Postoperative Return to Play and the Role of Imaging.

Return to play (RTP) following surgery is a complex subject at the interface of social and internal pressures experienced by the athlete, psychological readiness, and intrinsic healing of the surgically repaired structures. Although functional testing, time from surgery, clinical examination, and scoring metrics can help clarify an athlete's readiness to return to sport, imaging can allow for a more direct assessment of the structures in question. Because imaging is often included in the diagnostic work-up of pain following surgery, the radiologist must be familiar with the expected postsurgical imaging appearance, as well as the associated complications. We briefly review such findings following anterior cruciate ligament reconstruction, Achilles tendon repair, syndesmotic fixation, and ulnar collateral ligament reconstruction in the context of the athlete, highlighting issues related to RTP.

Diagnosis of non-osseous spinal metastatic disease: the role of PET/CT and PET/MRI.

The spine is the third most common site for distant metastasis in cancer patients with approximately 70% of patients with metastatic cancer having spinal involvement. Positron emission tomography (PET), combined with computed tomography (CT) or magnetic resonance imaging (MRI), has been deeply integrated in modern clinical oncology as a pivotal component of the diagnostic work-up of patients with cancer. PET is able to diagnose several neoplastic processes before any detectable morphological changes can be identified by anatomic imaging modalities alone. In this review, we discuss the role of PET/CT and PET/MRI in the diagnostic management of non-osseous metastatic disease of the spinal canal. While sometimes subtle, recognizing such disease on FDG PET/CT and PET/MRI imaging done routinely in cancer patients can guide treatment strategies to potentially prevent irreversible neurological damage.

A MSK Radiologist's Early Experience as a Department Chair: Climbing the Horizontal Ladder.

A radiologist's training is designed to produce a professional with excellent interpretation skills. However, in today's health care environment, a successful radiologist may not be a successful leader or the opposite may be true. Leadership requires a different set of skills with knowledge of common concepts across all levels of health care delivery. When asked to take on administrative responsibilities, you anticipate constant work with occasional glory, but you may not realize the ladder of success is actually horizontal and the spotlight quite bright.In this personal narrative, I have illustrated my pathway to the chair position in the context of climbing the career ladder and entering the stage of leadership. I discuss common concerns facing radiology today and how we can all use our experience and leadership skills to overcome these challenges with effective solutions.

Spotty Bone Marrow: A Frequent MRI Finding in the Feet of Ballet Dancers.

INTRODUCTION: Bone marrow signal abnormalities on magnetic resonance imaging (MRI) are common in athletes. However, few studies evaluate the MRI appearance of bone marrow in the feet of ballet dancers. Our study aims to describe the "spotty bone marrow" (SBM) pattern in the tarsal bones of a cohort of ballet dancers, establishing its prevalence, distribution, potential associations, and evolution.
Methods: Eighty-six MRIs of 68 ankles in 56 ballet dancers were retrospectively reviewed for mar- row signal alterations, which were classified as focal or SBM (defined as patchy fluid-sensitive signal hyperintensity spanning more than one location or tarsal bone). When SBM involved the talus, its anatomic distribution in the bone and morphologic pattern were recorded. Additional osseous and soft tissue findings were documented. For subjects with more than one MRI of the same ankle, the SBM's evolution was monitored.
Results: Spotty bone marrow was identified in 44 ankles (65%). Spotty bone marrow was isolated to the talus (44%), present in all tarsal bones (25%), or distributed between the talus and one to three other tarsal bones (31%). In the talus, The SBM involved the entire bone (65%), the neck and body (31%), or the head and neck (4%). The SBM most commonly showed a random morphologic pattern (87%) but occasionally showed a peripheral predominance (13%). There was no statistically significant difference in the prevalence of other pathologies in ankles with and without SBM. In eight ankles with a follow-up MRI, the SBM worsened in one, remained stable in two, and improved in five ankles. None progressed to a stress fracture.
Conclusion: Spotty bone marrow is an MRI finding frequently encountered in ballet dancers. It is usually self-limiting and should not be misinterpreted as a more aggressive pathology.

Magnetic resonance appearance of posterosuperior labral peel back during humeral abduction and external rotation.

OBJECTIVE: To describe the magnetic resonance appearance of posterosuperior labral peel back and determine the reliability of MR in the abducted and externally rotated (ABER) position for the prospective diagnosis of arthroscopically proven cases of posterosuperior labral peel back. METHODS: After approval by the institutional review board (IRB) of the University of Pittsburgh Medical Center, USA, databases of patients who underwent arthroscopy over a 2-year period for one of three clinical diagnoses [suspected type 2 superior labrum anterior to posterior (SLAP) tears, posterior instability, or multidirectional instability] were reviewed after anonymization by an honest broker. Sixty-three cases were selected by the following inclusion criteria: operative report documenting labral peel back in the ABER position, age <40 years, and preceding MR arthrogram evaluations with images in the ABER position (n=34). Inclusion criteria for the control group differed from those for the case group insofar as the operative note documented the absence of posterosuperior labral peel back (n=29). Cases and controls were randomized in one list and evaluated independently by two fellowship-trained musculoskeletal radiologists unaware of the surgical results and using a three-point grading system (0 = posterosuperior labrum normally positioned lateral/craniad to glenoid articular plane in ABER; 1 = posterosuperior labral tissue flush with the glenoid articular plane in ABER; 2 = posterosuperior labral tissue identified medial/caudal to glenoid articular plane in ABER). Only one image in ABER showing abnormal posterosuperior labral position was required for a grade of 1 or 2 to be assigned. Sensitivity, specificity, and positive and negative predictive value were calculated as well as the level of agreement between readers (kappa). RESULTS: Both readers assigned a grade of 2 to 25 of 34 patients with surgically proven labral peel back. Of the patients with surgically proven SLAP tears with peel back in ABER, reader A assigned a grade of 1 to seven patients and a grade of 0 to two patients, while reader B assigned a grade of 1 to eight patients and a grade of 0 to one patient. In the control group of 29 patients, reader A assigned 28 patients a grade of 0, one patient a grade 1, and no patients a grade 2. Reader B assigned 27 patients a grade of 0, two a grade 1, and no patients a grade 2. After the data had been dichotomized, with grade 1 and 0 cases both being regarded as negative, the MR criteria showed a sensitivity of 73%, specificity of 100%, positive predictive value of 100%, and negative predictive value of 78%. The kappa coefficient of inter-rater agreement was excellent at 0.9, with disagreement in only four of 63 cases. In five of the 34 cases with peel back, a labral tear, defined by imbibition of contrast agent within a gap between labrum and underlying glenoid bone, could not be identified in standard planes in the neutral position. CONCLUSIONS: The use of the glenoid articular plane as a reference line to evaluate labral peel back in the abducted and externally rotated position is a fairly accurate and highly precise method for detection of posterosuperior labral peel back. Raising the possibility of labral peel back may help alert the arthroscopist to the presence of superior labral instability while the arm is abducted and externally rotated.

Normal appearance and complications of double-bundle and selective-bundle anterior cruciate ligament reconstructions using optimal MRI techniques.

OBJECTIVE: Double-bundle and selective-bundle anterior cruciate ligament (ACL) reconstructions are increasingly performed to better reproduce the double-bundle anatomy of the native ACL and to improve knee stability and surgical outcomes. This article illustrates how to optimize visualization of the ACL bundle anatomy and the appearances of graft components and postoperative complications. CONCLUSION: It is important for the radiologist to be familiar with the appearance of double-bundle and selective-bundle ACL reconstructions and associated complications.

The Role of Imaging in Determining Return to Play.

Return-to-play (RTP) predictions focus on how long it takes an athlete to return to their full athletic activity after sustaining an injury. This article focuses on the role of imaging and the radiologist in RTP predictions for the most common and controversial injuries affecting athletes.