The Role of Ultrasound in the Diagnosis and Treatment of Meniscal Injuries.

PURPOSE OF REVIEW: This review evaluates the current understanding of the role of ultrasound in the diagnosis and treatment of meniscal disorders. RECENT FINDINGS: Ultrasound (US) demonstrates similar sensitivity and specificity when compared to magnetic resonance imaging in the evaluation of meniscal injuries when compared to arthroscopy. Meniscal extrusion (ME) under US can be a reliable metric to evaluate for meniscal root tears in knees with and without osteoarthritis (OA). Sonographic ME is associated with development of OA in knees without OA. US following allograft meniscal transplant may be useful in predicting graft failure. US findings can be used to screen for discoid menisci and may demonstrate snapping of a type 3 discoid lateral meniscus. Shear wave elastography for meniscal injuries is in its infancy; however, increased meniscal stiffness may be seen with meniscal degeneration. Perimeniscal corticosteroid injections may provide short term relief from meniscal symptoms, and intrameniscal platelet-rich plasma injections appear to be safe and effective up to three years. Ultrasound-assisted meniscal surgery may increase the safety of all inside repairs near the lateral root and may assist in assessing meniscal reduction following root repair. Diagnostic US can demonstrate with high accuracy a variety of meniscal pathologies and can be considered a screening tool. Newer technologies such as shear wave elastography may allow us to evaluate characteristics of meniscal tissue that is not possible on conventional imaging. US-guided (USG) treatment of meniscal injuries is possible and may be preferable to surgery for the initial treatment of degenerative meniscal lesions. USG or US-assisted meniscal surgery is in its infancy.

Does proximal versus distal injury location of the medial ulnar collateral ligament of the elbow differentially impact elbow stability? An ultrasound-guided and robot-assisted biomechanical study.

BACKGROUND: The location (proximal vs. distal) of elbow medial ulnar collateral ligament (MUCL) tears impacts clinical outcomes of nonoperative treatment. The purposes of our study were to (1) determine whether selective releases of the MUCL could be performed under ultrasound (US) guidance without disrupting overlying soft tissues, (2) assess the difference in medial elbow stability for proximal and distal releases of the MUCL using stress US and a robotic testing device, and (3) elucidate the flexion angle that resulted in the greatest amount of medial elbow laxity after MUCL injury. METHODS: Sixteen paired, fresh-frozen elbow specimens were used. Valgus laxity was evaluated with both US and robotic-assisted measurements before and after selective MUCL releases. A percutaneous US-guided technique was used to perform proximal MUCL releases in 8 elbows and to perform distal MUCL releases in their matched pairs. The robot was used to determine the elbow flexion angle at which the maximum valgus displacement occurred for both proximally and distally released specimens. Open dissection was then performed to assess the accuracy of the percutaneous releases. RESULTS: Percutaneous US-guided releases were successfully performed in 15 of 16 specimens. The proximal release resulted in greater valgus angle displacement (11° ± 2°) than the distal release (8° ± 2°) between flexion angles of 30° and 70° (P < .0001 at 30°, P < .0001 at 40°, P = .001 at 50°, P = .005 at 60°, and P = .020 at 70°). Valgus displacement between release locations did not reach the level of statistical significance between 80° and 120° (P = .051 at 80°, P = .131 at 90°, P = .245 at 100°, P = .400 at 110°, and P = .532 at 120°). When we compared the values for the mean increase in US delta gap (stressed - supported state) from before to after MUCL release, the proximally released elbows had larger increases than the distally released elbows (5.0 mm proximal vs. 3.7 mm distal, P = .032). After MUCL release, maximum mean valgus displacement occurred at 49° of flexion. CONCLUSIONS: US-guided selective releases of the MUCL can be performed reliably without violating the overlying musculature. Valgus instability is not of greater magnitude for distal releases when compared with proximal releases. This findings suggests there must be alternative factors to explain the difference in clinical prognosis between distal and proximal tears. The observed flexion angle for maximum valgus laxity could have important implications for elbow positioning during US or fluoroscopic stress examination, as well as surgical repair or reconstruction of the MUCL.

Radiological Prevalence of Popliteal Artery Entrapment in Individuals With Anterior Leg Compartment Chronic Exertional Compartment Syndrome.

OBJECTIVE: Determine the radiological prevalence of popliteal artery entrapment (PAE) in subjects with anterior leg compartment chronic exertional compartment syndrome (CECS). DESIGN: Retrospective review. SETTING: Tertiary care center. PATIENTS: Of 71 patients diagnosed with anterior leg compartment CECS using an in-scanner exercise-based magnetic resonance imaging (MRI), 64 also completed Fast Imaging Employing Steady-State Acquisition (FIESTA) imaging. INTERVENTIONS: Electronic health records of patients diagnosed with anterior leg compartment CECS using an in-scanner exercise-based MRI between 2009 and 2018 were reviewed. MAIN OUTCOME MEASURES: Demographics, symptom laterality, and results of vascular work-up. RESULTS: Magnetic resonance imaging was positive for PAE in 33 of 64 (51.6%). Vascular evaluation was performed in 30 of 33 (90.9%). Of these 30, ankle-brachial indices (ABIs) with PAE maneuvers were performed in 29 (96.7%) and positive in 25 (86.2%). Pre-exercise and post-exercise ABIs were performed in 29 (96.7%) and abnormal in 20 (69.0%). Thirteen arterial duplex ultrasounds were performed; 10 were consistent with PAE (76.9%). An MR angiogram was performed in 8 (26.7%) and consistent with PAE in all. One computed tomography angiogram (3.3%) was completed and was normal. Overall, one or more tests were positive for PAE in all 30 with vascular evaluation. CONCLUSIONS: The radiological prevalence of PAE and anterior leg CECS was 51.6%. All subjects with vascular studies (90.9%) had one or more tests confirming radiological PAE. These findings suggest that the coexistence of PAE and CECS is common, and the PAE protocol used has a high correlation with vascular studies.

The Telemedicine Musculoskeletal Examination.

Telemedicine uses modern telecommunication technology to exchange medical information and provide clinical care to individuals at a distance. Initially intended to improve health care for patients in remote settings, telemedicine now has a broad clinical scope with the general purpose of providing convenient, safe, and time- and cost-efficient care. The coronavirus disease 2019 pandemic has created marked nationwide changes in health care access and delivery. Elective appointments and procedures have been canceled or delayed, and multiple states still have some degree of shelter-in-place orders. Many institutions are now relying more heavily on telehealth services to continue to provide medical care to individuals while also preserving the safety of health care professionals and patients. Telemedicine can also help reduce the surge in health care needs and visits as restrictions are lifted. In recent weeks, there has been a significant amount of information and advice on how to best approach telemedicine visits. Given the frequent presentation of individuals with musculoskeletal complaints to the medical practitioner, it is important to have a framework for the virtual musculoskeletal physical examination. This will be of importance as telemedicine continues to evolve, even after coronavirus disease 2019 restrictions are lifted. This article will provide the medical practitioner performing a virtual musculoskeletal examination with a specific set of guidelines, both written and visual, to enhance the information obtained when evaluating the shoulder, hip, knee, ankle, and cervical and lumbar spine. In addition to photographs, accompanying videos are included to facilitate and demonstrate specific physical examination techniques that the patient can self-perform.

Outcomes of Acute Inpatient Rehabilitation After Ventricular Assist Device Placement.

OBJECTIVE: The aim of the study was to compare outcomes of inpatient rehabilitation after ventricular assist device placement with outcomes for other cardiac diagnoses. DESIGN: This was a retrospective review of the electronic health records of 265 patients admitted to inpatient rehabilitation: 166 patients were admitted after ventricular assist device placement and 99 were admitted for other cardiac disease. Data collected included functional independence measure score on admission and discharge, dates of admission and discharge, and disposition. RESULTS: Patients admitted after ventricular assist device placement had a mean functional independence measure gain of 25.7 and length of stay of 8.7 days. Patients admitted for other cardiac diagnoses had a mean functional independence measure gain of 25.9 and length of stay of 9.4 days. These differences were not statistically significant. Change in functional independence measure from admission to discharge was statistically significant within each group (P < 0.001). Most patients were discharged home, and the proportions who returned to acute care or home were not different between groups. CONCLUSIONS: Both the ventricular assist device and nonventricular assist device groups had significant and equivalent improvements in functional outcomes after inpatient rehabilitation. This study found that ventricular assist device patients benefit from inpatient rehabilitation with similar disposition rates as patients with other cardiac diagnoses. Inpatient rehabilitation is the appropriate setting for this group. TO CLAIM CME CREDITS: Complete the self-assessment activity and evaluation online at http://www.physiatry.org/JournalCME CME OBJECTIVES: Upon completion of this article, the reader should be able to: (1) Describe the role of rehabilitation in the care of individuals after ventricular assist device (VAD) placement; (2) Compare the outcomes of inpatient rehabilitation for individuals after VAD placement to those admitted for other cardiac reasons; and (3) Recognize potential complications that may occur during the course of a VAD patient's inpatient rehabilitation stay. LEVEL: Advanced ACCREDITATION: The Association of Academic Physiatrists is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.The Association of Academic Physiatrists designates this Journal-based CME activity for a maximum of 1.0 AMA PRA Category 1 Credit(s)™. Physicians should only claim credit commensurate with the extent of their participation in the activity.