Faculty Bibliography

The primary goal of comparative effectiveness research (CER) is to define the optimal choice among alternative diagnostic and interventional strategies for a given clinical scenario among major stakeholders in the health care system. In an era where health care decision makers are demanding greater evidence of improved patient outcomes from the use of medical technologies, musculoskeletal (MSK) imagers must be more engaged in generating quality CER. We provide an overview of CER and its expanding role in U.S. health care, the current funding environment for CER and MSK imaging, potential areas for CER in MSK radiology, and a discussion of foreseeable challenges for CER in MSK imaging.

Purpose: Quantification of tendon retraction is paramount in the surgical decision-making algorithm for proximal hamstring avulsion injury. Not only is it used to determine if surgery is indicated, but it may lead the surgeon to change the pre-operative plan from a more aesthetically-appealing gluteal fold incision to a more extensile, longitudinally-based proximal thigh incision. However, the hamstring origin on the ischial tuberosity is broad. Variability in location on the ischial tuberosity used as the proximal landmark and occasional difficulty in locating the proximal tendon stump may lead to differences in perceived retraction, altering the surgical decision making process. We hypothesize there will be substantial variability in the ischial tuberosity location used as the proximal marker, not only between orthopaedists and radiologists, but also amongst radiologists themselves. Materials and Methods: Two surveys were created for the purpose of this study. One survey was sent to members of the Society of Skeletal Radiology (SSR), querying the preferred ischial tuberosity landmark, perceived difficulties in quantifying retraction, and the impact of radiology measurements on clinical decision making. A similar survey, with added questions on the impact of imaging findings in clinical management was approved and posted onto the American Orthopaedic Society for Sports Medicine (AOSSM) website. Results: Two hundred and fifteen SSR members responded to the survey. For cases of complete and partial hamstring avulsion, there was variability among musculoskeletal (MSK) radiologists in the proximal landmark used for quantification of retraction, with n = 100 (47%) using the conjoint tendon origin, n = 84 (39%) using the semimembranosus tendon origin, and n = 31(14%) using the posterior-inferior edge of the ischial tuberosity. Difficulty in determining location of the retracted tendon stump was reported by n = 93(44%) of MSK radiologists. Most MSK radiologists (n = 118, 55%) reported measurements in their dictation and were unsure as to whether or not they are used to guide clinical management. Results of the second survey posted by AOSSM will be subsequently reported when available. Conclusion: Differences in choosing an ischial tuberosity landmark and occasional difficulty in locating the proximal tendon stump may lead to substantial variability in measured tendon retraction among MSK radiologists in cases of proximal hamstring avulsion. Radiologists should consider a standardized approach to measuring tendon retraction or should clearly stipulate the location of the proximal landmark in their reports

Purpose: Rotator cuff pathology is typically seen inmiddle age or elderly patients and is unusual in young patients. We have recently noted rotator cuff tendinosis and partial thickness tendon tears in several young (<21 years of age) patients with a history of competitive swimming. The purpose of this study was to determine the frequency of such injuries and to determine if there was any specific pattern of rotator cuff pathology in young competitive swimmers. Materials and Methods: A retrospective review of our MRI database between 2006 through 2016 was performed using the search terms "swimmer" and swimming in patients younger than 21 years of age who had shoulder MRIs. MRIs were reviewed for rotator cuff tendinosis and tears using the criteria described in the literature. A control group was comprised of 20 patients with similar age group who had shoulder MRIs and no history of competitive swimming. Results: There were 17 patients who fit our inclusion criteria; 10 females and 7 males. All were described in the history as competitive swimmers presenting with shoulder pain. The ages of these patients ranged from 11 to 19 years of age (average 14). There were 7 (41%) patients with rotator cuff pathology. Four of these patients had supraspinatus tendinosis and 2 had co-existing infraspinatus tendinosis. Additionally, 3 patients had low grade (less than 25% thickness of tendon) articular sided partial-tears involving supraspinatus tendon with underlying tendinosis. There were no full thickness tears. The subscapularis and teres minor tendons were normal in all patients. No rotator cuff tendinosis or tears were identified in the control group of patients. Conclusion: Rotator cuff pathology is typically the result of chronic repetitive injury and seen in middle aged to older patients. Competitive swimming appears to increase the risk of rotator cuff injury in young patients most likely due to repetitive overhead motion. The pathology typically presents as tendinosis or low grade partial thickness tears of the supraspinatus tendon

PURPOSE: To develop an accelerated SEMAC metal implant MRI technique (Sparse-SEMAC) with reduced scan time and improved metal distortion correction. METHODS: Sparse-SEMAC jointly exploits the inherent sparsity along the additional phase-encoding dimension and multicoil encoding capabilities to significantly accelerate data acquisition. A prototype pulse sequence with pseudorandom ky -kz undersampling and an inline image reconstruction was developed for integration in clinical studies. Three patients with hip implants were imaged using the proposed Sparse-SEMAC with eight-fold acceleration and compared with the standard-SEMAC technique used in clinical studies (three-fold GRAPPA acceleration). Measurements were performed with SEMAC-encoding steps (SES) = 15 for Sparse-SEMAC and SES = 9 for Standard-SEMAC using high spatial resolution Proton Density (PD) and lower-resolution STIR acquisitions. Two expert musculoskeletal (MSK) radiologists performed a consensus reading to score image-quality parameters. RESULTS: Sparse-SEMAC enables up to eight-fold acceleration of data acquisition that results in two-fold scan time reductions, compared with Standard-SEMAC, with improved metal artifact correction for patients with hip implants without degrading spatial resolution. CONCLUSION: The high acceleration enabled by Sparse-SEMAC would enable clinically feasible examination times with improved correction of metal distortion. Magn Reson Med, 2016. (c) 2016 Wiley Periodicals, Inc.

OBJECTIVE: The number of 4th-year medical student applications to the field of diagnostic radiology has decreased from 2009-2015. The purpose of this study was to learn how radiology departments are recruiting medical students. MATERIALS AND METHODS: An anonymous online survey hyperlink was distributed to the members of the Society of Chairs of Academic Radiology Departments regarding both innovative and proven recruitment strategies. The results were synthesized with a recently published survey of medical students about factors influencing them to go into radiology. RESULTS: Forty of 126 radiology departments completed the survey. Most felt that radiology exposure and curricula require alteration given recent downward trends in medical student applications. A majority (79%) had changed their outreach to medical students in response to these trends. The responding department chairs felt that interactive learning while on rotation was the most important strategy for recruitment. The presence of a diversity program, dedicated medical school educator, or rotating daily assignment for students did not affect the likelihood of filling residency spots in the main match. CONCLUSION: Many radiology departments are changing their outreach to medical students to improve recruitment. Effective strategies to focus on include early active outreach by involving students in the radiology department, thereby framing radiologists as clinicians.

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: 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