Faculty Bibliography

Background Information: Ultrasound-guided joint injection is an efficient and cost-effective means of safely administering therapeutic medications into various joints, most commonly the hip and shoulder joints. Advantages over more traditional fluoroscopic guidance include lack of ionizing radiation, relative ease of access, mobility, and reduced costs. Ultrasound can be made available in an office or out-patient setting. However, ultrasound is operator-dependent, and there are a number of potential technical pitfalls. Consequently, many radiologists are more comfortable with fluoroscopy. The purpose of this exhibit is to address technical issues and potential pitfalls using ultrasound guidance for joint injection and to enable the radiologist to become more comfortable and confident in using this approach. Educational Goals/Teaching Points: This exhibit will describe the application of ultrasound-guided joint injection with technical tips and tricks and highlight the common pitfalls and technical issues encountered and how to avoid and overcome them. Key Anatomic/Physiologic Issues and Imaging Findings/Techniques: Multiple joints are amenable to ultrasound-guided injection. Ultrasound-guided therapeutic injection with a combination of steroid and local anesthetic is most commonly requested in the hip and shoulder joints. Around the knee joint, aspiration of popliteal cysts with subsequent therapeutic injection is also commonly performed. Ankle joints, metatarsophalangeal joints, and elbow joints may also be injected using sonographic guidance. The general principles of ultrasound-guided joint injection are discussed and the technique and optimal approach for each individual joint are described. Commonly encountered technical problems include difficulty in initially localizing the anatomy, problems with orientation, difficulty in seeing the needle, obscuration of the window or FOV due to bony structures or introduction of gas, and difficulty in breaching thick capsules. The means of overcoming !

The purpose of this study was to investigate the association of aortic arch calcification, a surrogate marker of atherosclerosis, with rotator cuff tendinosis and tears given the hypothesis that decreased tendon vascularity is a contributing factor in the etiology of tendon degeneration. A retrospective review was performed to identify patients ages 50 to 90 years who had a shoulder MRI and a chest radiograph performed within 6 months of each other. Chest radiographs and shoulder MRIs from 120 patients were reviewed by two sets of observers blinded to the others' conclusions. Rotator cuff disease was classified as tendinosis, partial thickness tear, and full thickness tear. The presence or absence of aortic arch calcification was graded and compared with the MRI appearance of the rotator cuff. The tendon tear grading was positively correlated with patient age. However, the tendon tear grading on MRI was not significantly correlated with the aorta calcification scores on chest radiographs. Furthermore, there was no significant correlation between aorta calcification severity and tendon tear grading. In conclusion, rotator cuff tears did not significantly correlate with aortic calcification severity. This suggests that tendon ischemia may not be associated with the degree of macrovascular disease

The purpose of this study was to evaluate non-contrast magnetic resonance imaging (MRI) findings of adhesive capsulitis and correlate them with clinical stages of adhesive capsulitis. This will hopefully define a role for shoulder MR imaging in the diagnosis of adhesive capsulitis as well as in potentially directing appropriate treatment. Forty-seven consecutive non-contrast magnetic resonance imaging examinations of 46 patients with a clinical diagnosis of adhesive capsulitis were retrospectively reviewed and correlated with clinical staging. Specific MRI criteria correlated with the clinical stage of adhesive capsulitis, including the thickness and signal intensity of the joint capsule and synovium as well as the presence and severity of scarring in the rotator interval. Routine MRI of the shoulder without intraarticular administration of gadolinium can be used to diagnose all stages of adhesive capsulitis, including stage 1, where findings may be subtle on clinical examination. We believe that future studies assessing the role of MRI in guiding the initiation of appropriate treatment should be undertaken

PURPOSE: To describe the procedure of ultrasound-guided Morton's neuroma and recurrent stump neuroma injections and early clinical outcomes after a single injection. MATERIALS AND METHODS: Retrospective review of 44 percutaneous ultrasound-guided neuroma injections in 24 patients who had completed clinical outcomes questionnaires. A 10-point pain scale [scale of 1 (no pain) to 10 (severe pain)] in a 7-day pain log format was distributed to patients at the time percutaneous neuroma injection was performed. RESULTS: Neuromas were clearly visualized with sonography as hypoechoic nodules and were distinguishable from other causes of forefoot pain, such as metatarsophalangeal joint synovitis and intermetatarsal bursae. The sizes of the neuromas injected ranged between 4 and 19 mm. Postinjection, all neuromas displayed increased echogenicity and/or the appearance of fluid surrounding it, confirming localization of the therapeutic mixture. We arbitrarily subdivided the pain ratings into symptomatic (greater than 4) and asymptomatic (less than or equal to 4) for statistical analysis. Average pain level pre injection was 5.2 and average pain level was 3.7 at 7 days post single injection, with 62% of the initially symptomatic patients asymptomatic on day 7 (p < 0.000001). Overall, 76% of the total number of neuromas injected once were asymptomatic on day 7. CONCLUSION: Ultrasound can be used to accurately target Morton's neuromas and, therefore, appropriately direct therapeutic interventions, with good short-term clinical results

We describe a 41-year-old man with a 1-week history of nausea and vomiting 1 month after chemoembolization of a liver metastasis. The patient subsequently became febrile and developed right upper quadrant abdominal and midback pain. Findings of initial laboratory and imaging studies (a noncontrast computed tomographic [CT] scan and ultrasound) were not remarkable. Hepatobiliary scintigraphy, performed to rule out cholecystitis, revealed an abnormal area in the right lobe of the liver consistent with a focal bile leak into an abscess cavity. The patient was subsequently treated for liver abscess. In conclusion, hepatobiliary scintigraphy should be considered as a first-line test in the work-up of patients whenever a postchemoembolization complication is considered likely