Faculty Bibliography

OBJECTIVE: To investigate whether carpometacarpal (CMC) injections can be performed accurately in the office setting in patients with moderate to severe CMC osteoarthritis (OA). METHODS: Patients were recruited from rheumatology and hand surgical practices as part of an open label trial of hylan G-F 20 for CMC OA. CMC injections were performed without radiologic guidance, using anatomic landmarks to guide needle placement. Once injected, the patient was immediately taken to an adjacent ultrasound suite, and the injected CMC joint examined for evidence of intraarticular material and air microbubbles. RESULTS: Thirty-two patients were injected. All patients had ultrasound evidence of intraarticular material: 91% also had evidence of microbubbles in the joint. CONCLUSION: CMC injections can be performed accurately in the office setting, without the need for radiologic guidance, in patients with moderate to severe CMC OA.

Technical advances in imaging have increased their applicability to diagnosing conditions of the musculoskeletal system, especially in the postoperative setting, where traditionally metallic artifacts have hindered evaluation. Advances in computed tomography (CT), magnetic resonance (MR) imaging, ultrasound, and nuclear medicine have resulted in improved overall image quality. Specific modifications of imaging parameters, especially in CT and MRI, have improved the radiologist's ability to diagnose potential hardware complications such as loosening and osteolysis. Sonography can evaluate the periprosthetic soft tissues and enables both diagnostic information and therapeutic treatment at the same sitting. Lastly, diagnostic scintigraphic applications such as positron emission tomography (PET) have increased specificity in diagnosing potential infection in the arthroplasty setting. This review discusses some of the current applications of CT, MRI, ultrasound, and nuclear medicine in evaluating the postoperative orthopedic patient, concentrating on the appropriate imaging evaluation for the painful arthroplasty patient.

Haglund's syndrome is a cause of retrocalcaneal pain. The clinical diagnosis of Haglund's syndrome is often confusing as the clinical picture may mimic other causes of hindfoot pain such as isolated retrocalcaneal bursitis or hindfoot involvement from more systemic arthropathies such as Reiter's syndrome or rheumatoid arthritis. With the increasing frequency of employing sonography as a diagnostic tool in the evaluation of foot and ankle pathology, recognition of the sonographic appearance of Haglund's complex is important. We report a case of Haglund's syndrome diagnosed and treated with sonography.

Calcific myonecrosis, often reported in the setting of prior trauma or compartment syndrome, has traditionally been treated with surgical debridement; however, these cases are often complicated by poor wound closure and poor healing. Serial percutaneous aspirations, instead, have been proposed as an alternative treatment option. This is the first report, to our knowledge, of the use of ultrasound guidance in the aspiration of calcific myonecrosis as an aid in management.

BACKGROUND: It has been assumed that a robust vascular response at the tendon to bone interface during rotator cuff repairs is an integral part to the healing process. There are few studies that have explored this in an in-vivo prospective fashion. PURPOSE: To prospectively characterize vascular and anatomical patterns in repaired rotator cuff tendons using Power Doppler sonography in a double-blinded fashion. STUDY DESIGN: Case control study; Level of evidence, 3. METHODS: Fifty patients undergoing rotator cuff repair were enrolled: 28 mini-open, 14 open, and 8 arthroscopic repairs; 20 patients were controls. Patients underwent Power Doppler sonography at 6 weeks, 3 months, and 6 months postoperatively. Power Doppler sonography analysis examined 6 areas of the rotator cuff repair: discretely marginated intrasubstance, partial-thickness defects, full-thickness defects, focal thinning of repair, presence of bursal or joint fluid, and location of anchors. A subjective scoring system assessed blood flow in each region. RESULTS: There was a predictable, significant decrease in vascular scores after rotator cuff repair over time. The mean vascular score was 11.6 at 6 weeks, 8.3 at 3 months, 7.0 at 6 months, and 2.4 for controls. There was a significant difference (P < .05) in vascular recruitment scores between each time period, with the most robust flow at the peritendinous region. The lowest vascular score was at the anchor site or cancellous trough. Forty-eight percent of the patients had a rotator cuff repair defect postoperatively. These findings did not correlate with functional assessment and outcome at 6 months. There was no significant difference in vascular scores between the defect and no-defect groups. Mean University of California, Los Angeles; L'Insalata; and American Shoulder and Elbow Surgeons scores at 6 months were 28.6, 86.3, and 81.5, respectively. Thirty-three percent of asymptomatic controls had a rotator cuff tear that averaged 7.6 x 7.1 mm. CONCLUSION: The robust vascular response dropped with time, which is not seen in asymptomatic shoulders. Nearly half of the patients demonstrated persistent rotator cuff defects after rotator cuff repair that did not correlate with functional outcome and physical findings at 6 months.

This article describes the sonographic appearance of a variety of soft tissue masses. We review the current indications for performing musculoskeletal sonography as a screening and diagnostic tool in the clinical management of soft tissue masses.

OBJECTIVE: Our objective was to review our experience performing sonography-guided iliopsoas bursal/peritendinous injections as a diagnostic and therapeutic tool in the workup and treatment of patients with hip pain. CONCLUSION: Sonography-guided iliopsoas bursal/peritendinous injections are useful in determining the cause of hip pain. They can provide relief to most patients with iliopsoas tendinosis/bursitis after hip replacement. The results of injection alone are not as successful in cases of idiopathic iliopsoas tendinosis/bursitis, but the technique can help determine which patients may benefit from a surgical tendon release.

PURPOSE: The authors believe that ultrasound as a primary method of image guidance for performing hip aspirations is underutilized, and the authors report their experience in performing ultrasound-guided hip injections in 358 patients, using a free-hand technique. MATERIALS AND METHODS: A retrospective review of all adult ultrasound-guided hip injections performed at the authors' institution over a four-year period was performed. RESULTS: Retrospective review of an ultrasound database revealed 358 adult hip aspirations/injections were performed at the authors' institution from October 2000-October 2004. All procedures were performed using a longitudinal, anterior approach and without the use of a needle guide. There were no reported cases of inadvertent vascular or femoral nerve puncture. CONCLUSIONS: To the authors' knowledge, this is the largest reported series of sonographically-guided adult hip aspirations/injections without the use of a needle guide. The authors believe that ultrasound as a primary method of image guidance for performing hip aspirations is underutilized. The absence of radiation and relatively short procedure time of ultrasound-guided hip injections are favorable factors to both the authors' referring clinician population as well as the patients.

The choice to use MR imaging or ultrasound to depict tendon pathology has traditionally depended on the imager's level of experience and comfort with the modality, and less so the individual strengths of either modality. Although this may be an acceptable rationale, it does not fully take advantage of the strength of either modality or the potential benefits of combining both modalities. This article demonstrates the complementary roles of these two modalities through a variety of clinical examples, based on experience working in a subspecialty hospital dedicated to orthopedic and rheumatologic diseases.