Quantitative Cartilage T2 and T1rho Mapping: Is There a Clinical Role? From the AJR Special Series on Quantitative Imaging.

Despite more than 20 years of development, the MRI-based cartilage compositional biomarkers T2 and T1rho have not been routinely applied in clinical practice. This review examines these measures' historical development and frames the challenges in the application of these quantitative imaging tools to the care of patients with cartilage injury and osteoarthritis using the hierarchical model of efficacy proposed by Fryback and Thornbury. T2 and T1rho have been validated for the evaluation of early compositional and structural changes in cartilage extracellular matrix. Yet, these biomarkers lack direct correlation with pain or function loss, lack standardization of methods for acquisition and analysis, and have a limited role in guiding therapeutic management given the absence of effective disease-modifying osteoarthritis drugs. These issues present significant challenges in the path to the biomarkers' future implementation in clinical care. Nonetheless, these MRI-based cartilage compositional biomarkers provide an essential tool for musculoskeletal research and can provide important information on the biophysical properties of cartilage that will continue to contribute to our understanding of cartilage injury and osteoarthritis pathogenesis.

Distinct inflammatory Th17 subsets emerge in autoimmunity and infection.

Th17 cells play a critical role in both tissue homeostasis and inflammation during clearance of infections as well as autoimmune and inflammatory disorders. Despite numerous efforts to distinguish the homeostatic and inflammatory roles of Th17 cells, the mechanism underlying the divergent functions of inflammatory Th17 cells remains poorly understood. In this study, we demonstrate that the inflammatory Th17 cells involved in autoimmune colitis and those activated during colitogenic infection are distinguishable populations characterized by their differential responses to the pharmacological molecule, clofazimine (CLF). Unlike existing Th17 inhibitors, CLF selectively inhibits proautoimmune Th17 cells while preserving the functional state of infection-elicited Th17 cells partially by reducing the enzyme ALDH1L2. Overall, our study identifies two distinct subsets within the inflammatory Th17 compartment with distinct regulatory mechanisms. Furthermore, we highlight the feasibility to develop disease-promoting Th17 selective inhibitor for treating autoimmune diseases.

Utility and Associated Charge of Anteroposterior Radiographs in Rotational Ankle Fractures During Postoperative Follow-Up: The Results of an Orthopaedic Trauma Association Survey.

OBJECTIVES: To evaluate the perceived utility and associated charges of the anteroposterior (AP) radiograph during rotational ankle fracture postoperative follow-up. DESIGN: Survey study with charge analysis using published data at 50 orthopaedic hospitals in the United States. SETTING: Not Applicable. PARTICIPANTS: Orthopaedic Trauma Association Members with an active email address who were invited and interested in answering a survey. RESULTS: Ninety-four percent of respondents stated that they did routinely obtain an AP radiograph during rotational ankle fracture follow-up. However, 57% thought that the AP view should be eliminated from standard follow-up and only 51% found this view useful after initial treatment. CHARGE ANALYSIS: The mean difference between a 2-view and 3-view ankle radiograph series was $102.00. Using this value and the assumption that each patient with a rotational ankle fracture gets 3 follow-up radiographs, there is the potential for a charge reduction of $306 per patient. Assuming over 134,000 rotational ankle fractures, a charge reduction of 41 million US dollars (USD) per year is possible if the AP image is routinely removed. Actual savings are likely to be less based on agreed on payer rates. Although less easy to quantify, there is also a potential reduction of radiation exposure, radiologists' interpretation time, and data storage. CONCLUSIONS: Routine AP radiographs should potentially be eliminated from routine postoperative ankle x-ray protocols based on this survey of experienced orthopaedic surgeons. If this specific radiograph is ordered on a case-by-case basis, then significant savings may occur.

How are our residents doing on trauma tonight? The frequency of overnight resident-faculty report discrepancies in trauma patients.

PURPOSE: To determine if preliminary radiology reports issued overnight (10 pm to 7 am) on adult trauma patients cause major changes of high clinical significance or patient harm. METHODS: Following extraction of preliminary and final radiology reports from the report server, presence of changes was determined by an automated text differential checker. If text changes were present, reports were then subsequently manually graded by an attending radiologist and placed in category by degree of severity. 81 weeks of trauma report data were analyzed by two faculty radiologists. RESULTS: Of the 6063 preliminary reports from 1214 separate overnight trauma patients, 65.5% had no changes in final report text. The remaining reports were graded: A 8.9% (503), B 17.2% (1005), C 7.0% (426), and D 1.3% (100). No reports demonstrated a major change of high clinical significance (E) or patient harm (F). CONCLUSION: Most preliminary report changes were minor and had no clinical significance. Furthermore, the few that were deemed to be major changes were of little clinical significance, particularly in the setting of the other traumatic injuries that the patient may have sustained. No negative patient safety events were caused by an error in a radiology resident preliminary report.

Everything Every Radiologist Always Wanted (and Needs) to Know About Clinical Decision Support.

As of January 2020, clinical decision support needs to be implemented across US health systems for advanced diagnostic imaging services. This article reviews the history, importance, and hurdles of clinical decision support and discusses a few pearls and pitfalls regarding its implementation.

External Orthopaedic Implants in the Magnetic Resonance Environment: Current Concepts and Controversies.

MRI provides diagnostic three-dimensional imaging and remains extremely important in the diagnosis and management of spinal trauma as well as other acute traumatic injuries, including those of the extremities. The American Society for Testing and Materials has created standards against which all implantable medical devices are tested to ensure safety in an MR environment. Most implantable passive orthopaedic devices can undergo MRI without consequence to the patient. However, the American Society for Testing and Materials has recently updated its terminology resulting in confusion among providers and institutions. Primary safety concerns are radiofrequency-induced heating and magnetically induced torque or displacement. These safety concerns have emerged as a recent source of debate, particularly regarding the imaging of patients with external fixation and cervical immobilization devices in place. Surveys have shown a lack of consensus among radiologists regarding this issue. Having an institutional protocol in place for the imaging of these patients streamlines the diagnosis and early stabilization of certain polytraumatized patients. The purpose of this review is to summarize the pertinent literature as well as the current industry recommendations regarding the safety of commonly used external fixation, cervical immobilization, and traction devices in the MR environment.

Prevalence of MRI Shoulder Abnormalities in Asymptomatic Professional and Collegiate Ice Hockey Athletes.

BACKGROUND: The literature demonstrates a high prevalence of asymptomatic knee and hip findings on magnetic resonance imaging (MRI) in athletes. Baseball pitchers are shown to have a high prevalence of asymptomatic shoulder MRI findings, but the incidence of asymptomatic shoulder MRI findings has not been systematically evaluated in nonthrowing contact athletes. PURPOSE/HYPOTHESIS: The purpose of this study was to determine the prevalence of shoulder abnormalities in asymptomatic professional and collegiate hockey players. We hypothesized that, similar to overhead throwing athletes, ice hockey players will have a high prevalence of asymptomatic MRI findings, including labral, acromioclavicular (AC), and rotator cuff pathology on MRI. STUDY DESIGN: Cross-sectional study; Level of evidence, 4. METHODS: A total of 25 asymptomatic collegiate and professional hockey players (50 shoulders) with no history of missed games or practice because of shoulder injury, pain, or dysfunction underwent bilateral shoulder noncontrast 3.0-T MRI. MRIs were read blinded by 2 board-certified radiologists at 2 separate time points, 3 months apart, to determine the prevalence of abnormalities of the joint fluid, bone marrow, rotator cuff tendon, biceps tendon, labrum, AC joint, and glenohumeral joint. Interrater and intrareader reliability was determined, and regression analysis was performed to identify the prevalence and relationship to stick-hand dominance. RESULTS: Labral abnormalities were seen in 25% of the shoulders. AC joint abnormalities and rotator cuff findings were noted in 8% and 6% of shoulders, respectively. One shoulder was noted to have a biceps tendon abnormality, and 1 shoulder demonstrated glenohumeral joint chondral findings. Interrater reliability coefficients were 0.619 for labral abnormalities. Intrareader reliability kappa coefficients were 0.493 and 0.718 for both readers, respectively, for labral abnormalities. Regression analysis was performed and revealed that the overall shoulder pathology was more common in the nondominant stick hand (top stick hand) (coefficient -0.731; P = .021). CONCLUSION: Professional and collegiate ice hockey players had an overall prevalence of labral abnormalities in 25% of their shoulders, with findings more often found in the nondominant stick hand. Rotator cuff abnormalities were uncommon in ice hockey players. These findings differ significantly from published reports examining professional baseball players and other overhead sports athletes.

Improvement in knee osteoarthritis pain and function following bariatric surgery: 5-year follow-up.

BACKGROUND: Weight loss through bariatric surgery improves short-term knee pain and symptoms in patients with osteoarthritis. There is little research regarding whether patients maintain symptomatic improvement in long-term follow-up after bariatric surgery. OBJECTIVES: We hypothesized that bariatric surgery is a reliable method of maintaining weight loss in these patients with continued improvements in knee pain and symptoms at 5-year follow-up compared with baseline. SETTING: University hospital. METHODS: A 5-year prospective observational study was performed in patients with symptoms and radiographic evidence of knee osteoarthritis who were undergoing bariatric surgery. The Western Ontario and McMaster Universities Index of Osteoarthritis and Knee Osteoarthritis Outcome Score Surveys were administered at baseline, 6 months, 12 months, 2 years, and 5 years. Patients who met all inclusion criteria and followed up at baseline, 6 months, 1 year, and 5 years were included in the study (n = 13). Statistical analysis was performed using Student t and Wilcoxon signed rank tests. RESULTS: Patients on average maintained a percent total weight loss of 22.3% at 5-year follow-up (P < .0001). There was a statistically significant improvement from baseline in all subscales-pain, stiffness, and physical function-as measured by Western Ontario and McMaster Universities at 6 months, 1 year, and 5 years. A statistically significant change in pain (P = .0005) and function/activities of daily living (P = .0088) was maintained at 5-year follow-up as measured by the Knee Osteoarthritis Outcome Score. CONCLUSIONS: Bariatric surgery is a reliable method to maintain weight loss, reduce pain and stiffness, and improve function in patients with knee osteoarthritis at 5-year follow-up.

Playing Well With Others: The Challenge of Academic and Community Radiology Practice Integration.

OBJECTIVE. In this article, we review models for clinical integration across the full spectrum of radiologic services in merged health systems that include both academic and community practice components. We also discuss the issues involved in the integration of disparate practice models and reward systems for both the community radiology group and the academic faculty practice group. CONCLUSION. Although we see advantages to the current trends in mergers and acquisitions within academic radiology, it remains to be seen whether academic and community practice radiology groups can truly work and play well together.

Subtle radiographic findings of acute, isolated distal radioulnar joint dislocation.

Distal radioulnar dislocations typically occur in association with fractures of the distal radius and/or ulna. Rare isolated dislocations or subluxations are more difficult to diagnose and are initially missed in up to 50 % of cases. We present two cases of missed isolated volar rotatory dislocation of the distal radioulnar joint. Subtle, overlooked radiographic findings of abnormal radioulnar alignment and ulnar styloid projection are highlighted. The supplemental role of cross-sectional imaging is reviewed. Adequate clinical information, appropriate radiographic technique, and high index of suspicion are necessary for the accurate and timely diagnosis of this rare injury pattern.

Outcomes following impaction bone grafting for treatment of unstable osteochondritis dissecans.

BACKGROUND: Many methods have been proposed to treat unstable osteochondritis dissecans (OCD). Our purpose is to report outcomes in a cohort of patients undergoing impaction bone grafting for treatment of knee OCD. METHODS: Patients undergoing impaction bone grafting for knee OCD between 1998 and 2011 were contacted and stratified into (a) those who have undergone subsequent surgery on the affected knee and (b) those who have not had revision surgery performed on the affected knee since the impaction bone grafting procedure. For those not undergoing another procedure, physical examination, radiographs, MRI, and functional outcomes (SF12, Tegner, Activity Rating Scale, and IKDC) were obtained. RESULTS: Of nine patients (10 knees) undergoing the procedure, seven (eight knees) were available for follow-up. Three had revision surgery. One had debridement due to surface overgrowth and had no symptoms 43months following debridement, while two had osteochondral allograft and autograft procedures at three and 10years after initial surgery, respectively. Four patients did not require a revision surgical procedure at average follow-up of 55.4months (range, 21-116months). All had complete MRI fill of the cartilaginous defect with less than 50% of surface irregularity and redeveloped the tidemark and a heterogeneous cartilaginous surface. Follow-up Tegner, ARS, and SF12-PCS averaged 6.8, 67.5, and 56.6, respectively. All four had good/excellent IKDC results. CONCLUSION: Impaction bone grafting can reliably restore osteocartilaginous defect produced by OCD and is a readily available and less-expensive option in treating OCD lesions. Further investigation is necessary to determine the long-term durability of the results. Level IV - Case series.

ACR Appropriateness Criteria Follow-Up of Malignant or Aggressive Musculoskeletal Tumors.

Appropriate imaging modalities for the follow-up of malignant or aggressive musculoskeletal tumors include radiography, MRI, CT, (18)F-2-fluoro-2-deoxy-D-glucose PET/CT, (99m)Tc bone scan, and ultrasound. Clinical scenarios reviewed include evaluation for metastatic disease to the lung in low- and high-risk patients, for osseous metastatic disease in asymptomatic and symptomatic patients, for local recurrence of osseous tumors with and without significant hardware present, and for local recurrence of soft tissue tumors. The timing for follow-up of pulmonary metastasis surveillance is also reviewed. The ACR Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed every three 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.

ACR Appropriateness Criteria Acute Trauma to the Knee.

More than 500,000 visits to the emergency room occur annually in the United States, for acute knee trauma. Many of these are twisting injuries in young patients who can walk and bear weight, and emergent radiographs are not required. Several clinical decision rules have been devised that can considerably reduce the number of radiographs ordered without missing a clinically significant fracture. Although a fracture is seen on only 5% of emergency department knee radiographs, 86% of knee fractures result from blunt trauma. In patients with a fall or twisting injury who have focal tenderness, effusion, or inability to bear weight, radiographs should be the first imaging study obtained. If the radiograph shows no fracture, MRI is best for evaluating for a suspected meniscus or ligament tear, or the injuries from a reduced patellar dislocation. Patients with a knee dislocation should undergo radiographs and an MRI, as well as an angiographic study such as a fluoroscopic, CT, or MR angiogram. The ACR Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed every three 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.

Posterior Displacement of Supraspinatus Central Tendon Observed on Magnetic Resonance Imaging: A Useful Preoperative Indicator of Rotator Cuff Tear Characteristics.

PURPOSE: To characterize the orientation of the normal supraspinatus central tendon and describe the displacement patterns of the central tendon in rotator cuff tears using a magnetic resonance imaging (MRI)-based method. METHODS: We performed a retrospective MRI and chart review of 183 patients with a rotator cuff tear (cuff tear group), 52 with a labral tear but no rotator cuff tear (labral tear group), and 74 with a normal shoulder (normal group). The orientation of the supraspinatus central tendon relative to the bicipital groove was evaluated based on axial MRI and was numerically represented by the shortest distance from the lateral extension line of the central tendon to the bicipital groove. Tear size, fatty degeneration, and involvement of the anterior supraspinatus were evaluated to identify the factors associated with orientation changes. RESULTS: The mean distance from the bicipital groove to the central tendon line was 0.7 mm and 1.3 mm in the normal group and labral tear group, respectively. Full-thickness cuff tears involving the anterior supraspinatus showed a significantly greater distance (17.7 mm) than those sparing the anterior supraspinatus (4.9 mm, P = .001). Fatty degeneration of the supraspinatus was significantly correlated with the distance (P = .006). Disruption of the anterior supraspinatus and fatty degeneration of the supraspinatus were independent predictors of posterior displacement. CONCLUSIONS: The supraspinatus central tendon has a constant orientation toward the bicipital groove in normal shoulders, and the central tendon is frequently displaced posteriorly in full-thickness rotator cuff tears involving the anterior leading edge of the supraspinatus. The degree of posterior displacement is proportional to tear size and severity of fatty degeneration of the supraspinatus muscle. A simple and quick assessment of the central tendon orientation on preoperative MRI can be a useful indicator of tear characteristics, potentially providing insight into the intraoperative repair strategy. LEVEL OF EVIDENCE: Level IV, diagnostic case-control study.

ACR Appropriateness Criteria Acute Trauma to the Foot.

This ACR Appropriateness Criteria article offers imaging triage guidance for several variants of patients presenting with acute foot trauma. Patients meeting inclusion criteria for the Ottawa Rules should undergo a 3-view radiographic series. Diabetic patients with peripheral neuropathy should undergo radiography, even though they do not meet the Ottawa Rules inclusion criteria. Patients with suspected midfoot and/or Lisfranc injury should undergo 3-view radiographs with weight bearing on at least the anterior-posterior view. Patients with suspected Lisfranc injury and normal radiographs should be considered for MRI and CT on a case-by-case basis. MRI or ultrasound could confirm cases of suspected acute tendon rupture. Radiography is the initial imaging modality for suspected plantar plate injury after metatarsal-phalangeal joint injury. Weight-bearing anterior-posterior, lateral, and sesamoid axial views may detect proximal migration of the hallux sesamoids. Ultrasound or MRI can directly evaluate the capsuloligamentous complex, specifically the plantar plate. Radiography can detect radiopaque penetrating foreign bodies, and ultrasound can be helpful in detecting those that are nonradiopaque. The ACR Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed every 3 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 instances in which evidence is lacking or is not definitive, expert opinion may be used to recommend imaging and treatment.

ACR Appropriateness Criteria acute trauma to the ankle.

Acute ankle injuries are frequently diagnosed and treated in emergency departments and outpatient clinics. Recent evidence-based clinical treatment guidelines and systematic review of economic analyses support the use of 3-view (anteroposterior, lateral, and mortise) radiographic evaluation of patients meeting the criteria of the Ottawa ankle rules. Cross-sectional imaging has a limited secondary role primarily as a tool for preoperative planning and as a problem-solving technique in patients with persistent symptoms and suspected of having occult fractures. The ACR Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed every 3 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.

Asymptomatic hip/groin pathology identified on magnetic resonance imaging of professional hockey players: outcomes and playing status at 4 years' follow-up.

PURPOSE: The purpose of this study was to evaluate the clinical outcomes and playing status of professional hockey players 4 years after they underwent bilateral magnetic resonance imaging (MRI) of asymptomatic hips. METHODS: Twenty-one professional hockey players with no previous hip/groin pain underwent hip/pelvis MRI. Each MRI study was evaluated by 3 subspecialty-trained musculoskeletal radiologists for alpha-angle measurement and the presence of adductor-abdominal rectus abnormalities, acetabular labral tears, osteochondral lesions of the femoral head or acetabulum, hip effusion, adjacent muscle contusions or strain injury, and stress fractures. The MRI findings of the players were previously published. In the present study, each athlete was followed up by (1) completion of a questionnaire assessing hip/groin dysfunction at 1 and 2 years' follow-up and (2) number of games played over the course of the next 4 years. A significant difference in the number of games played was considered when a player missed more than 5 games compared with the index year. RESULTS: We enrolled 21 players in the study. Of these players, 4 had no abnormality bilaterally, 10 had muscle strain and/or tendinosis in 1 or both hips, and 15 had labral tears identified in 1 or both hips. Eight players had a combination of labral tears and muscle strain/tendinosis. Of 21 professional hockey players, 16 (76%) and 14 (67%) were available at 1 and 2 years' follow-up, respectively. Nineteen of 21 players (90%) continued to play professional hockey at 4 years' follow-up. The development of any hip and/or pelvis symptoms occurred in only 3 players (14%) within 4 years. Only 1 of the 3 players missed any games because of hip and/or pelvis symptoms. The affected player missed several games because of proximal iliotibial band symptoms that occurred in the third year after MRI. CONCLUSIONS: Hip/pelvis pathology is commonly uncovered on MRI of asymptomatic hockey players; however, this pathology does not produce symptoms or result in missed games within 4 years in most players. LEVEL OF EVIDENCE: Level IV, therapeutic case series.

Anatomy integration blueprint: A fourth-year musculoskeletal anatomy elective model.

Current undergraduate medical school curricular trends focus on both vertical integration of clinical knowledge into the traditionally basic science-dedicated curricula and increasing basic science education in the clinical years. This latter type of integration is more difficult and less reported on than the former. Here, we present an outline of a course wherein the primary learning and teaching objective is to integrate basic science anatomy knowledge with clinical education. The course was developed through collaboration by a multi-specialist course development team (composed of both basic scientists and physicians) and was founded in current adult learning theories. The course was designed to be widely applicable to multiple future specialties, using current published reports regarding the topics and clinical care areas relying heavily on anatomical knowledge regardless of specialist focus. To this end, the course focuses on the role of anatomy in the diagnosis and treatment of frequently encountered musculoskeletal conditions. Our iterative implementation and action research approach to this course development has yielded a curricular template for anatomy integration into clinical years. Key components for successful implementation of these types of courses, including content topic sequence, the faculty development team, learning approaches, and hidden curricula, were developed. We also report preliminary feedback from course stakeholders and lessons learned through the process. The purpose of this report is to enhance the current literature regarding basic science integration in the clinical years of medical school.

ACR appropriateness criteria acute hip pain-suspected fracture.

Substantial cost, morbidity, and mortality are associated with acute proximal femoral fracture and may be reduced through an optimized diagnostic imaging workup. Radiography represents the primary diagnostic test of choice for the evaluation of acute hip pain. In middle aged and elderly patients with negative radiographs, the evidence indicates MRI to be the next diagnostic imaging study to exclude a proximal femoral fracture. CT, because of its relative decreased sensitivity, is only indicated in patients with MRI contraindications. Bone densitometry (DXA) should be obtained in patients with fragility fractures. 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 where evidence is lacking or not definitive, expert opinion may be used to recommend imaging or treatment.