Faculty Bibliography

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 evaluate sustainability of impact of rapid, focused process improvement (PI) events on process and performance within an academic radiology department. METHODS: Our department conducted PI during 2011 and 2012 in CT, MRI, ultrasound, breast imaging, and research billing. PI entailed participation by all stakeholders, facilitation by the department chair, collection of baseline data, meetings during several weeks, definition of performance metrics, creation of an improvement plan, and prompt implementation. We explore common themes among PI events regarding initial impact and durability of changes. We also assess performance in each area pre-PI, immediately post-PI, and at the time of the current study. RESULTS: All PI events achieved an immediate improvement in performance metrics, often entailing both examination volumes and on-time performance. IT-based solutions, process standardization, and redefinition of staff responsibilities were often central in these changes, and participants consistently expressed improved internal leadership and problem-solving ability. Major environmental changes commonly occurred after PI, including a natural disaster with equipment loss, a change in location or services offered, and new enterprise-wide electronic medical record system incorporating new billing and radiology informatics systems, requiring flexibility in the PI implementation plan. Only one PI team conducted regular post-PI follow-up meetings. Sustained improvement was frequently, but not universally, observed: in the long-term following initial PI, measures of examination volume showed continued progressive improvements, whereas measures of operational efficiency remained stable or occasionally declined. CONCLUSIONS: Focused PI is generally effective in achieving performance improvement, although a changing environment influences the sustainability of impact. Thus, continued process evaluation and ongoing workflow modifications are warranted.

OBJECTIVE: Assess the diagnostic accuracy of 3-T indirect magnetic resonance arthrography (iMRA) for hip cartilage and labral pathology detection using arthroscopy as the reference standard and compare it to the published performance of direct magnetic resonance arthrography (dMRA). MATERIALS AND METHODS: Between 2009 and 2011, 290 patients suspected of having femoroacetabular impingement underwent iMRA. Our study group consisted of 41 of these patients (17 males, mean age 35 years; 24 females, mean age 33 years) who did not have a prior history of hip surgery and who subsequently underwent arthroscopy. Two experienced musculoskeletal radiologists separately evaluated the randomized and anonymized studies for the presence and quadrant location of labral and cartilage pathology. These recorded data were compared to arthroscopic reports. RESULTS: Forty-one patients had labral pathology, 34 patients had acetabular and 5 patients had femoral cartilage pathology at arthroscopy. Sensitivity, specificity, accuracy, negative- and positive-predictive values for labral lesion detection were respectively 98, 99, 99, 99 and 98 %; for acetabular cartilage lesion detection they were 69, 98, 89, 87 and 95 %; for femoral cartilage lesion detection they were 69, 95, 93 and 39 %. Sensitivities of iMRA by quadrant (anteroinferior, anterosuperior, posteroinferior, posterosuperior) for the labrum were 100.0, 95.0, NA and 85.7 %, for acetabular cartilage were NA, 58.8, NA and 39.5 % and for femoral cartilage were 50.0, 33.3, 75.0 and 75.0 %). NA indicates results not available because of the absence of findings in those quadrants. Specificities of iMRA by quadrant (anteroinferior, anterosuperior, posteroinferior, posterosuperior) for the labrum (95.0, 100.0, 95.1, 67.5 %), acetabular (100.0, 85.7, 92.6, 79.5 %) and femoral cartilage (100.0, 94.7, 96.2, 85.9 %). CONCLUSION: iMRA at 3 T is accurate in detecting labral pathology suggesting that it is a viable alternative to dMRA.

The mechanics of the throwing shoulder are complex, resulting in a variety of adaptations that can lead to increased performance for the athlete. These adaptations can eventually fail and result in pathology to the stabilizing structures of the shoulder, most notably the rotator cuff and glenoid labrum. The understanding of the relationship between the mechanisms and injuries is evolving, resulting in improved diagnostic, therapeutic, and preventative measures. Our goal is to clarify the relationship between the mechanisms, common types of injury, and their appearance on imaging, specifically MRI, in a comprehensive, easy-to-understand manner that will leave you more confident when evaluating this subset of patients.

The employment of part-time radiologists (PTRs) has both advantages and disadvantages in various practice settings. The authors examine the pros and cons of PTRs and review the literature regarding PTRs both within and outside the specialty of radiology. The complexity of this issue is manifested in our inability to reach consensus on many policy issues for PTRs. Nevertheless, this article should be helpful in offering an objective, nonbiased background to initiating a discussion on employing PTRs in various radiology practices.

OBJECTIVE. The purpose of this article is to review the current understanding of the underlying pathophysiology of the Hill-Sachs lesion and anterior glenoid bone loss and to discuss the role of imaging in identifying and accurately describing these injuries. CONCLUSION. Understanding the underlying mechanics of anterior shoulder instability that result in Hill-Sachs lesions and glenoid bone loss, the strengths and weaknesses of the different imaging modalities ordered for their evaluation, and the methods used to characterize these osseous injuries on imaging are essential for the radiologist in this clinical setting.

PURPOSE: The authors describe their initial experience in implementing an integrated radiology reading room within a urologic oncology clinic, including the frequency and nature of clinician consultations and the perceived impact on patient management by clinicians. METHODS: A radiology reading room was established within an office-based urologic oncology clinic in proximity to the surgeon's work area. A radiologist was present in this reading room for a 3-hour shift each day. The frequency and nature of consultations during these shifts were recorded. Also, the clinic's staff completed a survey assessing perceptions of the impact of the integrated reading room on patient management. RESULTS: One hundred two consultations occurred during 57 included dates (average, 1.8 consultations per shift): 52% for review of external cases brought in by patients on discs, 43% for review of internal cases, and 5% for direct review by the radiologist of imaging with patients. The maximum number of consultations during a single shift was 8. All of the clinic's urologists indicated that >90% of consultations benefited patient care. The clinicians indicated tendencies to view consultations as affecting management in the majority of cases, to be more likely to seek consultation for outside imaging when the radiologist was on site, and to be less likely to repeat outside imaging when the radiologist was on site. CONCLUSIONS: The integrated reading room within the clinic has potential to improve the quality of care, for instance by facilitating increased review of outside imaging studies and thereby potentially reducing duplicate ordering and by enabling occasional direct image review with patients by radiologists.

OBJECTIVE: This study aimed at identifying the optimal threshold value to detect cartilage lesions with Standardized dGEMRIC at 3T and evaluate intra- and inter-observer repeatability. DESIGN: We retrospectively reviewed 20 hips in 20 patients. dGEMRIC maps were acquired at 3T along radial imaging planes of the hip and standardized to remove the effects of patient's age, sex and diffusion of gadolinium contrast. Two observers separately evaluated 84 Standardized dGEMRIC maps, both by visual inspection and using an average index for a region of interest in the acetabular cartilage. A radiologist evaluated the acetabular cartilage on morphologic MR images at exactly the same locations. Using intra-operative findings as reference, the optimal threshold to detect cartilage lesions with Standardized dGEMRIC was assessed and results were compared with the diagnostic performance of morphologic MRI. RESULTS: Using z < -2 as threshold and visual inspection of the color-adjusted maps, sensitivity, specificity and accuracy for Observer 1 and Observer 2, were 83%, 60% and 75%, and 69%, 70% and 69%, respectively. Overall performance was 52%, 67% and 58%, when using an average z for the acetabular cartilage, compared to 37%, 90% and 56% for morphologic assessment. The kappa coefficient was 0.76 and 0.68 for intra- and inter-observer repeatability, respectively, indicating substantial agreement. CONCLUSIONS: Standardized dGEMRIC at 3T is accurate in detecting cartilage damage and could improve preoperative assessment in FAI. As cartilage lesions in FAI are localized, visual inspection of the Standardized dGEMRIC maps is more accurate than an average z for the acetabular cartilage.

OBJECTIVE: To assess the ability of 3D MR shoulder reconstructions to accurately quantify glenoid bone loss in the clinical setting using findings at the time of arthroscopy as the gold standard. MATERIALS AND METHODS: Retrospective review of patients with MR shoulder studies that included 3D MR reconstructions (3D MR) produced using an axial Dixon 3D-T1W-FLASH sequence at our institution was conducted with the following inclusion criteria: history of anterior shoulder dislocation, arthroscopy (OR) performed within 6 months of the MRI, and an estimate of glenoid bone loss made in the OR using the bare-spot method. Two musculoskeletal radiologists produced estimates of bone loss along the glenoid width, measured in mm and %, on 3D MR using the best-fit circle method, which were then compared to the OR measurements. RESULTS: There were a total of 15 patients (13 men, two women; mean age, 28, range, 19-51 years). There was no significant difference, on average, between the MRI (mean 3.4 mm/12.6 %; range, 0-30 %) and OR (mean, 12.7 %; range, 0-30 %) measurements of glenoid bone loss (p = 0.767). A 95 % confidence interval for the mean absolute error extended from 0.45-2.21 %, implying that, when averaged over all patients, the true mean absolute error of the MRI measurements relative to the OR measurements is expected to be less than 2.21 %. Inter-reader agreement between the two readers had an IC of 0.92 and CC of 0.90 in terms of percentage of bone loss. CONCLUSIONS: 3D MR reconstructions of the shoulder can be used to accurately measure glenoid bone loss.