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ACL reconstruction tunnel location is an important predictor for outcomes after surgery. The aim was to establish 3D and 2D MRI radiological measurements for native ACL tibial footprint that can provide information to facilitate pre-operative planning for anatomical graft placement. The measurements were also correlated in a subset of patients on arthroscopy.Retrospective evaluation of a consecutive series of knee MRIs with both 2D and 3D MR imaging was performed in 101 patients with 43 men and 66 women and ages 39.5 ± 11.9 years. Two measurements were obtained, tibial to ACL and intermeniscal ligament to ACL (T-ACL) and (IM-ACL), respectively. In a cohort of 18 patients who underwent knee arthroscopy, the T-ACL and IML-ACL distances were also determined by an orthopedic surgeon using a standard scale. ICC, Pearson correlation, and Bland-Altman plot were generated.For readers 1 and 2, the mean differences between 2D and 3D measurements of T-ACL and IM-ACL were 1.17 and 1.03 mm and 0.65 and 0.65 mm, respectively. The 2D measurements of T-ACL and IM-ACL were larger than the 3D measurements for both readers. The inter-reader reliability was excellent on 2D (0.81-0.96) and fair to excellent on 3D MRI (0.59-0.90). The mean arthroscopic IML-ACL was closer to that of 3D MRI compared to 2D MRI. The mean arthroscopic T-ACL was closer to 2D MRI than 3D MRI.Both 2D and 3D MRI show inter-reader reliability with small inter-modality mean differences in the measurements from the tibial or inter-meniscal ligament margins.• The mean differences between 2D and 3D measurements of tibia-ACL and intermeniscal ligament-ACL are small (1.2 mm). • As compared to arthroscopy, the mean T-ACL and IML-ACL were closer to measurements from 2D and 3D MRI, respectively. • Both 2D and 3D MRI can be reliably used to delineate ACL foot plate anatomy.

Scoliosis is a common orthopedic problem in patients with neurofibromatosis 1 (NF1). Spinal deformities are found in 77% of all NF1 cases, with no widely accepted etiology. This study aimed to evaluate the frequency and types of scoliosis in NF1 patients using whole-body magnetic resonance imaging and to assess the association of intraspinal and paraspinal tumors with the imaging findings of scoliosis.A total of 122 NF1 patients with whole-body magnetic resonance imaging were found from the electronic medical records. Ninety-seven cases that met the inclusion criteria were identified. All patients underwent 3-T magnetic resonance imaging with automated software fusion of the 3 sets of short TI inversion recovery and 3-dimensional T1-weighted coronal images. Frequency and location of scoliosis and intraspinal and paraspinal tumors were recorded. Patients with severe dystrophic-type scoliosis were separately identified, and Cobb angles were measured for all such cases. Association analysis was performed. A P value less than 0.05 was considered statistically significant.Ninety-seven patients with NF1 were evaluated. Two had prior spinal surgery and were excluded. The final sample of 95 patients included 33 (35%) men and 62 (65%) women with a mean ± SD body mass index of 25.82 (4.96) kg/m2. Of the 95 patients, 43 (45.3%) had scoliosis, 13 of 43 (30.2%) of which were severely angled. Of the 95 patients, 25 (26.3%) had locoregional tumor presence. Intraclass correlation for Cobb angles measured 0.99 (confidence interval, 0.98-1.0). Fisher exact test determined no association between scoliosis and presence of either paraspinal or intraspinal tumors (P = 0.485). There was also no association between the tumors and severe dystrophic scoliosis (P = 1.0).This study found no association between the presence of locoregional spinal tumors and scoliosis in NF1 patients. This work adds to the body of knowledge of scoliosis in NF1 patients and infers that presence of scoliosis should not mandate immediate search for locoregional spinal tumors.

Hallux valgus is a complex deformity with a variety of techniques described for correction. A biplanar plating system for triplanar correction system has been developed to address both the translation and rotational component of the hallux valgus deformity and allow an accelerated weightbearing protocol. The purpose of this study was to determine the correction and complications using radiographic parameters and patient reported outcomes. We sought to determine prognostic factors for successful correction, including age, gender, and preoperative deformity. From the medical records, we collected preoperative data. Patient-reported outcomes were obtained using AOFAS Hallux Metatarsophalangeal-Interphalangeal score, FAAM, and SF-12 scores preoperatively and postoperatively. Imaging was reviewed at preoperative and postoperative visits to determine hallux valgus angle, intermetatarsal angle, and tibial sesamoid position. Fifty-seven procedures, in 55 patients, were performed. There were 7 complications and mean follow-up time was 45.7 weeks (+ 28.3 weeks). Age over 62.5 years were associated with an increased risk of complications (p = .018). Males had an increased rate of complications (71%) compared with females. Radiographic parameters were significantly improved from preoperative values at alltime points (p.05). Only the AOFAS Hallux Metatarsophalangeal-Interphalangeal score was statistically significant at 3, 6 and 12 months. We sought to determine the effectiveness of biplanar plating and triplanar correction procedure with early weightbearing. Over a 12 month follow-up period, our results showed significant improvement in deformity and maintained correction. AOFAS Hallux Metatarsophalangeal-Interphalangeal scores significantly improved from the preoperative to the postoperative state. Our results show a nonunion rate of 5.2%, which is comparable to prior studies.

PURPOSE: We assessed the prevalence of low bone mineral density (BMD) in oncologic patients undergoing F-18-FDG-PET/CT. MATERIALS AND METHODS: Retrospective analysis of 100 patients who underwent F-18-FDG-PET/CT at a single center from October 2015 till May 2016. Quantitative computed tomography (QCT) was used to assess BMD at the lumbar spine (BMD(QCT)) and femoral necks (BMD(CTXA)). SUV(max) was used to evaluate metabolic activity of the bone marrow. Risk of osteoporosis-related fractures was calculated with femoral neck BMD(CTXA) and the FRAX® algorithm, which was compared against measurements of CT attenuation of the trabecular bone at L1 (L1(HU)). RESULTS: Osteoporosis/osteopenia were respectively present in 16%/46% of patients ≥ 50 years old. Bone marrow SUV(max) was correlated with BMD at the lumbar spine (ρ=0.36, p

Purpose Acetabular dysplasia (AD) is a debilitating condition which results in impaired hip function, leading to hip-spine syndrome with anomalies identifiable on plain radiographs. However, no study to date has investigated the association between radiographic spine anomalies and functional outcomes in AD. We hypothesize that AD patients with radiographic evidence of lumbar spine anomalies are associated with decreased function in comparison to those without such radiographic findings. Patients and methods One hundred thirty-five hips underwent a full four-view hip radiograph series, and two observers analyzed hip and spine variables using standard radiographs and obtained Castellvi grade, assessment of spondylolisthesis, and L4-S1 interpedicular distance. A comprehensive hip questionnaire was administered which included Harris Hip Score (HHS) and Hip Disability and Osteoarthritis Outcome Score (HOOS) to assess patient function. Correlations between HHS and HOOS and radiographic spinal measurements were calculated, and p-values were corrected for multiple comparison using the Holm’s method. Results Out of 135 patients, 119 were female (88.1%) and 16 were male (11.9%). Average age of presentation was 34.2 years, and average BMI was 26. There was no statistically significant correlation between Castellvi grade, presence of spondylolisthesis, or L4-S1 interpedicular distance and the patient-reported outcome measures HHS or HOOS. Conversely, a significant correlation was observed between Femoro-Epiphyseal Acetabular Roof (FEAR) index and HOOS of the contralateral hip (correlation coefficient = 0.38, adjusted p = 0.03) and Tönnis angle of AD severity and HHS of the contralateral hip (correlation coefficient = − 0.33, adjusted p = 0.04). Conclusion Severity of spinal anomalies measured by Castellvi grade and spondylolisthesis in patients with AD was not associated with decreased patient function in the ipsilateral diseased hip. To our knowledge, this is the first study to date to report the relationship between radiographically identifiable lumbosacral abnormalities and hip function in AD.

Glenoid bone stock and morphology and rotator cuff muscle quality and tendon integrity affect the outcome of total shoulder arthroplasty. We hypothesized that glenoid bone loss correlates with rotator cuff muscle fatty infiltration (FI), tendinopathy, and atrophy.Forty-three 3D CT scans and MRIs of 43 patients (mean age 62 years; SD 13 years; range 22-77 years) referred for primary shoulder pain were evaluated. Measurements of glenoid bone stock, version, and posterior humeral subluxation index (HSI) were assessed on an axial CT image reconstructed in the true scapular plane. Measurements utilized the Friedman line to approximate the pre-pathologic surface. Glenoid morphology was assigned by modified Walch classification. Rotator cuff FI, atrophy, and tendon integrity were assessed on corresponding MRIs.There was a very strong negative correlation between increasing glenoid version and HSI (r = - 0.908; p 0.0001). There was a moderately negative correlation between anterior bone loss and HSI (r = - 0.562; p 0.0001) and a moderately positive correlation between posterior bone loss and HSI (r = 0.555; p 0.0001). Subscapularis muscle FI correlated moderately with increased anterior and central bone loss and increased humeral head medialization (r = 0.512, p = 0.0294; r = 0.479, p = 0.033; r = 0.494, p = 0.0294; respectively). Inter-observer reliability (intra-class correlation coefficient [ICC] and kappa) was good to excellent for all measurements and grading.Glenoid anteversion and anterior and posterior bone loss are associated with varying HSI. Subscapularis muscle FI, not tendon integrity, correlates to anterior and central glenoid erosion. The study adds evidence that neither rotator cuff tendinopathy nor muscle atrophy exhibits a significant relationship to HSI.

To test the diagnostic efficacy of a multiparametric rheumatology lumbosacral magnetic resonance (MR) imaging protocol in detection and characterization of axial spondylarthritis (SpA) and compare it with serology and clinical findings.A consecutive series of multiparametric rheumatology lumbosacral MR imaging examinations performed on 3T MR scanner. Three-dimensional inversion recovery turbo spin echo, precontrast and postcontrast fat-suppressed T1-weighted images, as well as diffusion-weighted images were used to detect active erosions and enthesitis using established criteria. Pearson χ2 was used for categorical variables. Sensitivity, specificity, positive predictive value, negative predictive value, and accuracy were measured for magnetic resonance imaging (MRI) and serology, based on the final diagnosis from rheumatologists. An alpha error below 0.05 was considered statistically significant.The final study sample included 130 consecutive patients (80 women and 50 men; mean ± SD 44 ± 13 and 45 ± 14 years, respectively). Seventy-eight subjects were diagnosed with axial SpA and 52 with non-SpA arthropathy. In the non-SpA group, 27 patients were diagnosed with osteoarthritis, 6 had unremarkable imaging, whereas 19 were considered as clinically undetermined. There was positive correlation between positive MRI results and SpA diagnosis (P0.00001). No correlation existed between positive serology alone and SpA diagnosis (P = 0.0634). Although MRI and serology proved equally sensitive in detecting SpA, the specificity and overall accuracy of MRI were significantly higher. Inflammatory activity was detected in 45 (57.7%) cases, in the pelvic enthesis in 29 (37.2%) cases, in the lumbosacral spine in 16 (20.5%) cases, in the hip joints in 15 (19.2%) cases, and in the pubic symphysis in 5 (6.4%). Inactive sacral disease was seen in 7 of 35 enthesitis patients (20.0%), and in 2 SpA cases, there were no sacral lesions.The results suggest that in patients with suspected SpA, MRI should not be limited to the sacroiliac joints, but also include enthesitis sites and other joints of the axial skeleton. The multiparametric rheumatology protocol increases the efficacy of MRI in detecting enthesitis and joint inflammatory disease, thereby offering additional information to the clinician and assisting in the early diagnosis/detecting disease activity.

Many patients electing to undergo total hip arthroplasty (THA) value continuing active lifestyles when considering treatment options. Addressing these concerns requires evaluating the effect of preoperative activity level on patient-reported outcomes and improvement following THA.Three hundred thirty-five patients (368 hips) who underwent THA with a minimum 6-month (mean 533 ± 271 days) follow-up completed preoperative and postoperative University of California, Los Angeles (UCLA) activity score along with various patient-reported measures of function, pain, and mental state. Preoperative UCLA score divided patients into inactive, mild, and active groups. Analysis of covariance controlling for age, sex, body mass index, surgical approach, implant, bilateral cases, conversions, and follow-up time evaluated differences among groups for postoperative outcomes with subsequent Tukey-Kramer pairwise comparisons.Mildly active patients (73:139 male:female) had better postoperative outcomes than inactive patients (40:70 male:female) for UCLA score, EuroQol Visual Analog Scale (EQVAS), Hip Outcome Score (HOS), 12-item Short-Form (SF-12) Physical, and Visual Analog Pain Scale (average/now/worst) (P values0.001/0.001/0.001/0.001/0.003/0.001/0.001). Active patients (32:14 male:female) had better postoperative outcomes than inactive patients for UCLA score, EQVAS, HOS, SF-12 Physical, and Visual Analog Pain Scale Worst (P values0.001/0.024/0.001/0.001/0.017). No postoperative outcome differences existed between active and mild patients. Inactive patients displayed greater outcome improvements than mildly active patients for UCLA score, Harris Hip Score, and International Hip Outcome Tool (P values0.001/0.001/0.013) and active patients for UCLA score, EQVAS, HOS, International Hip Outcome Tool, and SF-12 Physical (P values0.001/0.008/0.013/0.022/0.004).Inactive patients achieve greater measure improvements following THA. Active patients achieve better absolute outcomes than inactive patients; however, increasing activity levels do not incrementally improve patient-reported outcome measures. Patients similarly improve pain and mental health regardless of activity level.

MR imaging of joints, particularly shoulder, requires a high degree of spatial resolution to ascertain anatomy and pathology. Unfortunately, motion artifacts can reduce the clinical quality of the examinations. BLADE sequence reduces motion degradation improving overall diagnostic imaging quality. The objective was to compare standard, rectilinear k-space coverage turbo spin echo (TSE), and BLADE sequences.Over a 4-month period, fifty-seven consecutive patients (22 males, 35 females; mean age: 48.5 years, range: 23-64 years) were scanned using traditional intermediate-weighted spin echo and BLADE sequences. Qualitative evaluation was performed by three musculoskeletal fellowship trained radiologists, each with more than 5 years of experience. Image sequences were evaluated using a Likert scale for each of the following five categories: motion degradation, ghosting/phase misregistration artifacts, star/radial encoding artifacts, fat suppression quality, and overall diagnostic quality. Additionally, image sequences were evaluated for signal-to-noise ratio (SNR) and contrast-to-noise ratio (CNR) using manually drawn regions of interest (ROI) analysis.Ghosting and phase artifacts were lower within BLADE sequence while streak artifacts were higher (p 0.001). Image fat suppression, tendon and labral appearances, and the overall SNR and CNR were comparable on both sequences (p 0.05).Addition of BLADE reduces motion degradation and improves overall diagnostic imaging quality. Application of BLADE in patient scans suspected of motion artifacts can reduce the frequency of repeat imaging in patients with claustrophobia or those where motion is a concern. By reducing overall imaging time and call backs, it could reduce the cost burden to patients and healthcare system.

BACKGROUND: Pyruvate dehydrogenase (PDH) and lactate dehydrogenase are essential for adenosine triphosphate production in skeletal muscle. At the onset of exercise, oxidation of glucose and glycogen is quickly enabled by dephosphorylation of PDH. However, direct measurement of PDH flux in exercising human muscle is daunting, and the net effect of covalent modification and other control mechanisms on PDH flux has not been assessed. PURPOSE: To demonstrate the feasibility of assessing PDH activation and changes in pyruvate metabolism in human skeletal muscle after the onset of exercise using carbon 13 ((13)C) MRI with hyperpolarized (HP) [1-(13)C]-pyruvate. MATERIALS AND METHODS: For this prospective study, sedentary adults in good general health (mean age, 42 years ± 18 [standard deviation]; six men) were recruited from August 2019 to September 2020. Subgroups of the participants were injected with HP [1-(13)C]-pyruvate at resting, during plantar flexion exercise, or 5 minutes after exercise during recovery. In parallel, hydrogen 1 arterial spin labeling MRI was performed to estimate muscle tissue perfusion. An unpaired t test was used for comparing (13)C data among the states. RESULTS: At rest, HP [1-(13)C]-lactate and [1-(13)C]-alanine were detected in calf muscle, but [(13)C]-bicarbonate was negligible. During moderate flexion-extension exercise, total HP (13)C signals (tC) increased 2.8-fold because of increased muscle perfusion (P = .005), and HP [1-(13)C]-lactate–to-tC ratio increased 1.7-fold (P = .04). HP [(13)C]-bicarbonate–to-tC ratio increased 8.4-fold (P = .002) and returned to the resting level 5 minutes after exercise, whereas the lactate-to-tC ratio continued to increase to 2.3-fold as compared with resting (P = .008). CONCLUSION: Lactate and bicarbonate production from hyperpolarized (HP) [1–carbon 13 {(13)C}]-pyruvate in skeletal muscle rapidly reflected the onset and the termination of exercise. These results demonstrate the feasibility of imaging skeletal muscle metabolism using HP [1-(13)C]-pyruvate MRI and the sensitivity of in vivo pyruvate metabolism to exercise states. © RSNA, 2021 Online supplemental material is available for this article.

Aims Some patients presenting with hip pain and instability and underlying acetabular dysplasia (AD) do not experience resolution of symptoms after surgical management. Hip-spine syndrome is a possible underlying cause. We hypothesized that there is a higher frequency of radiological spine anomalies in patients with AD. We also assessed the relationship between radiological severity of AD and frequency of spine anomalies. Methods In a retrospective analysis of registry data, 122 hips in 122 patients who presented with hip pain and and a final diagnosis of AD were studied. Two observers analyzed hip and spine variables using standard radiographs to assess AD. The frequency of lumbosacral transitional vertebra (LSTV), along with associated Castellvi grade, pars interarticularis defect, and spinal morphological measurements were recorded and correlated with radiological severity of AD. Results Out of 122 patients, 110 (90.2%) were female and 12 (9.8%) were male. We analyzed the radiographs of 122 hips (59 (48.4%) symptomatic left hips, and 63 (51.6%) symptomatic right hips). Average age at time of presentation was 34.2 years (SD 11.2). Frequency of LSTV was high (39% to 43%), compared to historic records from the general population, with Castellvi type 3b being the most common (60% to 63%). Patients with AD have increased L4 and L5 interpedicular distance compared to published values. Frequency of pars interarticularis defect was 4%. Intraclass correlation coefficient for hip and spine variables assessed ranged from good (0.60 to 0.75) to excellent (0.75 to 1.00). Severity of AD did not demonstrate significant correlation with frequency of radiological spine anomalies. Conclusion Patients with AD have increased frequency of spinal anomalies seen on standard hip radiographs. However, there exists no correlation between radiological severity of AD and frequency of spine anomalies. In managing AD patients, clinicians should also assess spinal anomalies that are easily found on standard hip radiographs. Cite this article: Bone Joint J 2021;103-B(8):1351–1357.

To develop and validate an Osseous Tumor Reporting and Data System (OT-RADS) with the hypothesis that the proposed guideline is reliable and assists in separating benign from malignant osseous tumors with a good area under the curve, and that could assist further patient management.In this multireader cross-sectional validation study, an agreement was reached for OT-RADS categories based on previously described magnetic resonance imaging features and consensus of expert musculoskeletal radiologists. World Health Organization classification was used, and a wide spectrum of benign and malignant osseous tumors was evaluated. Magnetic resonance imaging categories were as follows: OT-RADS 0-incomplete imaging; OT-RADS I-negative; OT-RADS II-definitely benign; OT-RADS III-probably benign; OT-RADS IV-suspicious for malignancy or indeterminate; OT-RADS V-highly suggestive of malignancy; and OT-RADS VI-known biopsy-proven malignancy or recurrent malignancy in the tumor bed. Four blinded readers categorized each tumor according to OT-RADS classification. Intraclass correlation (ICC) and Conger κ were used. Diagnostic performance measures including area under the receiver operating curve were reported. Osseous Tumor Reporting and Data System was dichotomized as benign (I-III) and malignant (IV and V) for calculating sensitivity and specificity.Interreader agreement for OT-RADS (ICC = 0.78) and binary distinction of benign versus malignant (κ = 0.67) were good to excellent, while agreement for individual tumor feature characteristics were poor to fair (ICC = 0.25-0.36; κ = 0.16-0.39). The sensitivities, specificities, and area under the receiver operating curve of the readers ranged from 0.93-1.0, 0.71-0.86, and 0.92-0.97, respectively.Osseous Tumor Reporting and Data System lexicon is reliable and helps stratify tumors into benign and malignant categories. It can be practically used by radiologists to guide patient management, improve multidisciplinary communications, and potentially impact outcomes.

To quantify and compare signal intensity (SI) changes on T1-weighted (W) and T2W Dixon imaging in yellow marrow, red marrow, and bone marrow lesions. A total of 141 patients (77 controls, 64 lesions—33 benign, 31 malignant) between January 2016 and December 2017 were retrospectively identified. For the control group, fixed 2-cm2 region of interests (ROI) were drawn at L5, bilateral ilium and femurs on in-phase and opposed-phase T1W and T2W Dixon images. For the lesion group, ROIs of best fit were drawn around each lesion on in-phase and opposed-phase T2W Dixon images. SI changes between in-phase and opposed phase maps for each group were compared. Inter-reader analysis was performed. Yellow marrow exhibited smaller SI changes as compared to red marrow on both T1W and T2W Dixon imaging at all locations (p

To quantify and compare changes in bone mineral density (BMD) via CT analysis in patients with and without spontaneous femoral fractures.Consecutive series of patients with CT imaging for spontaneous femoral fractures were compared to the age and gender matched controls. Bone density fixed region of interest measurements were obtained at the site of the fracture, proximally at the femoral head, and distally at the lesser trochanter in fracture patients and controls. Inter- and intrapatient comparisons were performed, including Chi-square and t-test analyses.24 spontaneous fractures and 25 controls were analyzed with no significant differences in mean age, gender, or body mass index. There were differences in the bone density between the fracture and contralateral non-fracture sides at (p = 0.0001) and distal (p 0.0001) to the fracture. Proximal and distal bone density differences existed between case fracture and control non-fracture sites (p 0.0001, p = 0.0001), and between the case non-fracture and control non-fracture sites (p 0.0001, p 0.0001). The reliability for measurements was good to excellent proximally (ICC = 0.63-0.87), moderate to excellent at the fracture site (ICC = 0.43-0.78), and fair to good distal (ICC = 0.24-0.68) to the fracture site.Patients with spontaneous femoral fractures exhibit lower bone density than the asymptomatic controls. Bone insufficiency is best demonstrated proximal or distal to, rather than at the fracture site.

Aim: To evaluate the utility of percutaneous CT guided bone biopsy (PCBB) for suspected osteomyelitis (OM) and its eventual impact on patient management and recovery. Material and methods: Patients who received a PCBB for suspected osteomyelitis from years 2012-2018. Patient demographics, lesion location, ulcer grade, signs of toxemia, serology, wound and blood cultures, bone biopsy and cross-sectional imaging results were recorded. Diagnostic yield of the bone biopsy and its role in influencing the final treatment plan and patient recovery were evaluated. Chi-square test was used. P-value less than 0.05 was considered statistically significant. Results: 115 patients with mean age 50.86 ± 14.49 years were included. The common locations were sacrum/ischium (49/115, 43%) and spine (35/115, 30%). Clinically, 40/115 (35%) had toxemia and 67/115 (58%) had ulcers. Per serology, 17/111 (15%), 95/106 (90%), and 86/98 (88%) had an elevated WBC, CRP, and sedimentation rate, respectively. 22/91 (24%) had a positive blood culture and all 23/23 had a positive wound culture. On imaging, definitive and possible OM were reported in 84.1% and 14.2%, respectively, with 1.8% as no OM. Only 24/115 (21%) had a positive bone biopsy culture and only 10/24 (42%) total positive bone cultures impacted the treatment plan. There was no significant effect of antibiotics on the diagnostic yield of culture (p = 0.08). No statistical significance was found when comparing treatment change based on bone culture results versus all other factors combined (p = 0.33), or when comparing clinical improvement with and without positive bone cultures (p = 0.12). Conclusion: Despite positive cross-sectional imaging findings of OM, bone biopsy yield of positive culture is low, and it leads to a small impact in changing the treatment plan or altering the course of patient recovery.

Aim Radiographs (X-rays) are used for the preoperative assessment of hallux valgus (HV). Our purpose was to determine how well quantitative measurements of HV on radiographs and MRI correlate with the qualitative soft tissue and internal derangement findings on MRI. Materials and methods After IRB approval, 56 consecutive patients with MRI and radiographs of the foot were retrospectively reviewed. Two trained readers independently evaluated radiographs, measuring hallux valgus angle (HVA) and intermetatarsal angle (IMA). Two separate readers assessed qualitative MRI data by evaluating 21 different soft tissue and bony features. Statistical analysis included inter-reader reliability (IRR) and correlation of quantitative and qualitative findings. Results Excellent IRR (ICC = 0.89–0.96) was observed for radiograph and MRI measurements of the hallux valgus severity. For qualitative assessments on MRI, IRR was good to excellent for all features (ICC = 0.63–0.9). No significant difference was found for HVA or IMA between normal and abnormal qualitative MRI features. No statistically significant correlation between the severity of hallux valgus and injury to hallux joints and supporting structures was found. Conclusion Hallux valgus measurements are reliable on x-rays and MRI and qualitative findings of 1st MTP joint show good to excellent inter-reader agreement on MRI. No statistically significant correlations exist between the severity of hallux valgus and qualitative MRI findings.

Determine correlations of 3DCT cam-type femoroacetabular impingement (FAI) measurements with surgical findings of labral tear and cartilage loss. Digital search of symptomatic cam-type FAI from July 2013 to August 2016 yielded 43 patients. Two readers calculated volumes of femoral head, bump, and alpha angles on 3DCT images. Correlations between CT and surgical findings, inter-, and intra-reader reliabilities were assessed using Spearman rank correlation and intraclass correlation coefficients (ICC). Thirteen men and 14 women aged 37 ± 10 (mean ± SD) years were included. Most common clinical finding was positive flexion–adduction–internal rotation (70.4%). Twenty-seven labral tears and 20 cartilage defects were surgically detected. Significant correlations existed between femoral bump, head volumes, and extent of the labral tear (p = 0.008 and 0.003). No significant correlations were found between the alpha angles at 12 to 3 o’clock and the extent of labral tear (p = 0.2, 0.8, 0.9, and 0.09) or any measurement with the cartilage loss (p values for alpha 12 to 3, bump, and head volumes = 0.7, 0.3, 0.9, 0.9, 0.07, and 0.2). Inter- and intra-reader reliabilities were excellent to moderate for femoral head and bump volumes (ICC = 0.85, 0.52, and 0.8, 0.5) and moderate to poor for alpha angles (ICC = 0.48, 0.40, 0.05, 0.25 and 0.3, 0.24, 0.29, 0.49). Three dimensional volumetric measurements of cam-type FAI significantly correlate with the extent of intraoperative labral tears. Superior inter- and intra-reader reliability to that of alpha angles renders it a more clinically relevant measurement for quantifying cam morphology. • The 3DCT bump volume and femoral head volume showed significant correlations with the extent of labral tear (p values = 0.008 and 0.003). • No significant correlations were seen between alpha angles and the extent of labral tear (p values > 0.05). • Inter- and intra-reader reliability was excellent to moderate (ICC = 0.85 and 0.52, 0.8, and 0.5) for femoral head and bump volumes while inter- and intra-reader reliability was fair to poor (ICC = 0.48, 0.40, 0.05, 0.25 and 0.3, 0.24, 0.29, 0.49) for alpha angles.

Perivascular epithelioid cell tumors (PEComas) are rare mesenchymal neoplasms composed of spindled to epithelioid cells that co-express both melanocytic and myogenic markers. Recently, in 2018, a distinctive variant of PEComa has been described that arises in association with tuberous sclerosis complex (TSC) and resembles a fibroma by conventional morphology (called fibroma-like PEComa). Herein, we describe a case of a fibroma-like PEComa in a 4-year-old male child with a known diagnosis of tuberous sclerosis who presented with a firm mass along the anteromedial aspect of the right knee. The mass was excised, and microscopic examination showed bland spindled to stellate cells embedded in a dense collagenous stroma, morphologically resembling a fibroma. Immunohistochemistry analysis showed positivity for desmin (a myogenic marker) and HMB45 (a melanocytic marker), a hallmark for PEComas. To our knowledge, only six cases of fibroma-like PEComa have been described in the literature so far and this is the first report of such a tumor in the medial retinaculum of the knee joint with illustrations of conventional and diffusion imaging features. This case highlights the unique association of fibroma-like PEComa lesions with TSC. This should be considered a differential diagnosis for T2 hypointense masses in tuberous sclerosis patients. In addition, a diagnosis of fibroma-like PEComa should prompt further evaluation for associated TSC.

Introduction To conduct a morphometric analysis of intact and torn menisci using isotropic meniscus plane three-dimensional (3D) reconstructions on 3-Tesla MRI and compare 2D versus 3D MRI for meniscus tear characterization. Materials and methods One hundred thirty three normal menisci from 92 patients (39 male, 53 female), and 38 arthroscopy-proven torn menisci from 36 patients (23 male, 13 female) were evaluated using 3D isotropic multi-planar MRI reconstructions and 2D MRI. Two observers measured the tibial plateau height and area, meniscal height, axial plane cross-sectional areas, and extrusion of intact menisci. Two observers also measured the meniscal tear length, tear area, and residual area of pathological menisci on 2D and 3D MRI. Intraclass correlation coefficients (ICC) were obtained. Institutional Review Board approval was obtained, and the informed consent was waived. Results Medial meniscus (MM) and lateral meniscus (LM) areas were 503.6 ± 85.1 mm2 and 396.6 ± 72.0 mm2 for Observer 1, and 515.8 ± 82.1 mm2 and 408.0 ± 68.3 mm2 for Observer 2 (ICC:0.86, 0.87). In torn menisci, average tear length, area, and residual area were 36.3 ± 13.6 mm, 182.6 ± 139.3 mm2 , and 235.4 ± 140.3 mm2 , respectively for Observer 1, and 38.9 ± 14.7 mm, 181.2 ± 135.6 mm2 , 238.2 ± 140.5 mm2 for Observer 2. In the MM and LM, bucket-handle and complex tears were largest in areas, respectively. ICCs were excellent (0.91-1.0) on 3D MRI and moderate-good (0.57-0.81) on 2D MRI. Conclusion Meniscus morphometry on 3D MRI shows moderate to excellent inter-observer reliability and meniscus tear extent is more reliably defined on 3D MRI than 2D MRI. Residual meniscus-area calculation can be performed on 3D MRI.

Objective:Femoroacetabular impingement (FAI) and hip dysplasia are the most common causes of groin pain originating from the hip joint. To date, there is controversy over cut-off values for the evaluation of abnormal femoral head-neck anatomy with significant overlap between the normal and abnormal hips. Our aim was to perform three-dimensional CT analysis of femoral head and bump anatomy to quantify common hip pathologies (FAI and hip dysplasia) vs controls.Methods:Consecutive patients who underwent three-dimensional CT imaging for hip dysplasia or CAM type FAI were compared to asymptomatic controls. α angles on radial CT and 3D volumetric femoral head and bump segmentations were performed by two readers. Inter- and intrapatient comparisons were performed including interreader and receiver operating characteristic analyses.Results:25 FAI patients, 16 hip dysplasia patients and 38 controls were included. FAI and dysplasia patients exhibited higher α angles and higher bump-head volume ratios than the controls (p < 0.05). Larger bump volumes were found among FAI than dysplasia patients and contralateral hips of FAI patients were also different than the controls. α angle at 2 o’clock and bump to head ratio showed the highest area under the curve for patients vs controls. The interreader reliability was better for volumetric segmentation (intraclass correlation coefficient = 0.35–0.84) as compared to the α angles (intraclass correlation coefficient = 0.11–0.44).Conclusion:Patients with FAI and dysplasia exhibit different femoral head anatomy than asymptomatic controls. Volumetric segmentation of femoral head and bump is more reliable and better demonstrates the bilateral femoral head anatomy differences in hip patients vs controls.Advances in knowledge:Utilizing information from 3D volumetric bump assessment in patients with FAI and dysplasia, the physicians may be able to more objectively and reliably evaluate the altered anatomy for better pre-surgical evaluation.

To analyze the impact of pelvic computed tomography (CT) technique optimization on estimated dose and subjective and objective image quality. An institutional review board (IRB)-approved retrospective records review was performed with waived informed consent. Five CT scanners (various manufacturers/models) were standardized to match the lowest dose profile on campus via subjective assessment of clinical images by experienced musculoskeletal radiologists. The lowest dose profile had previously been established through image assessment by experienced musculoskeletal radiologists after a department-wide radiation dose reduction initiative. A consecutive series of 60 pre- and 59 post-optimization bony pelvis CTs were analyzed by two residents, who obtained signal-to-noise ratio for femoral cortex and marrow, gluteus medius muscle, and subcutaneous and visceral fat in a standardized fashion. Two blinded attending radiologists ranked image quality from poor to excellent. Pre- and post-optimization subjects exhibited no difference in gender, age, or BMI (p > 0.2). Mean CT dose index (CTDIvol) and dose–length product (DLP) decreased by approximately 45%, from 39± 14 to 18± 12 mGy (p

Retrospective clinical case series.To study the role of magnetic resonance neurography (MRN) of the lumbosacral plexus in management of patients with failed back surgery syndrome (FBSS).FBSS is one of the major problems in health care, affecting up to 40% of patients after spine surgery. To date, no imaging modality has been used to effectively classify nerve compression, because nerve injuries are challenging to detect on conventional lumbar spine magnetic resonance imaging (MRI). To our knowledge, no previous studies have addressed the use of MRN in FBSS or compared it to lumbar spine MRI.From 203 consecutive 3 T MRN studies of lumbosacral plexus in 1 year, 12% (25/203) presented as FBSS. Demographic data, number of previous lumbar MRIs and their findings, MRN findings, interval between MRI and MRN, pre-and post-MRN diagnosis, pain levels, and treatments were recorded. Changes in diagnosis, treatment, and outcomes after MRN were determined.The final sample of 25 patients had a mean age 62 ± 15 and male to female ratio 1:1.08. Approximately 88% (22/25) had previous lumbar MRI, of which 27% had 3 or more. Most common imaging findings were neuroforaminal stenosis 22.6% (7/31) on MRI and neuropathy 22.9% (19/83) on MRN. Mean interval between MRI and MRN was 13.9 ± 28.3 months. Lumbar MRIs were inconclusive in 36% (8/22). MRN detected 63% (52/83) more findings and changed the diagnosis and treatment in 12% and 48% of FBSS cases, respectively. Favorable outcomes were recorded in 40% to 67% of patients following MRN-guided treatments.FBSS is a complex problem and MRN of lumbosacral plexus impacts its management by better directing source of symptoms.4.

Background/Objective Low back and pelvic pain are among the most prevalent conditions worldwide, with major social and economic costs. The aim of this study was to evaluate the role of magnetic resonance neurography (MRN) of lumbosacral plexus in the management and outcomes of these patients with chronic pain. Methods Consecutive patients with chronic lumbosacral and pelvic pain referred for MRN over a year were included. Preimaging and postimaging clinical diagnosis and treatment, pain levels, and location were recorded. Pain-free survival was compared between treatments using a Cox proportional hazards model. Results A total of 202 patients with mean age 53.7 ± 14.8 years and a male/female ratio of 1:1.53 were included. Of these patients, 115 presented with radiculopathy (57%), 56 with pelvic pain (28%), and 31 with groin pain (15%). Mean initial pain level was 6.9 ± 1.9. Mean symptom duration was 4.21 ± 5.86 years. Of these patients, 143 (71%) had a change in management because of MRN. After MRN, reduction in pain levels was observed in 21 of 32 patients receiving conservative treatment (66%), 42 of 67 receiving injections (63%), and 27 of 33 receiving surgery (82%). Follow-ups were available in 131 patients. Median pain-free survival was 12 months. Patients treated with surgery had significantly lower pain recurrence than patients receiving other treatments in the same time frame (hazard ratio, 3.6; 95% confidence interval, 1.4–9.2; P = 0.0061). Conclusions MRN use in chronic lumbosacral and pelvic pain led to a meaningful change in diagnosis and treatment. After MRN, conservative treatment and injections provided pain relief; however, patients benefited more from surgery than from any other treatment.

Objective Quantitative diffusion tensor imaging (DTI) of skeletal muscles is challenging due to the bias in DTI metrics, such as fractional anisotropy (FA) and mean diffusivity (MD), related to insufficient signal-to-noise ratio (SNR). This study compares the bias of DTI metrics in skeletal muscles via pixel-based and region-of-interest (ROI)-based analysis. Methods DTI of the thigh muscles was conducted on a 3.0-T system in N = 11 volunteers using a fat-suppressed single-shot spin-echo echo planar imaging (SS SE-EPI) sequence with eight repetitions (number of signal averages (NSA) = 4 or 8 for each repeat). The SNR was calculated for different NSAs and estimated for the composite images combining all data (effective NSA = 48) as standard reference. The bias of MD and FA derived by pixel-based and ROI-based quantification were compared at different NSAs. An “intra-ROI diffusion direction dispersion angle (IRDDDA)” was calculated to assess the uniformity of diffusion within the ROI. Results Using our standard reference image with NSA = 48, the ROI-based and pixel-based measurements agreed for FA and MD. Larger disagreements were observed for the pixel-based quantification at NSA = 4. MD was less sensitive than FA to the noise level. The IRDDDA decreased with higher NSA. At NSA = 4, ROI-based FA showed a lower average bias (0.9% vs. 37.4%) and narrower 95% limits of agreement compared to the pixel-based method. Conclusion The ROI-based estimation of FA is less prone to bias than the pixel-based estimations when SNR is low. The IRDDDA can be applied as a quantitative quality measure to assess reliability of ROI-based DTI metrics.

To assesses whether utilising bone marrow oedema (BMO) maps improved fracture read times and reader confidence in a large series of acute lower extremity trauma dual-energy computed tomography (DECT) studies.One hundred and six DECT studies, including 60 fracture cases and 46 non-fracture cases, were evaluated retrospectively in this cross-sectional study. Three-dimensional (3D) BMO maps were generated for each study and coded to display skeletal anatomy in blue and marrow oedema in green. Studies were interpreted by two readers in two timed stages (without and with BMO maps). Readers identified the number, anatomical location, and comminution of fractures. Reader confidence (five-point Likert scale) for fracture identification and anatomical regions where oedema was present was also recorded.Decreased read times (p0.01) were observed when readers utilised BMO maps for their fracture search. The presence of oedema on BMO maps corresponded with associated fracture in 75.7% reads. No differences in reader confidence were observed as a result of using this BMO-guided technique (95%, 5/5 for both readers with and without the aid of BMO maps).DECT BMO maps improve the speed of radiological identification of suspected acute lower extremity fractures with preserved reader confidence. It may help emergent detection of fractures, important for patient management and outcomes.

Background Majority of musculoskeletal cross-sectional imaging requests have a non-revealing and non-specific clinical history of pain. However, the location of pain is very relevant towards arriving at a specific orthopedic diagnosis. The purpose of this research was to study the impact of skin marker placement and training of technologists prior to knee MRI in detection of clinically important findings. Methods Total 200 consecutive left knee MRIs were evaluated before and after technologist training with regards to marker placement at the site of clinical symptoms or palpable finding. Marker location in relation to the knee was recorded and important findings were classified as correlated important finding, non-correlated important finding, other compartment important finding in non-correlated cases, and diffuse abnormality, i.e. tri-compartmental cartilage defects in both correlated and non-correlated cases. Differences among scans before and after technologist training were analyzed. Results The marker placement was observed in higher proportion of patients in post-training scans (78% vs 60%, p = 0.00). The most common location of the marker was in anterior or anterolateral knee (32% and 34% cases, respectively). The marker-important finding correlation was also higher post training, but not statistically significant (53% versus 38%, p = 0.57). Important findings correlated with the marker in more than 50% of the scans in the post-training set. Conclusion Marker placement can aid in detection of clinically important imaging finding and technologist training aids in increased rates of marker placement and improved correlation.

BACKGROUND AND PURPOSE: Clinical neurosensory testing is an imperfect reference standard to evaluate molar tooth extraction related peripheral trigeminal neuropathy. The purpose was to evaluate the diagnostic accuracy of MR neurography in this domain and correlation with neurosensory testing and surgery. MATERIALS AND METHODS: In this retrospective study, nerve caliber, T2 signal intensity ratio, and contrast-to-noise ratios were recorded by 2 observers using MR neurography for bilateral branches of the peripheral trigeminal nerve, the inferior alveolar and lingual nerves. Patient demographics and correlation of the MR neurography findings with the Sunderland classification of nerve injury and intraoperative findings of surgical patients were obtained. RESULTS: Among 42 patients, the mean ± SD age for case and control patients were 35.8 ± 10.2 years and 43.2 ± 11.5 years, respectively, with male-to-female ratios of 1:1.4 and 1:5, respectively. Case subjects (peripheral trigeminal neuropathy or injury) had significantly larger differences in nerve thickness, T2 signal intensity ratio, and contrast-to-noise ratios than control patients for the inferior alveolar nerve and lingual nerve (P = .01 and .0001, .012 and .005, and .01 and .01, respectively). Receiver operating characteristic analysis showed a significant association among differences in nerve thickness, T2 signal intensity ratio, and contrast-to-noise ratios and nerve injury (area under the curve, 0.83–0.84 for the inferior alveolar nerve and 0.77–0.78 for the lingual nerve). Interobserver agreement was good for the inferior alveolar nerve (intraclass correlation coefficient, 0.70–0.79) and good to excellent for the lingual nerve (intraclass correlation coefficient, 0.75–0.85). MR neurography correlations with respect to clinical neurosensory testing and surgical classifications were moderate to good. Pearson correlation coefficients of 0.68 and 0.81 and κ of 0.60 and 0.77 were observed for differences in nerve thickness. CONCLUSIONS: MR neurography can be reliably used for the diagnosis of injuries to the peripheral trigeminal nerve related to molar tooth extractions, with good to excellent correlation of imaging with clinical findings and surgical results.

Extra- and intraneural ganglion cysts have been described in the literature. The tibial nerve ganglion is uncommon and its occurrence without intra-articular extension is atypical. The pathogenesis of cystic degeneration localized to connective and perineural tissue secondary to chronic mechanical irritation or idiopathic mucoid degeneration is hypothesized. Since the above pathology is extremely rare and the magnetic resonance imaging examination detects the defining characteristics of the intrinsic alterations of the tibial nerve, the authors illustrate such a case of tibial intaneural ganglion cyst with its magnetic resonance neurography and sonography appearances.

Superior capsular reconstruction (SCR) is a novel technique for treating irreparable rotator cuff tears in younger patients in whom a reverse total shoulder arthroplasty is not the optimal treatment choice. This case study describes a middle-aged male with a recurrent, massive, irreparable rotator cuff tear treated with SCR that subsequently failed at the glenoid attachment. The patient underwent successful arthroscopic revision of the SCR. The case illustrates the MRI and arthroscopic correlations of the failed dermal allograft reconstruction, which to our knowledge has not been previously shown in the radiology literature.

The purpose of this work is to simulate radiographs from isotropic 3D MRI data, compare relationship of angle and joint space measurements on simulated radiographs with corresponding 2D MRIs and real radiographs (XR), and compare measurement times among the three modalities. Twenty-four consecutive ankles were included, eight males and 16 females, with a mean age of 46 years. Segmented joint models simulating radiographs were created from 3D MRI data sets. Three readers independently performed blinded angle and joint space measurements on the models, corresponding 2D MRIs, and XRs at two time points. Linear mixed models and the intraclass correlation coefficient (ICC) was ascertained, with p values less than 0.05 considered significant. Simulated radiograph models were successfully created in all cases. Good agreement (ICC > 0.65) was noted among all readers across all modalities and among most measurements. Absolute measurement values differed between modalities. Measurement time was significantly greater (p

Incidence of chronic postoperative neurogenic pain after open and laparoscopic trunk operations is reported between 1 and 20 percent, rendering a large population in the United States and worldwide. One possible treatment is selective surgical neurectomy.All patients who underwent neurectomy for chronic trunk or groin postoperative neurogenic pain were identified. Based on individual history and examination, patients underwent neurectomies of the ilioinguinal, iliohypogastric, genitofemoral, lateral-femoral cutaneous, or intercostal nerves. Recorded preoperative pain levels (Likert score ranging from 0 to 10) were compared to postoperative pain levels and quality-of-life indices were assessed.Fifty-six patients (32 men and 24 women) were included. Mean age was 49 years. All patients underwent preoperative nerve blocks by either surgeon, radiologist, or referring physician, and had either complete or significant response defined as over 50 percent relief. Forty-five patients completed the survey. Median follow-up was 2.8 years (range, 1.0 to 5.7 years). Average pain level was 9.0 preoperatively and 3.5 postoperatively. Quality-of-life impairment improved from 8.3 preoperatively to 3.5 postoperatively. A subset of patients (n = 12) had minimal improvement, reporting a decrease in pain from 8.5 to 7.2 and quality-of-life improvement from 8.5 to 7.1.Complete avoidance of nerve injury during all trunk and groin operations is likely unattainable. When chronic postoperative neurogenic pain develops, neurectomy can be an effective means of treatment, significantly improving pain and quality of life in most patients. Better insight is necessary into a patient subset responding to nerve blocks yet experiencing minimal postoperative improvement.Therapeutic, IV.

Purpose Axial spondyloarthritis (SpA) is a group of diseases with temporally disseminated symptoms and clinical signs, which render the diagnosis challenging. Laboratory and MRI findings are used in addition for confirming the diagnosis and evaluation of disease activity. The purpose of this study was to evaluate clinically suspected axial SpA to determine the technical success of a multiparametric and 3D rheumatology lumbosacral MR imaging (MRLI) protocol and to assess the disease distribution, inter-reader reliability, and impact on patient management. Methods A consecutive series of patients with clinical suspicion of axial SpA were included. Two rheumatologists recorded the clinical findings and disease activity on a confidence scale before and after MRLI. Two musculoskeletal (MSK) radiologists read the imaging data including enthesitis, arthritis, osseous lesions, ADC values, and enhancement. Prevalence-adjusted and bias-adjusted kappa (PABAK), ICC and Fisher exact test were calculated. Results There were 41 patients including 31 females and 10 males with ages of 41 ± 10 and 41 ± 12 (mean ± SD), respectively. The spine T2W imaging received the highest quality scores followed by whole abdomen-pelvis 3D-T2W imaging, 3D-CEMR (contrast-enhanced MRI), and DWI. On spine imaging, acute and chronic lesions of lumbar spine and sacroiliac joints were seen in 4/41, 18/41 and 6/41, and 27/41 of the patients, respectively. Several additional enthesopathy lesions were seen on the whole abdomen-pelvis 3D sequence. ADC value of bone lesions was different 0.95 ± 0.23 (mean ± SD) than normal bone (0.20 ± 0.1). PABAK for acute and chronic findings ranged 0.70–1.0 and 0.41-0.51, respectively. Imaging changed the diagnosis in 17 of 41 patients. No association was noted with respect to treatment change (p = 1) or clinical response (p = 0.2). Conclusion Multiparametric lumbosacral MR imaging is a technically successful modality to identify multiple spinal and additional extraspinal sites of involvement in SpA, which are helpful in establishing the diagnosis of axial SpA. Larger patient population study is warranted to evaluate further impact on the treatment efficacy.

Pediatric musculoskeletal tumors comprise approximately 10% of childhood neoplasms, and MR imaging has been used as the imaging evaluation standard for these tumors. The role of MR imaging in these cases includes identification of tumor origin, tissue characterization, and definition of tumor extent and relationship to adjacent structures as well as therapeutic response in posttreatment surveillance. Technical advances have enabled quantitative evaluation of biochemical changes in tumors. This article reviews recent updates to MR imaging of pediatric musculoskeletal tumors, focusing on advanced MR imaging techniques and providing information on the relevant physics of these techniques, clinical applications, and pitfalls.

Professional organizations recommend against repeat radiographs for routine follow-up of osteoarthrosis. However, clinics frequently obtain radiographs during or before the clinical visit. The purpose of our project was to determine the baseline frequency of unnecessary knee radiographs and whether educational interventions can reduce this frequency. This QI project was exempt from IRB review. Radiology reports of knee radiographs were searched in our database filtered by presence of the words “severe”, “degenerative”, “osteoarthritis”, and similar variants. We reviewed 500 consecutive corresponding medical records to confirm the presence of severe osteoarthritis, and presence of a repeat radiograph within 6 months. Indications for repeat radiographs were determined. Repeat radiographs were counted as “non-indicated” when medical records revealed no new symptoms. A focused educational intervention was provided to the orthopedic and family practice departments. An additional 500 radiology reports were evaluated 9 months after intervention in the same manner and the rate of non-indicated radiographs was calculated. Follow-up review of additional 500 radiology reports at 1-year time point was performed. Our initial search returned 1517 reports. Upon evaluation of 500 studies, there were 112/500 repeat radiographs (22%); 77/500 (15%) of knee radiographs were not indicated. Upon initial follow-up evaluation of 500 studies, there were 52/500 repeat radiographs (10%) and 40/500 (8%) radiographs were not indicated. The reduction of unnecessary repeat knee radiographs rate was sustained at 1 year. Focused educational intervention results in a substantial (50%) reduction of the number of unnecessary repeat knee radiographs in patients with known severe OA.

A single ADC value is used in clinical practice on multi b-value acquisitions. Low b-value acquisitions are affected by intravoxel incoherent motion, which is dependent on perfusion. Giant cell tumors (GCTs) are known to exhibit early arterial enhancement and low ADC values. Mean, minimum and fractional ADC characteristics of osseous and tenosynovial GCTs are systematically evaluated. Tenosynovial and osseous GCTs were included. Each lesion was evaluated on conventional MRI and DWI by two musculoskeletal radiologists. ADC was measured by placing an ROI on the most confluent enhancing portion of the lesion. Fractional and best fit ADC calculations were performed using MATLAB software. No statistically significant difference was found between tenosynovial and osseous lesions’ ADC values. Mean ADC for all lesions was 1.0 × 10−3 mm2/s (SD = 0.2 × 10−3 mm2/s) and minimum ADC was 0.5 × 10−3 mm2/s (SD = 0.3 × 10−3 mm2/s). Average mean ADC value obtained from B50–B400 slope was 1.1 × 10−3 mm2/s (SD = 0.2 × 10−3 mm2/s), and the average mean ADC value obtained from B400–B800 slope was 0.8 × 10−3 mm2/s (SD = 0.1 × 10−3 mm2/s) [p-value

To analyze regional muscle CT density and bulk in femoroacetabular impingement (FAI) and hip dysplasia (HD) versus controls. Patients who obtained perioperative CT imaging for FAI and HD before surgery were retrospectively studied. Asymptomatic controls included for comparison. Two readers independently evaluated regional hip muscle [iliopsoas (IP), rectus femoris (RF), gluteus minimus (Gm), and medius (GM)] density, muscle area, and muscle circumference. Inter-observer reliability calculated using intra-class correlation coefficient (ICC). A consecutive series of 25 FAI patients, 16 HD patients, and 38 controls were recruited in the study. FAI patients had significantly greater Gm and GM circumferences as well as greater RF and IP areas on the normal side compared to the asymptomatic control group (p values 0.004, 0.032, 0.033, and 0.028, respectively). In addition, Gm and RF circumferences and RF area were significantly larger (p values 0.029, 0.036, and 0.014, respectively) in FAI patients on the affected side compared to the control group. HD patients had significantly smaller Gm and GM circumferences on the affected side than normal side measurements in FAI group (p values 0.043 and 0.003, respectively). Normal side GM circumference was also smaller in HD patients than normal side FAI hips (p value 0.02). There was no significant difference between the measurements on normal and abnormal sides in each disease group. No significant difference was found between measurements of HD compared to controls (p > 0.05). No muscle density differences were seen among different groups. There was moderate to excellent inter-reader reliability for all measurements except Gm muscle density. Muscle analysis was able to quantify differences among patients with FAI, HD, and asymptomatic controls. These changes could indicate either a muscle imbalance contributing to the pathology or disuse atrophy, which may have implications for specific muscle-strengthening therapies and rehabilitation procedures in such patients.

Chronic neuralgia of the border nerves (ilioinguinal, iliohypogastric, and genitofemoral) is difficult to diagnose and treat clinically. We examined the role of MR neurography (MRN) in the evaluation of border nerve abnormalities and the results of treatments directed at the MRN-detected nerve abnormalities.This retrospective cross-sectional study included 106 subjects with groin or genital pain (mean [± SD] age, 50.7 ± 15.4 years) who showed mono- or multifocal neuropathy of the border nerves at 3-T MRN. Subjects who underwent CT-guided perineural injection were assessed for pain response. Injection responses were categorized as positive, possible positive, and negative. Subjects who received hyaluronidase, continuous radiofrequency ablation, or surgery were also evaluated for treatment outcomes.One hundred forty abnormal nerves were positive for neuropathy in 106 studies. Eighty of 106 subjects had single neuropathy, and 26 had multifocal neuropathy. Fifty-eight subjects underwent CT-guided perineural injections, with five receiving bilateral injections (63 injections). Improvement in subjective pain was seen in 53 of 63 cases (84.2%). A statistically significant improvement in pain response was noted in the isolated ilioinguinal nerve block group as compared with the isolated genitofemoral nerve block group (p = 0.0085). Thirteen of 58 subjects received multiple nerve injections at the same sitting. Both groups receiving single or multiple nerve injections had similar improvement in pain scores of 84% and 85%, respectively, although this difference was not statistically significant.Our retrospective analysis showed improved pain relief in subjects who underwent CT-guided nerve blocks on the basis of a positive MRN.

Objective: To evaluate the utility and efficacy of MR neurography (MRN) in the diagnostic work-up for intercostal neuralgia and to assess the treatment course and outcomes in MRN-imaged clinically suspected intercostal neuropathy cases of chronic chest and abdominal wall pain syndromes. Methods: Following a retrospective cross-sectional study, a consecutive series of patients who underwent MRN of torso for suspected intercostal neuralgia were included. Patient demographics, pain location/level/duration, previous work-up for the same indication, MRN imaging results, and MRN cost per patient were recorded. An inter-reader reliability assessment was performed on the MRN findings using Cohen’s weighted κ analysis. Post-MRN treatment choice, as well as success rates of MRN directed perineural injections and surgical management were also evaluated. Results: A total of 28 patients (mean ± SD age, 48.3 ± 18.0 years, female/male = 3.0) were included. Pain and/or numbness in the right upper quadrant were the most common complaints. The mean maximum pain level experienced was 7.4 ± 2.5 on a 1 (lowest pain level) - 10 (highest pain level) visual analog scale. The duration of pain before MRN work-up was 36.9 ± 37.9 months. The patients had seen an average of 5 ± 2.8 physicians for such syndromes. 20 (71%) patients had one or multiple other imaging studies for prior work-up. MRN identified positive intercostal nerve abnormality in 19 cases with clinical symptoms of intercostal neuralgia. From the inter-reader reliability assessment, a Cohen’s weighted κ value of 0.78 was obtained. The costs of work-up was about one-third with MRN for diagnostic purposes with less financial and psychological harm. Among the MRN-positive cases, 9/19 patients received perineural injections, of which 6 reported improvement after their first round, lasting an average of 41.1 ± 83 days. Among the nine MRN-negative cases, two received perineural injections, of which none reported improvement. Surgical management was mostly successful with a positive outcome in six out of seven operated cases (85.7%). Conclusion: MRN is useful in diagnostic algorithm of intercostal neuralgia and MRN-positive cases demonstrate favorable treatment response to perineural injections and subsequent surgical management. Advances in knowledge: The use of MRN in intercostal neuralgia is an application that has not been previously explored in the literature. This study demonstrates that MRN offers superior visualization of pathology in intercostal neuralgia and confirms that treatment directed at MRN identified neuropathy results in good outcomes while maintaining cost efficiency.

To determine the diagnostic accuracy and interobserver performance of diffusion tensor imaging (DTI) in diabetic peripheral neuropathy (DPN) and detect correlations with electrophysiology.Twelve healthy volunteers (controls) and ten DPN patients were enrolled to undergo MR examinations. Fractional anisotropy (FA) and apparent diffusion coefficient (ADC) values of tibial nerve (TN) and common peroneal nerve (CPN) were measured. Unpaired t test and Levene tests were performed to assess differences between the two groups. Receiver operating characteristic (ROC) analysis was performed for FA and ADC values. Pearson correlation coefficient was used to assess the correlation between DTI and electrophysiology parameters in the patient group.The FA values of TN and CPN in the DPN group were significantly lower and ADC were higher than the control group (p 0.05). Interobserver agreement was excellent. FA positively correlated and ADC negatively correlated with motor nerve conduction velocity (MCV) (p 0.05). There were no significant differences between motor nerve conduction amplitude and DTI parameters (p 0.05). Moderate diagnostic accuracy of DTI was seen in the diagnosis of DPN.DTI demonstrates moderate diagnostic accuracy and excellent interobserver performance in the detection of DPN involving the TN and CPN. There is moderate correlation with MCV.• FA values of TN and CPN are significantly lower in DPN. • ADC values of TN and CPN are significantly higher in DPN. • DTI demonstrates moderate diagnostic accuracy in detection of DPN. • There is excellent interobserver performance in DTI measurements. • Moderate correlation is seen between DTI parameters and MCV.

BACKGROUND AND PURPOSE: Chronic cauda equina syndrome, defined as persistent damage of the cauda equina nerve roots within the spinal canal can be a challenging diagnosis with varied presentations. MR neurography imaging is more commonly being used to evaluate the lumbosacral spine of patients suspected of having subacute or chronic cauda equina syndrome. Our aim was to evaluate the impact of lumbosacral plexus MR neurography in the diagnostic thinking and therapeutic management of patients presenting with chronic pelvic pain and dysfunction and suspected chronic cauda equina syndrome. MATERIALS AND METHODS: Consecutive MR neurography lumbosacral plexus examinations at our institution were reviewed retrospectively. Relevant data collected included the following: patient demographics, clinical history, pertinent physical examination findings, preimaging diagnostic impression, prior MR imaging lumbar spine findings, MR neurography findings, postimaging diagnosis, and postimaging treatment plan. The impact of imaging on the preimaging clinical diagnosis and therapeutic management was evaluated. RESULTS: Of 185 studies of patients who presented with chronic pelvic pain and/or dysfunction, 23 with clinically suspected chronic cauda equina syndrome and imaging findings were included in the study (2 subjects were lost to follow-up). The mean ages were 53 ± 12 years and 53 ± 16 years for men and women, respectively. The common etiologies included arachnoiditis (n = 8), tethered cord (n = 2), and simple/Tarlov cysts (n = 3). Eighteen of 23 (78%) subjects had a change in diagnosis resulting from MR neurography findings, and 5/23 (22%) had no change. Seventeen of 21 (81%) subjects had a change in management, and 4/21 (19%) had no change. CONCLUSIONS: MR neurography impacts the diagnosis and therapeutic management of patients with suspected chronic cauda equina syndrome.

Segmentation of whole-body MRI (WBMRI) to assess the feasibility, quantitate the total tumor volume (tumor burden) in patients with neurofibromatosis type 1 (NF1) and examine associations with demographic, disease-related and anthropomorphic features. A consecutive series of patients with NF1 underwent WBMRI and were reviewed for tumors. Tumors were segmented using a semiautomated software-based tool. Tumors were classified as superficial or deep and discrete or plexiform. Segmentation times were recorded. Segmentation yielded the quantity and tumor burden of superficial, internal and plexiform tumors. Correlations between segmentation data and demographic, disease-related and anthropomorphic features were examined. Fifteen patients were evaluated (42.3 ± 13.6 years, 10 female, 5 male). Segmentation times were a median of 30 min and yielded 2,328 tumors (1,582 superficial, 746 internal and 23 plexiform). One tumor was malignant. Tumor counts ranged from 14 to 397. Tumor burden ranged from 6.95 cm3 to 571 cm3. Individual tumor volume ranged from 0.0120 cm3 to 298 cm3. Significant correlation was found between the total volume of superficial tumors and height (ρ = 0.5966, p

To investigate the feasibility of diffusion-weighted magnetic resonance neurography (DW-MRN) in the visualisation of extremity nerves in the wrist and palm. Thirty-two volunteers and 21 patients underwent imaging of the wrist and palm on a 3-T MR scanner. In all subjects, two radiologists evaluated the image quality on DW-MRN using a four-point grading scale. Kappa statistics were obtained for inter-observer performance. In volunteers, the chi-squared test was used to assess the differences in nerve visualisation on DW-MRN and axial fat-suppressed proton density weighted imaging (FS-PDWI). In volunteers, the mean image quality scores for the median nerve (MN) and ulnar nerve (UN) were 3.71 ± 0.46 and 3.23 ± 0.67 for observer 1, and 3.70 ± 0.46 and 3.22 ± 0.71 for observer 2, respectively. The inter-observer agreement was excellent (k = 0.843) and good (k = 0.788), respectively. DW-MRN provided significantly improved visualisations of the second and the third common palmar digital nerves and three branches of UN compared with FS-PDWI (P

Purpose The purpose was to evaluate feasibility of bone and joint segmentations from three-dimensional magnetic resonance imaging (3D MRI). Methods Segmented joint models from 3D MRI data set were obtained for 42 patients. Blinded angular and joint space measurements were performed on 3D MRI model, two-dimensional (2D) MRI, and radiography (XR). Results Medial joint space was similar on both XR and 3D MRI ( P =.3). The XR measurements were statistically different but closer to 3D MRI for lateral patellar tilt angle, patellar tendon length, and lateral knee joint space, whereas 2D MRI measurements were closer to XR in terms of trochlear depth, sulcal angle, and patellar length. Conclusion 3D bone and joint segmentations are feasible from isotropic MRI data sets.

The purpose of this article is to evaluate the significance of subspecialty second-opinion consultations for CT and MRI examinations in musculoskeletal (MSK) radiology.All 3165 MSK CT and MRI examinations referred to one academic institution for second-opinion consultation during a 24-month period were reviewed by three MSK-trained radiologists. Outside and inside reports were compared by two independent MSK radiology fellows using a previously published 5-point scale. Clinically important differences (categories 4 and 5) were defined as those likely to change patient management. Statistical comparisons of rates were performed using a chi-square test with Bonferroni corrections. Interobserver reliability was reported using linear weighted kappa statistics and the percentage of agreement.Of all second-opinion examinations, 73.5% (2326/3165) had an outside report available for comparison and inclusion in this study. There were 610 of 2326 (26.2%) examinations with clinically important differences. The rate of clinically important discrepant readings was even higher in oncologic cases (36.3%; 331/911). When the final diagnosis was determined from pathology reports performed after internal interpretation, the second-opinion consultation was noted to be correct in 82.0% (334/407) of examinations with category 4 or 5 discrepancies. There was very good agreement (κ = 0.93) in scoring the discrepancies between second-opinion consultants.The subspecialty second-opinion consultation was more accurate than outside reports in 82.0% of examinations when pathologic confirmation was made. A moderate rate (26.2%) of discrepant interpretations was noted between outside and inside MSK imaging examinations, especially in tumor cases (36.3%). Most discrepancies were in interpreting rather than detecting abnormalities.

Accurate diagnosis and prompt therapy of musculoskeletal infections are important prognostic factors. In most cases, clinical history, examination and laboratory findings help one make the diagnosis, and routine magnetic resonance imaging (MRI) is useful to identify the extent of the disease process. However, in many situations, a routine MRI may not be specific enough especially if the patient cannot receive contrast intravenously, thereby delaying the appropriate treatment. Diffusion-weighted imaging (DWI) can help in many such situations by providing additional information, accurate characterization and defining the extent of the disease, so that prompt treatment can be initiated. In this article, we illustrate the imaging findings of the spectrum of musculoskeletal infections, emphasizing the role of DWI in this domain. • Abscess in background cellulitis is detected on DWI. • Infectious tenosynovitis shows diffusion restriction as compared to mechanical tenosynovitis. • Pyomyositis with abscess can be differentiated from diabetic myonecrosis on DWI. • Intraosseous abscess is bright on DWI versus devitalized tissue, sequestrum and air. • DWI can be used to differentiate spine infection from simple Modic changes.

This tertiary care experience examines the utility of magnetic resonance neurography (MRN) in the management of peripheral trigeminal neuropathies.Seventeen patients with clinically suspected peripheral trigeminal neuropathies (inferior alveolar nerve and lingual nerve) were imaged uniformly with 1.5-T examinations. MRN results were correlated with clinical and surgical findings in operated patients and the impact on clinical management was assessed.Clinical findings included pain (14/17), sensory changes (15/17), motor changes (2/17) and palpable masses (3/17). Inciting events included prior dental surgery (12/17), trauma (1/17) and idiopathic incidents (4/17). Non-affected side nerves and trigeminal nerves in the intracranial and skull base course were normal in all cases. Final diagnoses on affected sides were nerve inflammation (4/17), neuroma in continuity (2/17), LN transection (1/17), scar entrapment (3/17), infectious granuloma (1/17), low-grade injuries (3/17) and no abnormality (3/17). Associated submandibular gland and sublingual gland oedema-like changes were seen in 3/17 cases because of parasympathetic effects. Moderate-to-excellent MRN-surgical correlation was seen in operated (8/17) patients, and neuroma and nerve transection were prospectively identified in all cases.MRN is useful for the diagnostic work-up of suspected peripheral trigeminal neuropathy patients with significant impact on clinical management and moderate-to-excellent correlation with intra-operative findings.• MRN substantially impacts diagnostic thinking and management in peripheral trigeminal neuropathy. • MRN has moderate-to-excellent correlation with intra-operative findings. • MRN should be considered in pre-surgical planning of peripheral trigeminal neuropathy subjects.

Hyaline cartilage lining the surfaces of diarthrodial joints is an important construct for transmission of load and to reduce friction between the bones. Normal wear and tear accounts for about 3-5 percent knee cartilage loss ever year in otherwise healthy people after the age of 30 years. Several conditions and diseases lead to premature cartilage degeneration. Standardized description of cartilage loss, detailed evaluation of the joint health and determining the underlying etiology of cartilage loss are important for effective reporting, multidisciplinary communications and patient management. In this article, the authors discuss normal and abnormal imaging appearances of the hyaline cartilage of knee with focus on using controlled terminology and MRI classifications. The reader will benefit and learn key MR imaging features of a spectrum of common and uncommon conditions and diseases affecting the knee cartilage, such as trauma, secondary injury associated with meniscus and ligament injury related instability, arthritis, ischemia, idiopathic, and hereditary conditions including Matrix metalloproteinase-2 (MMP-2) mutations and mucopolysaccharidosis type IX disease with illustrative case examples.

To quantitatively characterize diabetic amyotrophy (DA), or diabetic lumbosacral radiculoplexopathy, and compare with controls using magnetic resonance neurography (MRN). Forty controls and 23 DA cases were analyzed qualitatively and quantitatively. Cross-sectional areas (CSAs) of bilateral L3 through S2 lumbosacral nerve roots, femoral nerves, and sciatic nerves (proximal and distal measurements) were measured. A linear model was used to assess the nerve location and case/control effect on angle-corrected CSAs. Intra- and inter-reader analysis was performed using intraclass correlation (ICC). In DA cases, abnormalities of the lumbosacral nerve roots, sciatic, femoral, and obturator nerves were seen in 21/23, 16/23, 21/23, and 9/23, respectively. Denervation abnormalities of multiple abdominopelvic muscles were seen. Quantitatively, the CSA of all measured LS plexus nerve roots and bilateral femoral nerves were significantly larger in DA cases vs. controls by 45% (95% CI, (30%, 49%); p