Faculty Bibliography

OBJECTIVE:The objective of this article is to review the normal anatomy and posttraumatic findings of the Chopart joint complex. Key imaging features of the normal ligaments and patterns of ligamentous and osseous injuries are discussed. CONCLUSION/CONCLUSIONS:Traumatic midtarsal injuries, particularly midtarsal sprain, are often overlooked clinically and on imaging but are relatively common and typically are associated with inversion ankle injuries. Radiologists should be familiar with Chopart joint anatomy and the imaging features of midtarsal injuries because early diagnosis may help optimize clinical management.

We describe an easily constructed, customizable phantom for magnetic resonance imaging-ultrasound fusion imaging and demonstrate its role as a learning tool to initiate clinical use of this emerging modality. Magnetic resonance imaging-ultrasound fusion can prove unwieldy to integrate into routine practice. We demonstrate real-time fusion with single-sequence magnetic resonance imaging uploaded to the ultrasound console. Phantom training sessions allow radiologists and sonographers to practice fiducial marker selection and improve efficiency with the fusion hardware and software interfaces. Such a tool is useful when the modality is first introduced to a practice and in settings of sporadic use, in which intermittent training may be useful.

OBJECTIVE:Injuries at the calcaneocuboid and talonavicular joint have been described as two distinct, unrelated entities in the radiology literature. Our purpose was to assess the coexistence of these injuries using radiography and MRI and to correlate our findings with radiologic and clinical diagnoses. MATERIALS AND METHODS/METHODS:Twenty-one patients with injury at the anterior calcaneal process on radiographs or MR images were retrospectively assessed for concomitant injury at the talonavicular joint. Radiologic and clinical diagnoses and treatment were documented. McNemar and kappa statistics were calculated; p values < 0.05 were considered statistically significant. RESULTS:Radiographic and MRI rates of detection of injuries across the Chopart joint were statistically different. Calcaneocuboid avulsion fractures were evident on 48% of radiographs and 100% of MR images (p = 0.001). Talonavicular joint injuries were evident on 38% of radiographs and 76% of MR images (p = 0.008). Concomitant injury at both joints was evident on 14% of radiographs and 76% of MR images (p < 0.0001). Interrater agreement was 0.488-0.637 and 0.286-0.364 for talonavicular and 0.144-0.538 and 0.976-1 for calcaneocuboid injuries on radiography and MRI, respectively. Sixty percent of calcaneocuboid fractures were prospectively missed on radiography (none on MRI), whereas 38% and 25% of talonavicular findings were missed on radiography and MRI, respectively. Sixty percent of injuries were clinically misdiagnosed as ankle sprains. Chopart joint injury was never mentioned in prospective clinical or imaging diagnoses. CONCLUSION/CONCLUSIONS:Calcaneocuboid and talonavicular injuries commonly coexist. Radiographs underestimate severity of injury; MR images show more subtle abnormalities. Lack of mention of Chopart joint injury clinically and on imaging reports underlies the need for greater familiarity with this entity.

Purpose: To present a 4 year clinical experience with ultrasound-guided therapeutic perineural injections of upper extremity peripheral nerves and evaluate utility of ultrasound guidance for diagnosis of intrinsic or perineural pathologies. Materials and Methods: A retrospective keyword PACS search was conducted for upper extremity therapeutic perineural injections (May 2012-January 2017), yielding 342 cases. 175 were excluded because no perineural injection was performed. 5 patients underwent injection of more than one nerve during one visit, yielding 174 perineural injections among 130 patients. Retrospective chart review was undertaken to determine patient demographics, clinical indications, presence of structural pathology, as well as presence of pain relief at interval clinical follow-up. Results: 174 injections among 130 patients were reviewed (mean age=57.75 years [15-97], 68 female (52%), 62 male (48%)). The most commonly injected nerves included the ulnar (n=81, 46%) and median (n=61, 35%) nerves. The least common was the suprascapular nerve (n=1, 0.6%). Ultrasound at the time of injection revealed >1 structural abnormality in 110 (63%) cases. The most common was nerve enlargement (n= 101, 92%), although a variety of structural abnormalities were detected, including prior ulnar nerve transposition (n=7, 4%), epicondylitis (n=4, 2%), thickening at the arcade of Frohse (n=3, 2%), low triceps insertion (n=2), ganglion cyst (n=1, 0.5%), anconeus epithrochlearis (n=1, 0.5%), and post-traumatic neuromas (n=1, 0.5%). Interval clinical follow-up was available for 68 patients, of which 51 (75%) reported symptomatic relief. Complications are relatively rare, occurring in only 1 (0.4%) case. Conclusion: Ultrasound-guided perineural injections about the upper extremity can be safely performed and provide lasting symptomatic relief for a variety of clinical indications. Sonographic evaluation at the time of injection allows identification of structural abnormalities that may contribute to neuropathic symptoms and allow more specific targeting, specific therapy, or surgical guidance

Purpose: Assess the impact of MR pelvic and lumbosacral neuorgraphy on ultrasound-guided pelvic perineural injections. Materials and Methods: A retrospective review of all ultrasound-guided pelvic perineural injections with prior MR pelvic and/or lumbosacral neurographic imaging over a 5-year period was performed. Demographics, presence of structural pathology on imaging, and immediate and interval pain relief was recorded. Results: 30 total injections were performed among 20 patients accounting for multiple injections in a single visit or multiple visits [mean age at injection: 52.03 (range 23-77), female (n= 24, 80%) male (n=6; 20%)]. In 24 cases a combination of steroid and anesthetic solution was administered. In the remaining 6 cases, only anesthetic solution was administered. Most commonly, injections involved the sciatic nerve (n = 21; 70%). Other injections in our series include pudendal (n=5, 16.7%), genitofemoral (n=2; 6.7%), lateral femoral cutaneous (n=1, 3.3%) and ilioinguinal (n= 1, 3.3%) nerves. Concurrent therapeutic procedures were performed in 10 cases (33%). Pre-procedure MR imaging revealed structural abnormality of the nerve or adjacent soft tissues in 11 of 22 MRIs performed amongst the 20 patients (50%). Pre-procedure ultrasound revealed structural abnormalities associated with the nerve in 9 cases of 19 cases that had complete documentation (47%). Of 26 injections with complete documentation, immediate improvement of symptoms was reported in 22 cases (85%). The remaining 4 cases either began with no pain (n=3), or reported no change in symptoms (n=1). Variable degrees of long-term symptom relief was achieved in 4 injections out of 11 steroid injections for which follow-up was available (37%). Conclusion: Ultrasound-guided perineural injections can be performed for treatment of a variety of pelvic neuropathies. MR imaging prior to sonographic intervention demonstrated an abnormality in nearly half of cases, and is a useful tool to appropriately target perineural injections

OBJECTIVE: This study determined the frequency and MRI appearance of osseous and ligamentous injuries in midtarsal (Chopart) sprains and their association with ankle sprains after acute ankle injuries. Prospective diagnosis of and interobserver agreement regarding midtarsal injury among musculoskeletal radiologists were also assessed. SUBJECTS AND METHODS: Two cohorts with ankle MRIs were identified via a digital PACS search: patients who had undergone MRI within 8 weeks after ankle injury and control subjects who had not sustained ankle trauma. Studies were retrospectively reviewed in consensus as well as independently, assessing ligamentous and osseous injury to the Chopart joint (calcaneocuboid and talonavicular joints) and associated lateral collateral and deltoid ligamentous injury. Interobserver agreement was calculated, and prospective radiology reports were reviewed to determine the musculoskeletal radiologist's familiarity with Chopart joint injury. RESULTS: MR images of control subjects (n = 16) and patients with ankle injury (n = 47) were reviewed. The normal dorsal calcaneocuboid and calcaneocuboid component of bifurcate ligaments were variably visualized; the remaining normal ligaments were always seen. Eleven patients (23%) had midtarsal ligamentous and osseous injury consistent with midtarsal sprain (eight acute or subacute, one probable, and two old). Six (75%) of eight acute or subacute cases had coexisting lateral collateral ligament injury. Eighty-nine percent of osseous injuries were reported prospectively, but 83% of ligamentous injuries were missed. Substantial interobserver agreement was achieved regarding diagnosis of midtarsal sprain. CONCLUSION: Midtarsal sprains are commonly associated with acute ankle injury and with ankle sprains. Presently, midtarsal sprains may be underrecognized by radiologists; thus, greater familiarity with the MRI spectrum of ligamentous and osseous injuries at the Chopart joint is important for accurate diagnosis and clinical management.

PURPOSE: To correlate shoulder ultrasound and radiography with F-FDG PET-CT to establish FDG uptake and therefore range of metabolic activity, as defined by SUV analysis, in various symptomatic shoulder pathologies. METHODS: Retrospective database query was performed for shoulder ultrasound and PET-CT scans between January 2012 and January 2017. Patients who had both studies within 1 year were included. Age- and sex-matched control patients with PET-CT scans only were also included. Retrospective image review determined shoulder pathology, and F-FDG SUVmax was measured using regions of interest placed at the glenohumeral joint, rotator cuff/bursa, and bicipital groove. Glenohumeral and acromioclavicular osteoarthrosis was assessed by radiography using the Kellgren-Lawrence classification system. RESULTS: Thirty-three patients had both imaging studies within 1 year. Ten patients (11 cases) were included, ranging in age from 56 to 90 years (mean, 67.9 years). Control subjects were selected among patients receiving PET-CT within 1 week of symptomatic patients. Glenohumeral osteoarthrosis was mild in 3 (27%), moderate in 2 (18%), and severe in 2 (18%). Six full-thickness rotator cuff tears (55%) were identified. SUVmax means were compared between the pathologic and control groups and were significantly higher in the former: glenohumeral joint (1.96 vs 1.32; P = 0.016), rotator cuff/bursa (2.80 vs 2.0; P = 0.005), and bicipital groove (2.19 vs 1.48; P = 0.007). The highest values were seen in full-thickness rotator cuff tear and severe biceps tenosynovitis. CONCLUSIONS: Increased metabolic activity about the shoulder is associated with a spectrum of rotator cuff, glenohumeral joint, and other soft tissue pathology that can be correlated with diagnostic ultrasound findings.

OBJECTIVE: To describe a 4-year clinical experience with ultrasound-guided therapeutic perineural injections of peripheral nerves about the foot and ankle. MATERIALS AND METHODS: Retrospective analysis of foot and ankle perineural injections performed between January 2012 and August 2016. Demographics, clinical indications, presence of structural pathology, immediate and interval pain relief, as well as complications were recorded. RESULTS: Fifty-nine therapeutic injections were performed among 46 patients, accounting for multiple injections in a single visit or multiple visits [mean age = 43 years (range 18-75), 31 female (67%) and 15 male (33%)]. Most commonly, perineural injections involved the hallux branch of the medial plantar nerve (n = 17, 22%). Least commonly, perineural injections involved the saphenous nerve (n = 3, 4%). Other injections in our series include sural (10), superficial (11) and deep (7) peroneal, medial (5) and lateral (3) plantar nerves, and the posterior tibial nerve (3). Ultrasound evaluation revealed structural abnormality associated with the nerve in 30 cases (51%)-most commonly thickening with perineural scarring (n = 14). Of 45 injections with complete documentation, immediate relief of symptoms was reported in 43 (96%) cases. Interval symptom relief was achieved in 23 injections [short term (n = 12), intermediate (n = 6), and long term (n = 5)] out of 38 for which follow-up was available (61%). Complications are rare, occurring in only one case. CONCLUSION: Ultrasound-guided perineural injections about the foot and ankle are safe and provide lasting symptomatic relief for many indications. Concomitant sonographic evaluation identifies structural abnormalities that may contribute to neuropathic symptoms, allowing targeting of injection or clinical therapy.

BACKGROUND:The aim of this study is to demonstrate the usefulness of adding 3-dimensional (3D) ultrasound in evaluation of renal transplant vasculature compared to 2-dimensional (2D) Duplex ultrasound. METHODS:One hundred thirteen consecutive renal transplant 2D and 3D ultrasound examinations were performed and retrospectively reviewed by 2 board-certified radiologists and a radiology resident individually; each reviewed 2D and then 3D images, including color and spectral Doppler. They recorded ability to visualize the surgical anastomosis and rated visualization on a subjective scale. Interobserver agreement was evaluated. Variant anastomosis anatomy was recorded. Tortuosity or stenosis was evaluated if localized Doppler velocity elevation was present. RESULTS:The reviewers directly visualized the anastomosis more often with 3D ultrasound ((Equation is included in full-text article.)=97.5%) compared with 2D ((Equation is included in full-text article.)=54.5%) [difference in means (DM) = 43% (95% confidence interval (CI) = 36%-50%) (P < 0.001)]. The reviewers visualized the anastomosis more clearly with 3D ultrasound (P < 0.001) [difference in medians = 0.5, 1.0, and 1.0, (95% CI = 0.5-1.0, 0.5-1.0, and 1.0-1.5)]. Detection of variant anatomy improved with 3D ultrasound by 2 reviewers [DM = 7.1% and 8.9% (95% CI = 1%-13% and 4%-14%, respectively) (P < 0.05)]. There was high interobserver agreement [(Equation is included in full-text article.)= 95.3%, (95% CI = 91.9%-98.7%) regarding anastomosis visualization among reviewers with wide-ranging experience. CONCLUSIONS:Direct visualization of the entire anastomosis was improved with 3D ultrasound. Three-dimensional evaluation improved detection of anatomic variants and identified tortuosity as the likely cause of borderline localized elevation in Doppler velocity. The data added by 3D ultrasound may obviate confirmatory testing with magnetic resonance angiography or computed tomographic angiography after equivocal 2D ultrasound results.

Purpose: Determine the frequency and pattern of Chopart joint injury in acute ankle injuries and assess familiarity of the interpreting radiologists with this injury. To the best of our knowledge this clinically difficult diagnosis has barely been reported in the radiology literature, yet may be important for diagnosis and treatment of calcaneocuboid joint instability. Materials and Methods: Normal Chopart joint: 25 MRIs in 25 patients without clinical or MRI evidence of ankle ligamentous pathology were reviewed to establish normal MRI appearance of the calcanocuboid and talonavicular joints, with attention to the dorsal calcaneocuboid, bifurcate, spring, short and long plantar, and talonavicular ligaments. Chopart joint injury: A digital search for ankle MRIs obtained within 8 weeks of clinical history of acute ankle injury was performed (2/2014-8/2016). The studies were retrospectively reviewed for ligamentous and osseous pathology at Chopart joint. Other relevant findings were recorded: Lateral collateral ligament injury, plantar talar marrow edema, and extensor digitorum brevis (E