[Show abstract][Hide abstract] ABSTRACT: Objectives: Arthroscopy for acetabular labral tears has minimal impact on pain and function in patients older than 50 years of age in the setting of concomitant osteoarthritis. Despite this, many physicians continue to seek diagnoses of labral tears in older arthritic patients with magnetic resonance arthrography. The inefficacy of surgical management and the suggested high prevalence of this condition in both symptomatic and asymptomatic patients call into question the utility of diagnosis through an invasive and expensive imaging modality. The purpose of this study is to assess the frequency of acetabular labral tears in patients aged 50 years and older with hip pain and to correlate the likelihood of a labral tear with the severity of osteoarthritis as visualized on conventional radiograph.
Preview · Article · Aug 2015 · Journal of Investigative Medicine
[Show abstract][Hide abstract] ABSTRACT: To evaluate the success rate of a low-dose (50 % mAs reduction) computed tomography (CT) biopsy technique. This protocol was adopted based on other successful reduced-CT radiation dose protocols in our department, which were implemented in conjunction with quality improvement projects.
The technique included a scout view and initial localizing scan with standard dose. Additional scans obtained for further guidance or needle adjustment were acquired by reducing the tube current-time product (mAs) by 50 %. The radiology billing data were searched for CT-guided musculoskeletal procedures performed over a period of 8 months following the initial implementation of the protocol. These were reviewed for the type of procedure and compliance with the implemented protocol. The compliant CT-guided biopsy cases were then retrospectively reviewed for patient demographics, tumor pathology, and lesion size. Pathology results were compared to the ultimate diagnoses and were categorized as diagnostic, accurate, or successful.
Of 92 CT-guided procedures performed during this period, two were excluded as they were not biopsies (one joint injection and one drainage), 19 were excluded due to non-compliance (operators neglected to follow the protocol), and four were excluded due to lack of available follow-up in our electronic medical records. A total of 67 compliant biopsies were performed in 63 patients (two had two biopsies, and one had three biopsies). There were 32 males and 31 females with an average age of 50 (range, 15-84 years). Of the 67 biopsies, five were non-diagnostic and inaccurate and thus unsuccessful (7 %); five were diagnostic but inaccurate and thus unsuccessful (7 %); 57 were diagnostic and accurate thus successful (85 %). These results were comparable with results published in the radiology literature.
The success rate of CT-guided biopsies using a low-dose protocol is comparable to published rates for conventional dose biopsies. The implemented low-dose protocol did not change the success rate of CT-guided musculoskeletal biopsies.
[Show abstract][Hide abstract] ABSTRACT: Subcutaneous panniculitis-like T-cell lymphoma (SPTCL) represents a rare subclassification of peripheral T-cell lymphoma (PTCL). We present a case of a 21-year-old female who presented with a 1-month history of pain in the left buttock and hip, tender left inguinal lymph nodes, fevers, and night sweats. Percutaneous core needle biopsy was diagnostic for SPTCL with CD8+ cells positive for cytotoxic granules. Magnetic resonance imaging (MRI) features of SPTCL with a review of the literature are discussed.
No preview · Article · Apr 2014 · Skeletal Radiology
[Show abstract][Hide abstract] ABSTRACT: The goal of our study was to determine the frequency of intra-articular calcifications on initial postoperative radiographs following arthroscopic ACL reconstruction, describe their appearance, hypothesize their etiology, and determine their significance.
Review of records and post-operative radiographs for individuals undergoing arthroscopic ACL reconstruction at our institution identified 758 knees between November 2002 and April 2010. All patients underwent femoral and tibial tunnel drilling regardless of graft source. All but 23 underwent notchplasty.
Intra-articular calcifications on initial postoperative radiographs were observed in 252 knees. The majority of calcifications were curvilinear, paralleling the posterior femoral condyles. Nineteen of the patients with calcifications on initial studies had repeat radiographs within 6 years. The calcifications resolved in every case.
This study shows that intra-articular calcifications are a common finding on initial post-operative radiographs following ACL reconstruction. We feel they are of doubtful clinical significance, and in our limited experience, they eventually resolve. They should not be confused with chondrocalcinosis or vascular calcification.
No preview · Article · Dec 2013 · Skeletal Radiology
[Show abstract][Hide abstract] ABSTRACT: BACKGROUND:Bone stress injuries are common in track and field athletes. Knowledge of risk factors and correlation of these to magnetic resonance imaging (MRI) grading could be helpful in determining recovery time. PURPOSE:To examine the relationships between MRI grading of bone stress injuries with clinical risk factors and time to return to sport in collegiate track and field athletes. STUDY DESIGN:Cohort study (prognosis); Level of evidence, 2. METHODS:A total of 211 male and female collegiate track and field and cross-country athletes were followed prospectively through their competitive seasons. All athletes had preparticipation history, physical examination, and anthropometric measurements obtained annually. An additional questionnaire was completed regarding nutritional behaviors, menstrual patterns, and prior injuries, as well as a 3-day diet record. Dual-energy X-ray absorptiometry was performed at baseline and each year of participation in the study. Athletes with clinical evidence of bone stress injuries had plain radiographs. If radiograph findings were negative, MRI was performed. Bone stress injuries were evaluated by 2 independent radiologists utilizing an MRI grading system. The MRI grading and risk factors were evaluated to identify predictors of time to return to sport. RESULTS:Thirty-four of the athletes (12 men, 22 women) sustained 61 bone stress injuries during the 5-year study period. The mean prospective assessment for participants was 2.7 years. In the multiple regression model, MRI grade and total-body bone mineral density (BMD) emerged as significant and independent predictors of time to return to sport. Specifically, the higher the MRI grade (P = .004) and lower the BMD (P = .030), the longer the recovery time. Location of the bone injury at predominantly trabecular sites of the femoral neck, pubic bone, and sacrum was also associated with a prolonged time to return to sport. Female athletes with oligomenorrhea and amenorrhea had bone stress injuries of higher MRI grades compared with eumenorrheic athletes (P = .009). CONCLUSION:Higher MRI grade, lower BMD, and skeletal sites of predominant trabecular bone structures were associated with a delayed recovery of bone stress injuries in track and field athletes. Knowledge of these risk factors, as well as nutritional and menstrual factors, can be clinically useful in determining injury severity and time to return to sport.
No preview · Article · Jul 2013 · The American Journal of Sports Medicine
[Show abstract][Hide abstract] ABSTRACT: The use of image-guided percutaneous core needle biopsy (PCNB) to obtain tissue diagnosis of musculoskeletal lesions has become the standard of care in adult patients with a success rate of over 80%. Previous reports indicate a similar success rate in diagnosing pediatric solid tumors. In this large study, we analyzed >10 years of data in which PCNB was used for tissue diagnosis of musculoskeletal lesions in children; we evaluated the histopathologic accuracy, anesthetic requirements, and complications of these procedures. In 122 children, tissue diagnosis was successfully obtained in 82% of cases, and there were 0 complications associated with the procedure. There was a significantly higher PCNB diagnostic success rate in malignant lesions (93%). These data suggest that the use of PCNB is a safe and effective means of diagnosing musculoskeletal lesions in children.
No preview · Article · Apr 2013 · Journal of Pediatric Hematology/Oncology
[Show abstract][Hide abstract] ABSTRACT: PURPOSE
To evaluate the success rate of a low-dose (50% reduction) computed tomography (CT) biopsy protocol adopted in our institution following application of similar protocols for non-interventional studies in conjunction with a quality improvement project.
METHOD AND MATERIALS
Low-dose CT biopsy protocol includes scout view and initial localizing scan with standard dose. Additional scans taken for guidance or needle adjustment were obtained by reducing the combination of tube current and exposure time (mAs) by 50%. The radiology billing data were searched for CT guided procedures performed between 11/2010 and 06/2011 (over 8 months). These were retrospectively reviewed for the type of procedure and compliance with the implemented technique. The compliant CT guided biopsy cases were then retrospectively reviewed for patient demographics, and the biopsy pathology results were compared to the ultimate diagnoses. A biopsy was considered as diagnostic if it provided a definitive pathologic diagnosis or was clinically useful; as accurate if it was concordant with the ultimate diagnosis with respect to identification of malignancy, grade, and histopathologic features; and as successful if it was both diagnostic and accurate.
A total of 92 CT guided procedures were performed during the selected period. Two were excluded as they were not biopsies (1 joint injection and 1drainage). Of the remaining 90 procedures, 19 were excluded due to non-compliance (the protocol was not followed), and 4 were excluded due to lack of available follow-up in our digital medical records. A total of 67 useful biopsies were performed in 63 patients (2 had 2 and 1 had 3 biopsies). There were 32 males and 31 females. The average age was 50 (range 15-84 years). Of the 67 biopsies 5 were non-diagnostic, not accurate and unsuccessful (7%); another 5 were diagnostic, but not accurate and thus unsuccessful; 57 were diagnostic, accurate and successful (85%).
The success rate of CT guided biopsies using this low-dose (50% reduced dose) protocol was comparable to the rates previously published for conventional dose biopsies. The implemented low-dose protocol does not decrease the success rate of a CT guided biopsy. We will continue our low-dose CT guided biopsy protocol for future procedures.
Low dose CT biopsy protocol is easy to implement and does not compromise the outcome of biopsies.
[Show abstract][Hide abstract] ABSTRACT: Magnetic resonance imaging (MRI) is well established as a powerful imaging modality for the shoulder. In the last decade, ultrasound has emerged as an effective imaging option, alongside MRI, for evaluation of the shoulder. With MRI and ultrasound, clinicians now have two viable advanced imaging options for the diagnostic evaluation of shoulder pain. This article discusses the advantages and disadvantages of ultrasound and MRI for the shoulder. Applications where ultrasound is considered the imaging test of choice, those where MRI is more advantageous, and those where both ultrasound and MRI are viable alternatives for shoulder imaging are discussed.
No preview · Article · Sep 2012 · Current Sports Medicine Reports
[Show abstract][Hide abstract] ABSTRACT: To retrospectively assess percutaneous core needle biopsies performed by radiologists and the association with tumor seeding along the biopsy tract when anatomic compartment guidelines are not consistently observed.
Retrospective data from computerized patient records and digital images from 363 consecutive computed tomography-guided biopsies of the lower extremity (thigh and leg) performed by radiologists at a single institution from August 2002 to August 2008 were analyzed for breaches of biopsy guidelines.
Of the 363 biopsies, 243 (67%) were of soft tissue lesions and 120 (33%) were of bony lesions. There were 188 (52%) malignant and 175 (48%) benign lesions. The following biopsy breaches were observed: 13 (3.6%) of anatomic compartment, 42 (11.6%) of "vital structures," and 82 (68.3%) of needle path for bony tumors. Vital structures as defined by the literature included, but were not limited to, the following: knee joint capsule, greater trochanteric bursa, rectus femoris and vastus intermedius muscles, tibial tubercle, peroneus brevis and peroneus longus distal tendons, and neurovascular bundles. No cases of tumor recurrences could be attributed to needle seeding along a biopsy tract for any of these biopsy guideline breaches.
The concern for needle tract seeding with musculoskeletal tumors is more widespread than the evidence supporting it as a significant or frequent complication. In this study, breaching anatomic compartment, vital structures (other than neurovascular structures), and suggested exact needle path guidelines were not associated with needle tract seeding in the lower extremity.
No preview · Article · Mar 2012 · Journal of vascular and interventional radiology: JVIR
[Show abstract][Hide abstract] ABSTRACT: PURPOSE
Knee effusions commonly occur with injury or inflammation. Imaging is more accurate in detecting small amounts of joint fluid compared with clinical examination. MRI in particular is extremely sensitive for detecting effusions. Cadaveric studies have demonstrated that in the supine position an effusion tends to pool laterally in the knee. The purpose of this paper is to further localize the fluid distribution of knee effusions in patients on MR imaging, which can be used to optimize assessment of effusions with sonography.
METHOD AND MATERIALS
We retrospectively reviewed 80 knee MRIs of adult outpatients (ages 18-80) who were reported to have a joint effusion and no history of prior surgery or fracture. All knees were imaged on a 3T MR scanner. On axial fat-saturated T2 weighted images, using standardized PACS measurement tools, the thickest area of fluid collection in the midline, medial, and lateral recesses of the central and/or suprapatellar synovial compartments was measured. Statistical analysis was performed using a paired T-test.
The fluid thickness in the lateral recess of the synovial compartment with an average thickness of 7.5 mm, was significantly more prominent than centrally, averaging 6.7 mm (p<0.02). The fluid thickness in the medial recess, averaging 5 mm, was significantly less than centrally (p<0.01).
A significantly larger amount of fluid accumulates in the lateral aspect of the central and suprapatellar synovial recesses when compared to the midline and medial aspects on knee MRI. Ultrasound traditionally relies on the appearance of the suprapatellar recess at midline to assess for a knee joint effusion. Our results suggest that in order to avoid underestimating the presence or size of a knee effusion, sonographic evaluation of the knee joint should routinely include an assessment of the lateral recess.
Predominant distribution of intraarticular fluid into the lateral recess in supine patients with knee effusion on MRI is relevant and applicable to sonographic evaluation of the joint for effusion.
[Show abstract][Hide abstract] ABSTRACT: A solid knowledge of underlying histopathology of benign bone tumors aids in differential diagnoses of these tumors. Important factors in diagnosis of a bone tumor include patient age and gender; the bone involved; the location of the tumor along, within, or on the bone; lesion margin; matrix proliferation; and periosteal reaction. This article provides a review of the origin of the tumor matrix and its influence on the imaging properties of these tumors.
No preview · Article · Nov 2011 · Radiologic Clinics of North America
[Show abstract][Hide abstract] ABSTRACT: Sarcomas are rare mesenchymal malignancies. Accurate preoperative diagnosis is a prerequisite in considering investigational or institutional management algorithms that include neoadjuvant treatment. We reviewed our experience using core needle biopsy for chest wall sarcomas.
A retrospective review of our sarcoma databases revealed that 40 core needle biopsies and 35 tumor resections were performed in 34 patients, with chest wall musculoskeletal tumors, referred to the University of California, Los Angeles from 1991 to 2010. Primary, metastatic, or recurrent sarcomas involving the sternum, ribs, and soft tissues of the chest wall were evaluated for (1) adequacy of tissue from image-guided core needle biopsies and (2) accuracy in determining malignancy, histological subtype, and sarcoma grade.
Twenty-eight of the 40 needle biopsy samples (70%) were adequate for histopathological analysis. Forty-two percent of nondiagnostic findings occurred due to insufficient tissue, whereas the remainder had sufficient tissue, but the pathologist was unable to determine specific histology. Excluding the nondiagnostic samples, the accuracy in determining malignancy, histological subtype, and grade in sarcomas was 100, 92, and 87%, respectively. The sensitivity and specificity of determining malignancy and high-grade sarcomas were 100, 100, 77, and 100%, respectively. There were no complications from the image-guided biopsies.
We demonstrated that image-guided core needle biopsy when performed and reviewed by experienced radiologists and musculoskeletal pathologists is a safe and accurate diagnostic technique for chest wall sarcomas. Core needle biopsy should be considered in the multidisciplinary approach to chest wall musculoskeletal tumors, especially when induction therapy is considered.
No preview · Article · Sep 2011 · Journal of thoracic oncology: official publication of the International Association for the Study of Lung Cancer
[Show abstract][Hide abstract] ABSTRACT: The shoulder joint is a complex array of muscles, tendons, and capsuloligamentous structures that has the greatest freedom of motion of any joint in the body. Acute (<2 weeks) shoulder pain can be attributable to structures related to the glenohumeral articulation and joint capsule, rotator cuff, acromioclavicular joint, and scapula. The foundation for investigation of acute shoulder pain is radiography. Magnetic resonance imaging is the procedure of choice for the evaluation of occult fractures and the shoulder soft tissues. Ultrasound, with appropriate local expertise, is an excellent evaluation of the rotator cuff, long head of the biceps tendon, and interventional procedures. Fluoroscopy is an excellent modality to guide interventional procedures. Computed tomography is an excellent modality for characterizing complex shoulder fractures. Computed tomographic arthrography or fluoroscopic arthrography may be alternatives in patients for whom MR arthrography is contraindicated. A multimodal approach may be required to accurately assess shoulder pathology. 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 in which evidence is lacking or not definitive, expert opinion may be used to recommend imaging or treatment.
Full-text · Article · Sep 2011 · Journal of the American College of Radiology: JACR
[Show abstract][Hide abstract] ABSTRACT: To create an average atlas of knee femoral cartilage morphology, to apply the atlas for quantitative assessment of osteoarthritis (OA), and to study localized sex differences.
High-resolution 3D magnetic resonance imaging (MRI) data of the knee cartilage collected at 3 T as part of the Osteoarthritis Initiative (OAI) were used. An atlas was created based on images from 30 male Caucasian high-risk subjects with no symptomatic OA at baseline. A female cohort of age- and disease-matched Caucasian subjects was also selected from the OAI database. The Jacobian determinant was calculated from the deformation vector fields that nonlinearly registered each subject to the atlas. Statistical analysis based on the general linear model was used to test for regions of significant differences in the Jacobian values between the two cohorts.
The average Jacobian was larger in women (1.2 ± 0.078) than in men (1.08 ± 0.097), showing that after global scaling to the male template, the female cartilage was thicker in most regions. Regions showing significant structural differences include the medial weight bearing region, the trochlear (femoral) side of the patellofemoral compartment, and the lateral posterior condyle.
Sex-based differences in cartilage structure were localized using tensor based morphometry in a cohort of high-risk subjects.
Full-text · Article · Aug 2011 · Journal of Magnetic Resonance Imaging
[Show abstract][Hide abstract] ABSTRACT: The purpose of this article is to investigate potential technical, imaging, and histopathologic contributors to the success of CT biopsy.
Four hundred forty-four consecutive CT biopsies of musculoskeletal lesions performed from 2005 to 2008 were retrospectively classified as diagnostic or nondiagnostic and as accurate or inaccurate. A biopsy was considered as diagnostic if it provided a definitive pathologic diagnosis or was clinically useful; as accurate if it was concordant with the ultimate diagnosis with respect to identification of malignancy, grade, and histopathologic features; and as successful if it was both diagnostic and accurate. Biopsy success rate, diagnostic yield, and accuracy were assessed according to lesion location, use of sedation, biopsy equipment type, bone lesion matrix type, and lesion histologic type (i.e., bone or soft-tissue origin, malignant or benign neoplasm, and low-or intermediate-to-high-grade neoplasm).
Of 444 biopsies, 71% were diagnostic, 86% were accurate, and 70% were successful. Biopsy success and diagnostic yield were greater in bone lesions, malignant neoplasms, and intermediate-to-high-grade neoplasms compared with soft-tissue lesions (p < 0.01), benign neoplasms (p < 0.0001), and low-grade neoplasms (p < 0.0001). Success and diagnostic yield were not significantly associated with technical or imaging factors. Biopsy accuracy was not associated with any of the tested variables. Of the 128 nondiagnostic biopsy results, 53% were accurate with respect to subsequent surgical pathologic findings. Most of these biopsy results were of benign soft-tissue lesions.
CT biopsy of musculoskeletal lesions is accurate and effective. It may be limited in the evaluation of benign and low-grade soft-tissue neoplasms.
Full-text · Article · Aug 2011 · American Journal of Roentgenology
[Show abstract][Hide abstract] ABSTRACT: Historically, magnetic resonance imaging (MRI) has been very useful in diagnosing meniscal tears but not as valuable in predicting whether a meniscal tear is reparable. Given that several recent studies suggested that MRI can be used to predict tear reparability, the topic has resurfaced as a controversy in the orthopaedic and radiology literatures.
Experienced musculoskeletal radiologists can use MRI to predict the reparability of meniscal tears with good to excellent accuracy using the same arthroscopic criteria used by surgeons intraoperatively.
Cohort study (diagnosis); Level of evidence, 3.
Fifty-eight patients with meniscal tears treated with repair were matched by age and sex with 61 patients with tears treated with meniscectomy. Two senior musculoskeletal radiologists independently and blindly reviewed preoperative MRI of these 119 meniscal tears. Using established arthroscopic criteria, the radiologists were asked to grade each tear 0 to 4, with 1 point for each of the following: a tear larger than 10 mm, within 3 mm of the meniscosynovial junction, greater than 50% thickness, and with an intact inner meniscal fragment. Only a tear with a score of 4 would be predicted to be reparable.
The 2 radiologists' ability to correctly estimate reparability was poor, with 58.0% and 62.7% correct predictions (κ = 0.155 and 0.250, respectively). Interrater reliability assessment showed that the raters agreed on a score of 4 (reparable) versus <4 (not reparable) 73.7% of the time (κ = 0.434) but came to identical scores only 38.1% of the time (κ = 0.156). Determining the status of the inner fragment was the most predictive individual criterion and the only one to reach statistical significance (χ(2) = 14.9, P <.001).
Magnetic resonance imaging is not an effective or efficient predictor of reparability of meniscal tears with the current arthroscopic criteria.
No preview · Article · Dec 2010 · The American Journal of Sports Medicine
[Show abstract][Hide abstract] ABSTRACT: PURPOSE/AIM
The aim of this exhibit is to: 1. Review the range of primary cartilaginous lesions, benign and malignant; 2. Discuss the common locations of cartilage lesions in bones, as well as around bony structures; 3. Present the cross-sectional imaging appearance of primary cartilaginous lesions.
1. Normal articular cartilage 2. Primary cartilaginous lesions a. Osteochondroma and subtypes b. Enchondroma and subtypes c. Juxtacortical chondroma d. Chondromyxoid fibroma e. Chondroblastoma f. Chondrosarcoma and subtypes 3. MR and CT imaging of cartilaginous lesions 4. Sample cases 5. Emerging techniques
The goal of this exhibit is to help radiologists: 1. Understand the spectrum of primary lesions of cartilage; 2. Appreciate the characteristic features and locations of primary cartilaginous lesions; 3. Recognize the cross-sectional imaging appearance of primary cartilaginous lesions.
[Show abstract][Hide abstract] ABSTRACT: Hyperkyphosis is implicated in a mounting list of negative outcomes, including higher mortality. Hyperkyphosis research is hindered due to difficulties inherent in its measurement. By showing that three clinical measures of kyphosis are suitable for use in large scale, longitudinal, hyperkyphosis studies, we will facilitate much needed research in this field.
The objective of this study is to describe the reliability of three non-radiological kyphosis measures (Debrunner kyphosis angle, flexicurve kyphosis index, and flexicurve kyphosis angle) and their validity compared to the Cobb angle and to approximate a Cobb angle from non-radiological kyphosis measures.
We analyzed data from 113 participants aged ≥ 60 years with kyphosis angle ≥ 40°. Cobb angle was measured on a standing lateral thoracolumbar radiograph using bounds at T4 and T12. Non-radiological measures of kyphosis were made three times by a single rater and a 4th time by a blinded second rater.
Intra- and inter-rater reliabilities for non-radiological assessments were high (intra-class correlations of 0.96 to 0.98) and did not differ from each other. Pearson correlations, estimating validity, ranged from 0.62 to 0.69 and did not differ. The Debrunner angle was close to the Cobb angle, with scaling factor of 1.067 and an offset of 5°. The Flexicurve kyphosis angle had to be scaled by 1.53 to obtain the equivalent Cobb angle. The scaling factor for the Flexicurve kyphosis index to Cobb angle was 315, with an offset of 5°. Compared to the measured Cobb angle, Cobb angles predicted using the non-radiological measures had similar magnitude errors (standard deviations of the differences ranging between 10.24 and 11.26).
Each non-radiological measurement had similar reliability and validity. Low cost, ease of use, and robustness to variations in spine contour argue for the Flexicurve in longitudinal kyphosis assessments. The approximate conversion factors provided will permit translation of non-radiological measures to Cobb angles.
Preview · Article · Oct 2010 · Osteoporosis International