School of Physiotherapy and Exercise Science, Centre for Musculoskeletal Research, Griffith University, Gold Coast campus, Griffth, QLD 4222, Australia. b.beck@griffith.edu.au
School of Physiotherapy and Exercise Science, Centre for Musculoskeletal Research, Griffith University, Gold Coast campus, Griffth, QLD 4222, Australia. b.beck@griffith.edu.au
PURPOSE: To examine the relationship between severity grade for radiography, triple-phase technetium 99m nuclear medicine bone scanning, magnetic resonance (MR) imaging, and computed tomography (CT); clinical severity; and recovery time from a tibial stress injury (TSI), as well as to evaluate interassessor grading reliability.
MATERIALS AND METHODS: This protocol was approved by the Griffith University Human Research Ethics Committee, the Stanford University Panel on Human Subjects in Medical Research, the U.S. Army Human Subjects Research Review Board, and the Australian Defense Human Research Ethics Committee. Informed consent was obtained from all subjects. Forty subjects (17 men, 23 women; mean age, 26.2 years ± 6.9 [standard deviation]) with TSI were enrolled. Subjects were examined acutely with standard anteroposterior and lateral radiography, nuclear medicine scanning, MR imaging, and CT. Each modality was graded by four blinded clinicians. Mixed-effects models were used to examine associations between image severity, clinical severity, and time to healing, with adjustments for image modality and assessor. Grading reliability was evaluated with the Cronbach α coefficient.
RESULTS: Image assessment reliability was high for all grading systems except radiography, which was moderate (α = 0.565-0.895). Clinical severity was negatively associated with MR imaging severity (P ≤ .001). There was no significant relationship between time to healing and severity score for any imaging modality, although a positive trend existed for MR imaging (P = .07).
CONCLUSION: TSI clinical severity was negatively related to MR imaging severity. Radiographic, bone scan, and CT severity were not related to time to healing, but there was a positive trend for MR imaging.
- PreMedline Identifier: 22623695
From MEDLINE®/PubMed®, a database of the U.S. National Library of Medicine.
Summary
This multicenter study examined the comparative relationship among severity grades of tibial stress injury (TSI) that were evaluated by several imaging modalities. The study cohort included 40 patients who underwent standard anteroposterior and lateral radiography, scintigraphy, MRI, and CT. Associations among image severity, clinical severity, and time to healing were assessed after adjustment for image modality and assessor (4 blinded clinicians). An injury was considered to be healed when the patient could hop on the affected limb for 30 seconds to a height of 10 cm without pain.[1]
Clinical severity was negatively associated with MRI severity. No statistically significant relationship was found between time to healing and severity score for any of the imaging modalities.
Viewpoint
TSI is relatively common in military recruits and athletes. Imaging plays an important role in diagnosing the injury. Bone scanning has been considered the gold standard for imaging-based diagnosis of TSI. However, although this imaging modality is sensitive, specificity is low.[2]
Beck and colleagues' study systematically compared 4 imaging modalities in this important clinical setting. A pivotal issue is whether imaging can accurately predict time to healing in TSI, because that may have practical implications (eg, return to athletic activity). In this study, MRI was the most relevant in diagnosing early TSI (marrow edema); in addition, MRI-based severity had a positive, although statistically insignificant, relationship with time to healing.
The investigators suggested that MRI may be the most sensitive imaging modality for detecting TSI and predicting time to healing. However, additional studies are needed to corroborate with these conclusions.
References
- Swenson EJ Jr, DeHaven KE, Sebastianelli WJ, Hanks G, Kalenak A, Lynch JM. The effects of a pneumatic leg brace on return to play in athletes with tibial stress fractures. Am J Sports Med. 1997;25:322-328. Abstract
- Chisin R, Milgrom C, Giladi M, Stein M, Margulies J, Kashtan H. Clinical significance of nonfocal scintigraphic findings in suspected tibial stress fractures. Clin Orthop Relat Res. 1987;220:200-205. Abstract
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