Faculty Bibliography

Purpose: Assess, utilizing MRI, the normal maturation and stress injury to the coracoid process and bipolar growth plate, at the interface with the underlying scapula. To the best of our knowledge this has not yet been described in the literature. Materials and Methods: The study was divided into 2 parts: (A) Maturation of the coracoid process and bipolar growth plate. Retrospective review of 182 consecutive shoulder MRIs in 160 children without clinical or MRI evidence of coracoid pathology (107 boys, 53 girls, ages 0 to <5, n=36, 5 to <10, n = 25, 10 to <15, n = 67, and 15 to 18, n = 54). The studies were reviewed with special attention to the development and fusion of the coracoid to the scapula, via the bipolar growth plate. (B) Growth plate injuries. Retrospective review of shoulder MRIs with coracoid growth plate disturbance (7 boys, 1 girl, mean age 15). Results: (A)Maturation of the coracoid process and bipolar growth plate. At 0 to <5 years the cartilaginous coracoid precursor conformed to the shape of a mature coracoid process, with a small oval primary ossification center within it. The bony margins at the coracoid-scapular interface transformed from smooth to irregular with advancing age. At 5 to <10 years of age, a more distinct, undulating, bipolar growth plate developed. Complete closure of the bipolar plate was observed as early as 11 years of age and was noted in 41 % of patients by age 14 and in 86 % of 15 to 18 year olds. (B) Growth plate injuries. The 8 patients with growth plate stress injuries included 2 patients with neuromuscular disorders and 6 patients with sports related symptoms. The growth plate demonstrated widening, irregularity, and increased signal, with surrounding soft tissue and opposing bony marrow edema and hypertrophy. Conclusion: MRimaging of normal maturation as well as stress injury of the base of the coracoid is crucial for accurate imaging diagnosis. Injury to the base of the coracoid, while uncommon, should be considered when assessing adolescents with shoulder symptomatology

Purpose: To characterize the utility of shoulder imaging in the outpatient setting; Define predictor variables for useful shoulder imaging in terms of guiding the selection of the primary diagnosis and treatment Materials and Methods: We conducted a retrospective review of adult patients over a 32 month period evaluated and imaged for a primary complaint of shoulder pain in one of three outpatient settings: (1) orthopaedics, (2) emergency department [ED], and (3) internal medicine [IM]. Our sample population was chosen through a review of electronic medical records, using shoulder related ICD-9 codes and physician names. The main outcome variable for this study was imaging utility. A useful imaging examination was defined as a study that satisfied at least one of the following 4 criteria: changed the clinical diagnosis, guided a change in treatment selection, provided a final diagnosis, or guided definitive treatment. A utility score was assigned to each study based on the number of criteria satisfied (range 0-4) with a score of 0 defined as no utility, 1 low utility, 2 moderate utility, and score of > 3 high utility. For patients receiving multiple sequential imaging studies during their workup, each study was included and scored separately. The potential predictor variables evaluated for useful imaging included age, gender, trauma history, symptom chronicity, and injury setting (sports vs. non-sports). Statistical analysis included 95 % confidence intervals and binary logistic regression. Results: A total of 122 patients (70 female/52 male; mean age 47 years (range 18-84)) underwent a total of 171 imaging studies (109 radiographs/57 MRIs/3 CT/2 ultrasound) as part of their initial workup. 106 studies were ordered from orthopaedics, 64 from ED, and 1 from IM. CT and ultrasound utility were not assessed due to low number of cases. Overall, 95.9 % of the imaging studies met the minimum criteria for utility, most commonly helping guide the selection of a definitive treatment (71.9 %). 30.4 % of the studies were categorized as moderately useful, while 12.9 % were classified as highly useful. 95.4 % of radiographs met the criteria for utility, the majority of which were categorized as low utility (78.9 %). Both sports related injury history and trauma were predictive of at least moderate utility for radiographs (p = 0.039, p = 0.004). Younger age was a significant predictor of at least moderate utility for radiographs, most commonly in patients under 32 (p=0.003, AUC 0.748). 96.5 % of MRIs met the criteria for utility, the majority of which were categorized as moderate or high utility (84.2 %). None of the variables investigated were found to significantly predict MRI utility. For patients undergoing radiographs and MRI, MRI was found more useful than radiographs in 53 % of patients with an average utility score of 2.1. Equal utility was found in 42 % of cases, while radiographs were found most useful in 5 % of patients. Conclusion: Our study suggests that both radiographs and MRI have utility in the outpatient evaluation of shoulder pain. This serves as a potential first step towards the development of evidence based imaging algorithms that can be used and tested in future studies

Purpose: Examine the accuracy of diagnosing adhesive capsulitis (AC) on MRI, using physical exam and clinical impression of an orthopedic sports clinician as the diagnostic reference standard. Materials and Methods: Retrospective query of our digital database was performed to identify all shoulder MRIs performed at our institution in 2013. The first 100 consecutive subjects aged >40 were included for further review. MRI reports were assessed for the presence of the following information: 1. Thickening of the capsule at the axillary recess (AR), 2. Thickening of the coracohumeral ligament (CHL), 3. Infiltration/ edema of subcoracoid fat, 4. Disproportionate fluid within the proximal biceps tendon sheath, and 5. Imaging impression ofAC. Orthopedic notes were assessed for documented range of shoulder motion and overall clinical impression (10 sports fellowship-trained orthopedic surgeons, 1 shoulder and elbow fellowship-trained orthopedic surgeon, and 1 sports medicine trained primary care physician). Sensitivity, specificity, negative predictive value (NPV), positive predictive value (PPV) and overall accuracy were calculated. Fisher exact tests were performed to determine whether each imaging finding was predictive of a positive clinical diagnosis of AC, or likely to predispose to a false positive diagnosis of AC. Results: One hundred shoulder MRI reports in 99 patients were analyzed (59men, 40 women;mean age 58, range 40-87). 17 patients were diagnosed with AC based on imaging findings. Of these patients, frequency of imaging findings included: thickening of the AR (11) or the CHL (8), infiltration of subcoracoid fat (13), and disproportionate fluid in the proximal biceps tendon sheath (3). Six patients had a clinical diagnosis of AC. Fifteen MRIs demonstrated false positive results, while false negative results were seen in 4 cases. The overall sensitivity for theMRI diagnosis of AC was 33.3%with a specificity of 84%. The PPV was 11.8 %,NPV 95.2 %, and overall accuracy 81 %. Fisher exact test P values to determine whether each imaging finding was predictive of a reference standard diagnosis of AC ranged from 0.109 to 1.000. P values to determine whether each imaging finding would lead to a false positive MRI diagnosis were <0.001 for subcoracoid fat infiltration, thickening of the AR, and thickening of the CHL, and p = 1.000 for disproportionate fluid in the biceps tendon sheath. Conclusion: The predictive value of the established MRI findings of adhesive capsulitis may not be as strong as previously shown. Radiologists should be aware of potential imaging over diagnosis and should correlate imaging findings with documented physical exam, when available

Purpose: A routine shoulderMRI protocolwith multi-planar 2D fast spin echo (FSE) sequences usually requires 15-20 min of imaging time.With recent technological advances of multichannel coils and MRI systems, these same sequences can nowbe acquired rapidly using parallel imaging. The purpose of this study was to evaluate if a 5-min shoulder MRI protocol using parallel imaging is interchangeable with a routine shoulder MRI protocol. Materials and Methods: 153 shoulder MRI exams performed on an 8 channel 3 T system (Siemens Verio) with a 4 channel shoulder coil (Invivo) were retrospectively reviewed. All scans included a routine 5 sequence protocol (coronal oblique fat suppressed (fs) PD-weighted and T2-weighted FSE sequences, sagittal oblique fs fluid sensitive and non fs T1-weighted FSE sequences, and an axial fluid sensitive FSE sequence) and 4 fast sequences with an acceleration factor of 2 and slightly larger voxels (coronal oblique, sagittal oblique, and axial fs fluid sensitive sequences and a sagittal oblique non fs T1-weighted sequence). After separation and anonymization of the two protocols, 2 musculoskeletal radiologists independently evaluated the following structures: supraspinatus and infraspinatus tendons (normal/tendinosis, low grade partial-thickness tear, high grade partial-thickness tear, full thickness tear); subscapularis tendon (normal/tendinosis, partial thickness tear, incomplete full thickness tear, and complete full thickness tear); rotator cuff muscle fatty infiltration (none, minimal, mild, moderate, marked); biceps tendon (normal, tendinosis/ partial tear, complete tear); and labrum by quadrant (intact, tear). A test for interchangeability between the fast and routine protocols was performed by comparing the difference between the inter-reader agreement for the routine protocol with the inter-reader agreement when 1 reader was reading the routine protocol and the other reader was reading the fast protocol. Results: The mean age of the patients was 46.75 years (18 - 80) with 85 men and 68 women. The average imaging time was 5 min, 23 s (4:47 - 6:45) for the fast protocol and 14 min, 6 s (12:43 - 16:34) for the routine protocol. The inter-reader agreement for supraspinatus/ infraspinatus pathology was 79.5 % for the routine protocol versus 80.8 % between the routine and fast protocols (95 % CI for difference -5.5 to 2.9 %, p = 0.539). The agreement for subscapularis pathology was 83.4 % for the routine protocol versus 83.4 % between the two protocols (95 % CI -3.8 to 3.8%, p = 1.0). The agreement on muscle fatty infiltration was 89.4 % for the routine protocol versus 91.4 % between the two protocols (95 % CI -4.5 to 0.6 %, p = 0.141). The agreement on biceps pathology was 70.9 % for the routine protocol versus 68.2 % between the two protocols (95 % CI -2.4 to 7.7 %, p = 0.302). The agreement on labrum was between 77.5 and 94.0 % for the routine protocol versus 75.5-93.4 % between the two protocols (95 % CI -3.2 to 6.6 %, p value=0.105-1.0). Conclusion: A 5-min shoulder MRI is clinically interchangeable with a routine shoulderMRI for evaluation of the rotator cuff, biceps tendon and glenoid labrum. Using a 5-min protocol could improve the efficiency and lower the costs of performing a shoulder MRI

Purpose: To evaluate whether there is a correlation between T2/T2* mapping and ultrasound elastography measurements in the supraspinatus tendon. Materials and Methods: Seven shoulders in 6 patients (2 males/4 females; mean age 60.7 years/range 44-72 years) clinically suspected of having rotator cuff pathology underwent shoulder MR imaging, including coronal, sagittal, and axial fat suppressed T2W and sagittal T1W sequences, with the addition of T2 and T2* mapping sequences. The T2 mapping sequence consisted of 2D multi-echo SE sequence with 5 echoes (TR/TE =1000/9.9 ms/DELTATE = 9.9 ms/FA 180degree/b andwidth = 337 Hz/px/ FOV= 128 mm/resolution = 0.5 x 0.5 x 3.0 mm³), while the T2* mapping sequence consisted of 2D multi-echo spoiled GRE sequence with 6 echoes (TR/TE = 428/3.01 ms/DELTATE = 6.33 ms/FA 60degree/bandwidth = 480 Hz/px/ resolution = 0.5 x 0.5 x 3.0 mm3). SNR was estimated using the background ROI method and corrected with the background Rayleigh distribution. T2/T2* maps were constructed inline by using pixelwise monoexponential fit with nonnegative least squares provided by the vendor (MapIt). The anteroposterior (AP) extent, degree of retraction, and percent thickness of tendon tearing, as well as the Goutallier grade of fatty degeneration of the supraspinatus/infraspinatus musculature were measured on the conventional MRI sequences. Each shoulder then underwent ultrasound that included elastography (USE), derived from acoustic radiation force impulse pulses produced by a 9 MHz transducer. Ultrasound shear-wave-velocities (SWV) were obtained in multiple ROIs drawn within the insertional 1-2 cm of the supraspinatus tendon at the mid-portion of the greater tuberosity superior facet using specialized built-in software. ROIs were organized, and averaged when necessary, into three equidistant groups, medial, middle, and lateral, corresponding to their location relative to the tendon insertion. T2 and T2* values were calculated from the T2 and T2* maps using three equidistant ROIs corresponding to the same medial, middle, and lateral locations as on the USE. Statistical analysis included Pearson correlation coefficients (r). Results: Average SNR in the supraspinatus tendon was 26.8 in the T2W images and 59.2 in the T2*W images. Five shoulders had full-thickness supraspinatus tendon tears with mean retraction of 26 mm and AP extent of 21.4 mm, one shoulder had a non-retracted partial-thickness tear involving less than 50 % of the tendon thickness, and one had tendinosis without a tear. All shoulders had Goutallier grade 1-2 fatty degeneration of the supraspinatus/infraspinatus musculature. The mean +/- standard deviation of the values across all ROIs were 9.4 +/- 2.8 m/s for the SWVon USE, 35.2 +/- 9.3 ms on T2 maps, and 21.3 +/- 3.9 ms on T2* maps. There was strong negative correlation between T2* and SWV values when comparing both lateral ROI's (r=-0.92/p = 0.03) and mean of all three ROI locations (r = -0.90/p = 0.04). There was also strong correlation between T2 values and degree of supraspinatus tendon retraction when comparing the mean of all three ROIs (r = 0.79/p=0.03). Conclusion: There may be an association between T2* values measured on MRI and shear wave velocities measured on ultrasound in the degenerated supraspinatus tendon. This has the potential to provide more quantitative information on tendon quality in terms of elasticity on MRI, and, in turn,more clinically useful information to the orthopaedic surgeon planning rotator cuff repair

Purpose: To compare the accuracy of an optimized 3D TSE (SPACE) sequence using SPARSE-SENSE (SS) acceleration with 2D TSE sequences for the detection of internal derangement of the knee. Materials and Methods: An optimized accelerated SPACE sequence prototype was developed using avariable-density poisson-disc undersampling pattern of the two phase-encoding dimensions. Optimized parameters were: TR1100, TE22, TF28, variable flip angle evolution for PD weighting, SS undersampling factor of 9, fat suppression, presence of an optimized MT module, and 0.5 x 0.5 x 0.6 mm3 voxel size. This sequence (TA 4:57) was added to our conventional knee examination (sagittal PD and FS T2, coronal PD and FS PD, axial FS T2 2D TSE sequences (TA 10:56)) for 579 patients undergoing knee MR examinations imaged on a 3T scanner (Magnetom Skyra, Siemens Healthcare). An iterative SS reconstruction [2] was performed by enforcing sparsity in the wavelet representation of the knee images. Images were then reformatted in all 3 orthogonal planes at 1.5mmthickness. 50 of the 579 patients underwent arthroscopy of the knee and two experienced MSK radiologists blindly reviewed the SS SPACE sequence and the conventional 2D TSE sequences of these 50 patients at separate sittings to evaluate for the presence of meniscal or ligamentous tears. Results: 38 patients hadmedialmeniscal tears, 23 had lateral meniscal tears, and 16 had ACL tears. There was only 1 MCLand PCL tear and there were no LCL tears. The sensitivity, specificity, and accuracy for medial meniscal, lateral meniscal, and ACL tears on the 2D TSE images and SS Space images for each reader are presented below. Sensitivity Specificity Accuracy Sensitivity Specificity Accuracy Conclusion: An optimized and accelerated 3D TSE sequence has the potential to replace 2D TSE sequences for evaluation of internal derangement of the knee. If substantiated in larger clinical studies, this could lead to significant shortening of exam time, potentially enlarging the indication and utilization of knee MR as well as decreasing its cost

Purpose: iBalance high tibial osteotomy, (iHTO, Arthrex Inc, Naples, Florida), is a recently introduced surgical procedure for correction of knee varus malalignment. iHTO, utilizing a polyetheretherketone (PEEK) implant and osteoinductive compounds (OIC), presents challenging post operative radiographs which can easily be misinterpreted as infection. Our purpose is to report, based on review of 24 cases, the previously undescribed to the best of our knowledge, radiographic features of iHTO and its complications. Materials and Methods: Retrospective query of our digital database was performed to identify iHTO cases. The clinical and postsurgical images in all cases with > 1-month follow up imaging were reviewed with attention to 1. Correction of varus malalignment, 2. Healing at the osteotomy site, 3. Changes in the OIC, and 4. Complications. Results: There were 24 iHTOs in 23 patients (17 men, 6 women, ages 21-59, mean 44, median 46), imaged 1 to 29 months post-surgery, with angle of correction, when available, ranging from 5 to 14degree. Immediate post-surgical correction of varus malalignment was seen in 100 % of patients. 100 % depicted oval radiolucencies, at bone PEEK interface simulating erosions and infection. Four, often overlapping, signs of healing were noted: 1. Blurring of bony margins at the osteotomy site, noted within 2 weeks post surgery, 2. Blurring of sharp interface between OIC and host bone, 3. Anterior, posterior and less commonly medial bridging callus, 4. Resorption of OIC, noted as early as 4 months. Complications, seen in 7 cases (29 %), included genu varum recurrence (n = 2), painful exuberant bone formation, (n = 1), and propagation of the osteotomy through the lateral tibial cortex (n = 4). In patients with >6 months follow-up, nonunion and possible infection was seen in 1 patient. 2 patients required total knee arthroplasty due to iHTO failure. Conclusion: iBalance HTO typically depicts oval radiolucencies at the PEEK bone interface not to be mistaken for infection. Familiarity with this features, as well as with other signs of healing, should aid the radiologist in accurate interpretation of post operative films of iHTO patients

Purpose: (1) To analyze the use of multi-segmental computed tomography (CT) imaging in the emergency department (ED) for patients with a primary spine complaint in terms of diagnosing new, clinically relevant pathology; (2) To define predictor variable( s) for new pathology on ED CT spine imaging Materials and Methods: We performed a retrospective review of multi-segmental CT performed in the ED over a 24-month period for patients presenting with primary spine related complaints. Multi-segmental CT was defined as an examination that included more than one spine segment (cervical, thoracic, and/or lumbar). The data reviewed for each patient included age, gender, chief complaint, patient history, physical examination findings, ED management, and pertinent imaging. New pathology on CT was defined as a new fracture, progression of a known vertebral body compression fracture, new disc herniation, new discitis/osteomyelitis, new ligament injury, and/or new metastasis. Potential predictor variables evaluated included age, gender, history of trauma, and history of malignancy. Statistical analysis included Fisher's exact test, logistic regression, and ROC curve analysis. Results: Forty-two patients, 22 males/20 females (mean age of 70.4 years; range 29-96), were included in the study. There were 32 total spine examinations, 9 thoracolumbar examinations, and 1 cervicothoracic examination, and 116 spinal segments imaged, overall. Fifty percent of the imaging examinations (44 % total spine; 70 % non-total spine) demonstrated a new imaging finding. The most common finding was an acute fracture (16), including four patients who had new pathologic fractures of the vertebral bodies secondary to new metastatic disease. Overall, 22.4 % (26/116) of the imaged segments revealed new pathology, 29.3 % lumbar spine, 21.4 % thoracic spine, and 15.2 % cervical spine. New pathology seen on imaging directly corresponded to findings in the patient's clinical history and/or physical examination in 30 % of the imaged segments, most common in the lumbar spine (34.5 %) and least common in the cervical spine (20 %). New imaging findings were found in 15 % of segments that had no corresponding finding in the patient's clinical history or on physical examination, most common in the lumbar spine (16.7 %). History of cancer, trauma, and/or gender were not found to be predictive for new findings on CT, while age was found to be a significant predictor (p = 0.015). When age was used to predict whether new pathology would be detected in spine segments without concern based on clinical history and/or physical examination, area under the ROC curve was 0.741. If a decision rule was created for our study patients such that, 1) patients > 70 years undergo imaging of all three spine segments, and 2) patients < 70 years undergo imaging only where clinical history or physical exam suggest reason for concern, a 24.3 % reduction in imaging would have been realized while maintaining an accuracy of 96.2 % in uncovering new pathology. Conclusion: Our study suggests that spine CT imaging may be overutilized in the emergency department. The use of a patient age threshold may allow for better CT utilization and reduce unnecessary imaging in this setting

OBJECTIVE: The objectives of the article are to improve the radiologist's understanding of shoulder arthroscopy and see how it correlates with MRI. We review the basic principles of arthroscopy followed by a comparison of its strengths and weaknesses relative to MRI. This discussion is supplemented by a series of cases that show the relationship between arthroscopy and MRI in terms of the visualization of normal and abnormal anatomy in the diagnosis of common shoulder abnormalities. CONCLUSION: By understanding what our orthopedic colleagues are seeing (and not seeing) during arthroscopic shoulder surgery, we can better understand the strengths and weaknesses of MRI, which provides us the opportunity to improve our imaging interpretations and produce valuable management-guiding diagnostic reports.

BACKGROUND: Gout and osteoarthritis (OA) are the most prevalent arthritides, but their relationship is neither well established nor well understood. OBJECTIVES: We assessed whether a diagnosis of gout or asymptomatic hyperuricemia (AH) is associated with increased prevalence/severity of knee OA. METHODS: One hundred nineteen male patients aged 55 to 85 years were sequentially enrolled from the primary care clinics of an urban Veterans Affairs hospital, assessed and categorized into 3 groups: gout (American College of Rheumatology Classification Criteria), AH (serum urate >/=6.8 mg/dL, no gout), and control (serum urate <6.8 mg/dL, no gout). Twenty-five patients from each group subsequently underwent formal assessment of knee OA presence and severity (American College of Rheumatology Clinical/Radiographic Criteria, Kellgren-Lawrence grade). Musculoskeletal ultrasound was used to detect monosodium urate deposition at the knees and first metatarsophalangeal joints. RESULTS: The study showed 68.0% of gout, 52.0% of AH, and 28.0% of age-matched control subjects had knee OA (gout vs control, P = 0.017). Odds ratio for knee OA in gout versus control subjects was 5.46 prior to and 3.80 after adjusting for body mass index. Gout subjects also had higher Kellgren-Lawrence grades than did the control subjects (P = 0.001). Subjects with sonographically detected monosodium urate crystal deposition on cartilage were more likely to have OA than those without (60.0 vs 27.5%, P = 0.037), with crystal deposition at the first metatarsophalangeal joints correlating most closely with OA knee involvement. CONCLUSIONS: Knee OA was more prevalent in gout patients versus control subjects and intermediate in AH. Knee OA was more severe in gout patients versus control subjects.