Faculty Bibliography

Purpose: To demonstrate that sonographic morphologic properties of the supraspinatus tendon correlate with mechanical properties, as assessed quantitatively by shear-wave ultrasound elastography.
Material(s) and Method(s): This retrospective study included 36 patients who underwent sonographic evaluation of one or both shoulders on one or multiple dates from June 2013 through October 2014. A shoulder was excluded if the supraspinatus tendon contained calcifications or had undergone surgical repair for a tear. Each sonographic evaluation of each shoulder was regarded as a separate data point, totaling 76 sonographic evaluations of 36 patients. For each sonographic evaluation, the morphologic appearance of the proximal and distal supraspinatus tendon was graded (1 = normal or mild tendinosis without a tear, 2 = moderate or severe tendinosis without a tear, 3 = partial tear, 4 = full-thickness tear) by consensus of 2 musculoskeletal radiologists. In addition, for each sonographic evaluation, sample volumes were randomly placed within the proximal and distal supraspinatus tendon, viewed in the longitudinal dimension, to obtain shear-wave ultrasound elastography measurements. Finally, for 68 of the sonographic evaluations, on the same image used for sample volumes of the supraspinatus tendon, sample volumes were randomly placed within the deltoid muscle to obtain shear-wave ultrasound elastography measurements. Spearman rank correlations assessed the association between tendonmorphology grade and elastographymeasurements. Mann-Whitney tests compared elastography measurements between scans grouped by symptomatology or morphology grade. Bootstrap re-sampling procedures accounted for lack of statistical independence among scans of the same patient.
Result(s): Of the 36 patients, there were 21 males and 15 females (mean age 46, range 23-74). Of the 76 sonographic evaluations, there were 38 males and 38 females (mean age 44, range 23-74), 36 right and 40 left shoulders, and 21 symptomatic and 55 asymptomatic shoulders. The tendon morphology grade and elastography measurements were correlated in both the proximal (p < 0.001) and distal (p = 0.002) supraspinatus tendon. Comparing between grade 1 and grade >= 2 morphology, the elastography measurements differed significantly in both the proximal (p = 0.001) and distal (p = 0.012) supraspinatus tendon. Comparing between grade <= 2 and grade > 2 morphology, the elastography measurements also differed significantly in both the proximal (p = 0.002) and distal (p = 0.004) supraspinatus tendon. Interestingly, deltoid muscle elastography measurements also were associated with the morphology grade of the proximal (p = 0.004) and distal (p = 0.007) supraspinatus tendon; this measurement also differed significantly between asymptomatic and symptomatic scans (p = 0.001).
Conclusion(s): The sonographic morphologic properties of the supraspinatus tendon correlate with mechanical properties, as assessed by shear-wave ultrasound elastography. These findings indicate that shear-wave ultrasound elastography - a non-invasive, relatively inexpensive, and simple examination - can provide an objective measurement of tendon elasticity. Correlation of deltoid muscle elasticity with supraspinatus tendon morphology and symptomatology may be related to the two muscles being a force couple. Further research is needed to assess whether tendon elastography measurements correlate with the MRI morphologic appearance of the tendon and with intraoperative evaluation of tendon quality

Substantial cost, morbidity, and mortality are associated with acute proximal femoral fracture and may be reduced through an optimized diagnostic imaging workup. Radiography represents the primary diagnostic test of choice for the evaluation of acute hip pain. In middle aged and elderly patients with negative radiographs, the evidence indicates MRI to be the next diagnostic imaging study to exclude a proximal femoral fracture. CT, because of its relative decreased sensitivity, is only indicated in patients with MRI contraindications. Bone densitometry (DXA) should be obtained in patients with fragility fractures. The ACR Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed every 2 years by a multidisciplinary expert panel. The guideline development and review include an extensive analysis of current medical literature from peer-reviewed journals and the application of a well-established consensus methodology (modified Delphi) to rate the appropriateness of imaging and treatment procedures by the panel. In those instances where evidence is lacking or not definitive, expert opinion may be used to recommend imaging or treatment.

This article provides a brief overview of the current state of ultrasound (US) imaging of rotator cuff repairs with emphasis on current morphological assessment and development of newer techniques in which US may play an important role in assessing healing response. Emphasis is on the supraspinatus tendon inasmuch as it is the most commonly affected tendon in rotator cuff disease. Assessment of the tendon repair following joint replacement is also commented on in which the standard anterior approach may be associated with dehiscence of the subscapularis tendon.

OBJECTIVE: To investigate the efficacy of using contrast-enhanced ultrasound to assess the relationship of altered vascularity and tendon morphology following injection of platelet-rich plasma (PRP) for lateral epicondylitis. MATERIALS AND METHODS: This study prospectively evaluated six patients who had a baseline ultrasound confirming tendinosis of the common extensor tendon. Patients received a single 3-ml PRP injection under ultrasound guidance. Grayscale images of the injected elbow were obtained at baseline and were repeated at 1 and 6 months after injection. DEFINITY(R) contrast was also injected after by 2 sets of wrist-extension exercises in order to obtain contrast-enhanced images of the elbow. Qualitative and quantitative analyses of the level of enhancement to the regions of interest were performed using off-line quantitative analysis software. RESULTS: All patients had either moderate or severe common extensor tendinosis as determined on clinical examination and baseline imaging. Five patients demonstrated improved tendon morphology using ultrasound imaging 6 months after PRP injection (one patient was lost to follow-up). At baseline, there was evidence of increased vascularity at the myotendinous junction (MT) of the common extensor tendon when compared to its footprint (FP). There was a trend towards no change in FP vascularity between baseline and 6 months (p = 0.062) and between 1 and 6 months (p = 0.288). There was a trend for increased vascularity to the MT region from baseline to 6 months (p = 0.433) and from 1 to 6 months (p = 0.783). CONCLUSIONS: Contrast-enhanced ultrasound provides a sensitive method the display alterations in vascularity in the common extensor tendon of the elbow. PRP therapy for lateral epicondylitis can improve extensor tendon morphology. Corresponding increased extensor tendon FP vascularity, however, was not seen. There is a trend for increased vascularity at the MT up to 6 months following PRP injection, based on limited pilot data.

Chronic peripheral nerve pain is a common problem that can arise from numerous causes, for which neurolysis is a therapeutic option. It is postulated that cryotherapy will have less adverse events than other methods of nerve ablation. A retrospective case series review was performed in patients who had undergone sonographically guided cryoneurolysis for Morton neuromas, postsurgical and posttraumatic neuromas, and idiopathic neuralgia. Fifteen of 20 patients had a positive response to cryoneurolysis, as did 2 of 4 patients with borderline symptoms for chronic regional pain syndrome. In view of our positive results, we believe that cryoneurolysis should be considered a reasonable option in performing neurolytic therapy.

OBJECTIVE: Characterization of the distribution and imaging characteristics of platelet-rich plasma (PRP) and autologous blood after injection is currently limited despite the growing use. We sought to improve understanding of the distribution of PRP or autologous blood after it has been injected into a tendon to evaluate whether injected materials truly stayed within the local region of injection. MATERIALS AND METHODS: Fifty ultrasound-guided PRP or autologous blood injections performed for tendinopathy were retrospectively reviewed. Consensus review of the imaging data was performed by two radiologists to characterize the distribution of the injectate (i.e., within the tendon, along the tendon sheath, along the paratenon, or leakage into the adjacent joint or surrounding soft tissues). The presence of fluid and microbubbles from the injectate served as an indicator of material distribution. RESULTS: Image review verified the injectate within the tendon in 100% of cases. In 98% of reviewed cases, injected PRP or autologous blood dissected beyond the local injection site (defined as > 2 cm from the site of injection) and was identified in adjacent soft tissues in 51% of cases. Visualization of injectate along a paratenon or tendon sheath (when applicable) was seen in 86% and 100% of cases respectively; however, intraarticular extension was uncommon (8%). CONCLUSION: Our study showed that postinjection imaging may be of value in assessing the anatomic distribution of injectate after intratendinous therapy. Furthermore, our initial review found that in the majority of cases injected blood products tended to distribute beyond the local area of injection.

OBJECTIVE: Overuse and traumatic injuries of the elbow are common, occurring in both athletes and nonathletes. This article will discuss the commonly encountered soft-tissue and osseous pathologic abnormalities around the elbow and their imaging appearance on MRI and ultrasound. CONCLUSION: The current treatment of tendon disease of the elbow is reviewed, with a focus on platelet-rich plasma injection.

BACKGROUND: The objectives of this study were to characterize and compare the vascularity of arthroscopically repaired rotator cuff tendons at short-term and intermediate-term follow-up. MATERIALS AND METHODS: Nineteen patients who underwent arthroscopic rotator cuff repair were prospectively monitored for an average of 21.2 months. Initial baseline, grayscale ultrasound images of the operated-on shoulder were obtained on all patients at 3 months and at a minimum of 10 months postoperatively. Perflutren-lipid microsphere contrast (DEFINITY, Lantheus Medical Imaging, North Billerica, MA, USA) was injected after baseline grayscale images and after exercise to obtain contrast-enhanced images of the repair. Three regions of interest-supraspinatus tendon, peribursal tissue, and bone anchor site-were evaluated before and after rotator cuff-specific exercises. RESULTS: The peribursal tissue demonstrated the greatest blood flow, followed by the bone anchor site and tendon, in pre-exercise and postexercise states. Significantly less blood flow was observed in all regions of interest before exercise (P < .05) and only at the bone anchor site after exercise (P < .001) at latest follow-up compared with the 3-month values. Intratendinous blood flow remained relatively low at both evaluation points after surgical repair. CONCLUSION: Preliminary findings suggest that the peribursal tissue and bone anchor site are the main conduits of blood flow for the rotator cuff tendon after arthroscopic repair, with the supraspinatus tendon being relatively avascular. Blood flow of the repaired rotator cuff tendon decreases with time. Furthermore, exercise significantly enhances blood flow to the repaired rotator cuff.