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Objective: To review the spectrum of clinical and imaging features of glomus tumor involving the musculoskeletal system including the typically solitary forms as well as the rarer multifocal forms (glomuvenous malformation and glomangiomatosis)., Materials and Methods: A retrospective review of our institutional pathology database from 1996 to 2023 identified 176 patients with 218 confirmed glomus tumors. Primary imaging studies included MRI (125), radiographs (100), clinical/intraoperative photos (77), and ultrasound (36). Lesions were divided into two groups: those that are typically solitary involving specific anatomic areas (finger, toe, soft tissue, coccyx, and bone), and those that are multifocal (glomuvenous malformation and glomangiomatosis)., Results: The finger was the most frequently involved anatomic location for the classic (sporadic) glomus tumor occurring in 51% of patients, 77% of which were women, with the nail plate involved in more of the 75% of cases. Sporadic lesions involving the skin, subcutaneous adipose tissue, and deep soft tissue were termed "soft tissue," and were identified in 39% of patients, 90% of which were in the extremities and in men in 81% of cases. The multifocal syndromic forms of glomus disease occurred in younger individuals and involved less than 6% of the study group. Patients with glomuvenous malformation presented early with predominantly cutaneous involvement, while those with glomangiomatosis present later, often with both superficial and deep involvement, and a high rate of local tumor recurrence., Conclusion: While glomus tumor is generally uncommon, it frequently involves the musculoskeletal extremities. Knowledge of the spectrum of characteristic locations and appearances will facilitate definitive diagnosis., (© 2024. The Author(s), under exclusive licence to International Skeletal Society (ISS).)

Objective: The objective of this study is to explore the questions commonly asked online about biologic therapies for use in treatment of chronic sinusitis with nasal polyps (CRSwNP) and the quality of the available content. Methods: Most common search terms were identified via Google Trends. People Also Ask (PAA) questions were identified and extracted with their associated website using an online data-scraping program [Search Engine Optimization (SEO) Minion, Keywords Everywhere]. Sources were evaluated using Flesch Kincaid Grade Level (FKGL) and Flesch Reading Ease (FRE, higher number = better) score for readability; Journal of American Medical Association ( JAMA ) Benchmark criteria for quality assessment (0-4, 4 = all criteria met). Results: A total of 143 unique PAA questions and unique websites were identified. Questions were organized into 3 categories: questions about biologic therapies overall (38.46%), about CRSwNP (37.76%), and about treatment options for CRSwNP (23.78%). Websites answering PAA questions were from commercial (60.14%), medical practice (13.99%), academic (13.29%), and government (12.59%) sources. FKGL scores found the average reading level to be at approximately a 12th grade level (SD = 3.297) alongside a low reading ease FRE score of 37.6 (SD = 16.77). Mean JAMA criteria scores were 0.9895 (SD = 0.848), indicating largely low-quality materials. Conclusion: Biologic therapies are a novel treatment option for CRSwNP, and participants are seeking more information about these treatments and disease state. Online resources regarding biologics should be presented at a lower reading level. Sources with evidence-based information are needed. Physicians should be aware of these limitations in online material and counsel accordingly by curating and directing patients to good sources. Level of Evidence: Step 4., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: O.G.A. is a consultant for Medtronic and Aerin Medical. M.T. is a consultant for Aerin Medical, Medtronic, Acclarent, and LivaNova.

Objective: In-office ablation of the posterior nasal nerve (PNN) has emerged as an effective treatment option for chronic rhinitis patients. This study explored questions patients commonly search online regarding this therapy and the quality of content available., Study Design: A retrospective analysis of online search criteria and sources was performed with subsequent analysis of results., Setting: Search and data acquisition was in September of 2023., Methods: Most common search terms related to cryotherapy and radiofrequency neurolysis of the PNN were identified with associated People Also Ask (PAA) questions. Questions were categorized and organized into subtopics and sources evaluated using readability and quality metrics., Results: A total of 255 unique PAA questions and 175 unique websites were identified. The most common subtopics were related to facts about chronic rhinitis (26.7%) and rhinitis treatment options (25.1%). Nearly a quarter (24.3%) of websites were from commercial sources. Quality metrics indicate difficult-to-read and low-quality materials., Conclusion: Existing online resources need improvement to provide patients material that is easier to read. Physicians counseling patients should be aware of these areas for adequate shared decision making., Competing Interests: Omar G. Ahmed serves as a consultant for Aerin Medical (Sunnyvale, CA, USA) and Medtronic (Dublin, Ireland). Masayoshi Takashima is a consultant for Aerin Medical, Medtronic, Acclarent, and LivaNova. Nicholas R. Rowan is supported by the Johns Hopkins University Claude D. Pepper Older Americans Independence Center funded by the National Institute on Aging of the National Institutes of Health (P30AG021334)., (© 2024 The Author(s). OTO Open published by Wiley Periodicals LLC on behalf of American Academy of Otolaryngology–Head and Neck Surgery Foundation.)

Chronic hand and wrist pain is a common presenting complaint. The intricate anatomy results in a variety of pain generators-multiple bones, articular cartilage, intrinsic ligaments, triangular fibrocartilage complex, joint capsules and synovium, tendons and tendon sheaths, muscles, and nerves-in a compact space. The need for imaging and the choice of the appropriate imaging modality are best determined by the patient's presentation, physical examination, and the clinician's working differential diagnosis. Radiography is usually appropriate as the initial imaging study in the evaluation of chronic hand or wrist pain. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation., (Copyright © 2024 American College of Radiology. Published by Elsevier Inc. All rights reserved.)

Objective: To determine the preferred ankle, knee, and elbow arthrography injection techniques for Society of Skeletal Radiology (SSR) members and whether more recently described techniques are gaining acceptance. We also sought to determine whether the concept of knowledge translation might explain differences between the preferred technique, year of fellowship graduation, and year the newer technique was described., Materials and Methods: A 29-question survey was created in Qualtrics and submitted to current SSR members to determine if they perform knee, elbow, and ankle arthrography, and if so, the year of fellowship completion and preferred approaches. Survey respondents indicated the starting and ending needle tip positions for three knee, two elbow, and three ankle arthrography approaches using grids placed over provided frontal and lateral radiographs., Results: Two hundred seventy-four SSR members (mean post-fellowship 13 years; range 0-38) completed the survey and performed fluoroscopic-guided knee (93%), elbow (95%), and ankle (75%) arthrography. Preferred approaches included the following: knee lateral subpatellar (43%), anterior (40%); elbow radiocapitellar (74%); ankle anterior/peritendon (70%), lateral mortise (24%). Preference of newer technique was related to fellowship graduation year and publication year for the ankle mortise (26% before, 42% after; p = 0.03) and posterior trans-triceps elbow articles (19% before, 33% after; p < 0.01). The anterior knee approach preference increased from 11% in 2008 to 40% (p ≤ 0.001)., Conclusion: Nearly twice as many SSR members who graduated after the posterior trans-triceps and ankle mortise techniques were published prefer them for performing arthrography, possibly due to knowledge translation. The preference of the anterior knee arthrography approach has increased nearly fourfold since 2008., (© 2023. The Author(s), under exclusive licence to International Skeletal Society (ISS).)

Purpose: The National Resident Matching Program (NRMP) is used by an increasing number of diagnostic radiology (DR) residents applying to subspecialty fellowships. Data characterizing match outcomes on the basis of program characteristics are limited. The aim of this study was to determine if fellowship or residency size, location, or perceived reputation was related with a program filling its quota., Methods: Using public NRMP data from 2004 to 2022, DR residency, breast imaging (BI), musculoskeletal imaging (MSK), interventional radiology (IR), and neuroradiology (NR) fellowship programs were characterized by geography, DR and fellowship quota, applicants per position (A/P), and reputation as determined by being an Aunt Minnie best DR program semifinalist, Doximity 2021-2022 top 25 program, or U.S. News & World Report top 20 hospital. The DR program's reputation was substituted for fellowships at the same institution. A program was considered filled if it met its quota., Results: The 2022 A/P ratios were 1.02 for IR, 0.83 for BI, 0.75 for MSK, and 0.88 for NR. IR was excluded from additional analysis because its A/P was >1. The combined BI, MSK, and NR fellowships filled 78% of positions (529 of 679) and 56% of programs (132 of 234). Factors associated with higher program filling included Doximity top 25 program, Aunt Minnie semifinalist, and U.S. News & World Report top 20 hospital affiliation (P < .001 for all); DR residency quota greater than 9, and fellowship quota of three or more (P < .01). The Ohio Valley (Ohio, western Pennsylvania, West Virginia, and Kentucky) filled the lowest, at 39% of programs (P = .06)., Conclusions: Larger fellowship programs with higher perceived reputations and larger underlying DR residency programs were significantly more likely to fill their NRMP quota., (Copyright © 2024 American College of Radiology. Published by Elsevier Inc. All rights reserved.)

Objective: To determine if MRI altered management in patients ≥ 60 years old with chronic knee pain., Materials and Methods: Consecutive patients ≥ 60 years old with knee MRI and radiographs within 90 days were included. Exclusion criteria included mass/malignancy, recent trauma, and infection. Standing AP and PA flexion views were evaluated using Kellgren-Lawrence (KL) and International Knee Documentation Committee (IKDC) scales. Pertinent clinical history was recorded. MRIs were considered to alter management if subchondral fracture was identified or subsequent arthroscopy was performed due to an MRI finding., Results: Eighty-five knee MRI/radiograph exams were reviewed; mean 68.2 years (60-88), 47:38 F:M. Twenty knee MRIs (24%) had either a subchondral fracture (n = 9) or meniscal tear (n = 11) prompting arthroscopy. On PA flexion view, 0/20 of these studies had KL grade 4 and 70% (14/20) had KL grade 0-1 compared to the remaining MRIs having 15.4% (10/65) KL grade 4 and 38.5% (25/65) KL grade 0-1 (p = 0.03). A 10-pack-year tobacco history, 38% vs 18%, was associated with a subchondral fracture or arthroscopy (p = 0.06). Subchondral fractures were more prevalent in older patients (mean 72.4 vs 67.7 years; p = 0.03)., Conclusion: In patients ≥ 60 years old with chronic knee pain, MRI altered management in ~ 24% of cases; 70% in patients with KL grade 0-1, and none in patients with KL grade 4. MRI may benefit older patients with minimal osteoarthritis but not those with end-stage disease. Patients with ≥ 10 pack years of smoking may also benefit from MRI., (© 2024. The Author(s), under exclusive licence to International Skeletal Society (ISS).)

Background: Sinonasal neoplasms, whether benign and malignant, pose a significant challenge to clinicians and represent a model area for multidisciplinary collaboration in order to optimize patient care. The International Consensus Statement on Allergy and Rhinology: Sinonasal Tumors (ICSNT) aims to summarize the best available evidence and presents 48 thematic and histopathology-based topics spanning the field., Methods: In accordance with prior International Consensus Statement on Allergy and Rhinology documents, ICSNT assigned each topic as an Evidence-Based Review with Recommendations, Evidence-Based Review, and Literature Review based on the level of evidence. An international group of multidisciplinary author teams were assembled for the topic reviews using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses format, and completed sections underwent a thorough and iterative consensus-building process. The final document underwent rigorous synthesis and review prior to publication., Results: The ICSNT document consists of four major sections: general principles, benign neoplasms and lesions, malignant neoplasms, and quality of life and surveillance. It covers 48 conceptual and/or histopathology-based topics relevant to sinonasal neoplasms and masses. Topics with a high level of evidence provided specific recommendations, while other areas summarized the current state of evidence. A final section highlights research opportunities and future directions, contributing to advancing knowledge and community intervention., Conclusion: As an embodiment of the multidisciplinary and collaborative model of care in sinonasal neoplasms and masses, ICSNT was designed as a comprehensive, international, and multidisciplinary collaborative endeavor. Its primary objective is to summarize the existing evidence in the field of sinonasal neoplasms and masses., (© 2023 The Authors. International Forum of Allergy & Rhinology published by Wiley Periodicals LLC on behalf of American Academy of Otolaryngic Allergy and American Rhinologic Society.)

Purpose: Idiopathic carpal tunnel syndrome (CTS) is a common compressive neuropathy. Aging and female sex are risk factors, but the reasons are unclear. The purpose of this study was to evaluate whether identifiable radiographic changes resulting in a decrease in carpal tunnel area (CTA) over time exist., Methods: A database search of a multicenter, academic, tertiary institution from 1998 to 2021 identified 433 patients with serial wrist magnetic resonance images (MRI) at least 5 years apart. Fifty-six met the inclusion criteria with adequate films to measure CTA and transverse carpal ligament (TCL) thickness at the same slice location-the carpal tunnel inlet, hook of the hamate, and carpal tunnel outlet-independently by two observers who were blinded to each other's measurements. Rates for the change in CTA and TCL thickness were calculated at all three locations., Results: Thickness of the TCL increased, whereas that of the CTA decreased over time. Inlet CTA decreased by 0.9 mm 2 per year (95% CI: 0.34-1.5), outlet CTA decreased by 1.8 mm 2 per year (95% CI: 1.2-2.5), and CTA at the hook of the hamate decreased by 1.6 mm 2 per year (95% CI: 1.0-2.0 per year). The TCL thickened by 0.02 mm per year at all three sections. Taller patients had a decreased rate of CTA loss., Conclusions: In this select cohort, TCL thickened and CTA decreased with time. TCL thickening accounted for about half of the variation in CTA, suggesting that this is a possible contributor to this change. Hypertrophy of the carpal tunnel floor may account for the remaining variation in CTA. The question of whether these results are reliable and generalizable to the general population, or a major influence in the pathophysiology of CTS, is unknown., Clinical Relevance: Small decreases in CTA and thickening of the TCL occur with aging. Whether this is a contributing factor in the development of CTS requires further study., (Copyright © 2023 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.)

Total knee arthroplasty is the most commonly performed joint replacement procedure in the United States. This manuscript will discuss the recommended imaging modalities for six clinical variants; 1. follow-up of symptomatic or asymptomatic patients with a total knee arthroplasty. Initial imaging, 2. Suspected infection after total knee arthroplasty. Additional imaging following radiographs, 3. Pain after total knee arthroplasty. Infection excluded. Suspect aseptic loosening or osteolysis or instability. Additional imaging following radiographs, 4. Pain after total knee arthroplasty. Suspect periprosthetic or hardware fracture. Additional imaging following radiographs, 5. Pain after total knee arthroplasty. Measuring component rotation. Additional imaging following radiographs, and 6. Pain after total knee arthroplasty. Suspect periprosthetic soft-tissue abnormality unrelated to infection, including quadriceps or patellar tendinopathy. Additional imaging following radiographs. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation., (Copyright © 2023 American College of Radiology. Published by Elsevier Inc. All rights reserved.)

Invasive species have the potential to damage ecosystems outside their native range. At an invasion front, individuals are faced with the unfamiliar conditions of a novel environment. Therefore, certain behavioural traits such as boldness and movement likely play a role in invasion ecology. If behavioural traits of this kind are influenced by differing selection pressures between demographic groups of the same species, this could have broad implications for the management of expanding invasion fronts. To determine whether the invasive round goby (Neogobius melanostomus, Pallas, 1814) exhibits sex- and habitat-based differences in boldness and movement across the invasion front, the authors assessed individual movement and exploration tendency under controlled lab settings using video analysis in a behavioural assay. N. melanostomus from lakes tended to be bolder than those from streams, and females tended to be bolder than males. This study provides evidence for sex- and habitat-based differences in behaviour in this globally invasive species that the authors hope will assist in forming the foundation for contextually appropriate management strategies., (© 2022 Fisheries Society of the British Isles.)

Osteochondral lesions (OCLs) in the ankle are more common than OCLs of the foot, but both share a similar imaging appearance. Knowledge of the various imaging modalities, as well as available surgical techniques, is important for radiologists. We discuss radiographs, ultrasonography, computed tomography, single-photon emission computed tomography/computed tomography, and magnetic resonance imaging to evaluate OCLs. In addition, various surgical techniques used to treat OCLs-debridement, retrograde drilling, microfracture, micronized cartilage-augmented microfracture, autografts, and allografts-are described with an emphasis on postoperative appearance following these techniques., Competing Interests: Disclosure The authors report no conflicts of interest in this work., (Thieme. All rights reserved.)

Chronic shoulder pain is an extremely common presenting complaint. Potential pain generators include the rotator cuff tendons, biceps tendon, labrum, glenohumeral articular cartilage, acromioclavicular joint, bones, suprascapular and axillary nerves, and the joint capsule/synovium. Radiographs are typically the initial imaging study obtained in patients with chronic shoulder pain. Further imaging may often be required, with modality chosen based on patient symptoms and physical examination findings, which may lead the clinician to suspect a specific pain generator. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation., (Copyright © 2023 American College of Radiology. Published by Elsevier Inc. All rights reserved.)

Evaluation for suspected inflammatory arthritis as a cause for chronic extremity joint pain often relies on imaging. It is essential that imaging results are interpreted in the context of clinical and serologic results to add specificity because there is significant overlap of imaging findings among the various types of arthritis. This document provides recommendations for imaging evaluation of specific types of inflammatory arthritis, including rheumatoid arthritis, seronegative spondyloarthropathy, gout, calcium pyrophosphate dihydrate disease (or pseudogout), and erosive osteoarthritis. The ACR Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances in which peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation., (Copyright © 2023 American College of Radiology. Published by Elsevier Inc. All rights reserved.)

Chronic hip pain is a frequent chief complaint for adult patients who present for evaluation in a variety of clinical practice settings. Following a targeted history and physical examination, imaging plays a vital role in elucidating the etiologies of a patient's symptoms, as a wide spectrum of pathological entities may cause chronic hip pain. Radiography is usually the appropriate initial imaging test following a clinical examination. Depending on the clinical picture, advanced cross-sectional imaging may be subsequently performed for further evaluation. This documents provides best practice for the imaging workup of chronic hip pain in patients presenting with a variety of clinical scenarios. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment., (Copyright © 2023 American College of Radiology. Published by Elsevier Inc. All rights reserved.)

Background: Medicare reimbursement is rapidly declining in many specialties. An in-depth analysis of Medicare reimbursement for routinely performed diagnostic imaging procedures in the United States is warranted., Purpose/hypothesis: The purpose of this study was to evaluate Medicare reimbursement trends for the 20 most common lower extremity imaging procedures performed between 2005 and 2020, including radiographs, computed tomography (CT), and magnetic resonance imaging (MRI). We hypothesized that Medicare reimbursement for imaging procedures would decline substantially over the studied period., Study Design: Cohort study., Methods: The Physician Fee Schedule Look-up Tool from the Centers for Medicare and Medicaid Services was analyzed for reimbursement rates and relative value units associated with the top 20 most utilized Current Procedural Terminology (CPT) codes in lower extremity imaging from 2005 to 2020. Reimbursement rates were adjusted for inflation and listed in 2020 US dollars using the US Consumer Price Index. To compare year-to-year changes, the percentage change per year and compound annual growth rate were calculated. A 2-tailed t test was used to compare the unadjusted and adjusted percentage change over the 15-year period., Results: After adjusting for inflation, mean reimbursement for all procedures decreased by 32.41% ( P = .013). The mean adjusted percentage change per year was -2.82%, and the mean compound annual growth rate was -1.03%. Compensation for the professional and technical components for all CPT codes decreased by 33.02% and 85.78%, respectively. Mean compensation for the professional component decreased by 36.46% for radiography, 37.02% for CT, and 24.73% for MRI. Mean compensation for the technical component decreased by 7.76% for radiography, 127.66% for CT, and 207.88% for MRI. Mean total relative value units decreased by 38.7%. The commonly billed imaging procedure CPT 73720 (MRI lower extremity, other than joint, with and without contrast) had the greatest adjusted decrease of 69.89%., Conclusion: Medicare reimbursement for the most billed lower extremity imaging studies decreased by 32.41% between 2005 and 2020. The greatest decreases were noted in the technical component. Of the modalities, MRI had the largest decrease, followed by CT and then radiography., Competing Interests: One or more of the authors has declared the following potential conflict of interest or source of funding: N.H. has received education payments from Goode Surgical and ImpactOrtho. K.P. has received education payments from Arthrex. AOSSM checks author disclosures against the Open Payments Database (OPD). AOSSM has not conducted an independent investigation on the OPD and disclaims any liability or responsibility relating thereto., (© The Author(s) 2023.)

Objective: To determine the facilitators of and barriers to adherence to use of intranasal pharmacotherapy (daily intranasal corticosteroids and/or antihistamine, and nasal saline irrigation [NSI]), for allergic rhinitis (AR)., Methods: Patients were recruited from an academic tertiary care rhinology and allergy clinic. Semi-structured interviews were conducted after the initial visit and/or 4-6 weeks following treatment. Transcribed interviews were analyzed using a grounded theory, inductive approach to elucidate themes regarding patient adherence to AR treatment., Results: A total of 32 patients (12 male, 20 female; age 22-78) participated (seven at initial visit, seven at follow-up visit, and 18 at both). Memory triggers, such as linking nasal routine to existing daily activities or medications, were identified by patients as the most helpful strategy for adherence at initial and follow-up visits. Logistical obstacles related to NSI (messy, takes time, etc.) was the most common concept discussed at follow-up. Patients modified the regimen based on side effects experienced or perceived efficacy., Conclusions: Memory triggers help patients adhere to nasal routines. Logistical obstacles related to NSI can deter from use. Health care providers should address both concepts during patient counseling. Nudge-based interventions that incorporate these concepts may help improve adherence to AR treatment., Level of Evidence: 2., Competing Interests: The authors declare no conflicts of interest., (© 2022 The Authors. Laryngoscope Investigative Otolaryngology published by Wiley Periodicals LLC on behalf of The Triological Society.)

Osteoporosis constitutes a significant public health risk. An estimated 10.2 million adults in the United States >50 years of age have osteoporosis, a systemic condition that weakens the bones increasing the susceptibility for fractures. Approximately one-half of women and nearly one-third of men >50 years of age will sustain an osteoporotic fracture. These fractures are associated with a decrease in quality of life, diminished physical function, and reduced independence. Dual-energy X-ray absorptiometry (DXA) is the primary imaging modality used to screen for osteoporosis in women >65 years of age and men >70 years of age. DXA may be used in patients <65 years of age to evaluate bone mass density if there are additional risk factors. In certain situations, vertebral fracture assessment and trabecular bone score may further predict fracture risk, particularly in patients who are not yet osteoporotic but are in the range of osteopenia. Quantitative CT is useful in patients with advanced degenerative changes in the spine. Given the proven efficacy of pharmacologic therapy, the role of imaging to appropriately identify and monitor high-risk individuals is critical in substantially reducing osteoporosis-associated morbidity and mortality, and reducing the considerable cost to the health care system. The ACR Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation., (Copyright © 2022 American College of Radiology. Published by Elsevier Inc. All rights reserved.)

Background: Obstructive sleep apnea (OSA) leads to chronic sleep deprivation. The relationship between OSA and balance is poorly understood., Aim/objective: This study aimed to determine if OSA adversely affects standing balance., Material and Methods: Adults with a clinically indicated polysomnogram (PSG) diagnostic of OSA, who were not on therapy, were recruited from an academic tertiary care referral clinic. Subjects completed the Epworth Sleepiness Scale (ESS), the Stanford Sleepiness Scale (SSS), and the STOP-BANG questionnaire (SBQ). Their balance was tested with the Sensory Organization Test (SOT) of computerized dynamic posturography (CDP)., Results: Sixteen subjects participated in the study, including three with mild OSA, six with moderate OSA, and seven with severe OSA. CDP scores were not related to the subjective screening for OSA (ESS, SSS, and SBQ) or to objective measures of OSA (apnea-hypopnea index, respiratory disturbance index, and oxygen saturation nadir)., Conclusion: Subjective and objective measures of sleepiness and sleep disorder are not related to standing balance. The sleep deficit from OSA did not affect standing balance. Therefore, OSA patients are unlikely to be at significant risk for falls due to OSA., Competing Interests: The authors have declared financial relationships, which are detailed in the next section., (Copyright © 2022, Fox et al.)

Postoperative ankle imaging requires knowledge of the underlying surgical techniques, the usefulness of various imaging modalities, as well as an appreciation for the desired clinical outcomes. Surgical procedures discussed in this article are tibiotalar fracture fixation, tibiotalar, subtalar, and tibiotalocalcaneal arthrodesis, total ankle arthroplasty, talar osteochondral lesion repair and grafting, lateral ligamentous repair and reconstruction, and peroneal and Achilles tendon repair and reconstruction. Imaging can play a vital role in determining if the expected outcome has been achieved and identifying complications, with particular emphasis placed on the use of radiographs, computed tomography (including weight-bearing), magnetic resonance imaging, and ultrasonography., Competing Interests: None declared., (Thieme. All rights reserved.)

Shoulder arthroplasty is a common orthopedic procedure with a complication rate reported to be as high as 39.8% and revision rates as high as 11%. Symptoms related to postoperative difficulties include activity-related pain, decreased range of motion, and apprehension. Some patients report immediate and persistent dissatisfaction, although others report a symptom-free postoperative period followed by increasing pain and decreasing shoulder function and mobility. Imaging plays an important role in diagnosing postoperative complications of shoulder arthroplasties. The imaging algorithm should always begin with radiographs. The selection of the next imaging modality depends on several factors, including findings on the initial imaging study, clinical suspicion of an osseous versus soft-tissue injury, and clinical suspicion of infection.The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment., (Copyright © 2022 American College of Radiology. Published by Elsevier Inc. All rights reserved.)

Objective: This study aimed to investigate the effect of calcific tendinosis on the diagnosis of rotator cuff tears (RCTs) on magnetic resonance imaging (MRI) and magnetic resonance arthrography (MRA)., Materials and Methods: Calcific tendinosis was confirmed radiographically. Two musculoskeletal radiologists then retrospectively and independently reviewed the MRI/MRA examinations, with surgery or arthroscopy performed within 90 days of the MRI. Rotator cuffs were categorized as no tear, partial-thickness tear, and full-thickness tear. Partial-thickness tear/full-thickness tear groups were combined for analysis., Results: Forty-eight MRI (mean age, 63.4 years; range, 37-83 years; female-to-male ratio, 29:19) and 7 MRA (mean age, 49.2 years; range, 25-60 years; female-to-male ratio, 4:3) patients were included. Reader 1 and reader 2 sensitivity/specificity values for RCTs on MRI were 95%/50% and 89%/30%, and the values on MRA were 100%/67% and 100%/100%, respectively. Overall agreement was present in 87% (48 of 55; κ = 0.55 [95% confidence interval, 0.26-0.85])., Conclusions: Magnetic resonance imaging has decreased specificity in diagnosing RCTs when calcific tendinosis is present. Magnetic resonance arthrography performed better in this population and could be considered., Competing Interests: The authors declare no conflict of interests., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Objectives: First-line treatment of chronic rhinosinusitis includes topical corticosteroids aimed at decreasing inflammation of sinonasal mucosa. No guidelines exist regarding the effect of head position during administration of corticosteroids. We hypothesize certain positions enhance delivery to the paranasal sinuses, with further improvement in delivery after sinus surgery., Methods: A systematic review of the literature was conducted using Medline Ovid, Embase, Scopus, and Cochrane databases. All studies evaluating intranasal medications administered in 2 or more head positions were included. Study population, head position(s), method/volume of delivery, and outcome metrics were recorded., Results: Twenty-four studies compared head positions and their role in distribution of intranasal medication. Of 12 papers studying surgically naive subjects, 6 found improvement in delivery to specific sinonasal regions (middle meatus; lateral, superior, or posterior nasal cavity) and/or symptomatic improvement, in the lying head back (LHB) or head down and forward (HDF) positions, but only 3 reached statistical significance. Of 12 papers studying surgically altered patients, 10 found delivery improved in the HDF, LHB, and head forward 45° or 90° positions. Of 5 studies of extended frontal sinus procedures (Draf IIb/III), a majority found distribution to the frontal sinus improved with the head forward 90° position. Patients found the HDF position most uncomfortable., Conclusions: Studies found no statistically significant difference in distribution to unoperated sinuses among different head positions. A minority of studies supported the use of the LHB and HDF positions. This suggests that in surgically naive patients, intranasal corticosteroid delivery to sinonasal regions and/or symptomatic improvement may be best achieved with the sinuses positioned inferior to the delivery device. Surgery improved distribution to the paranasal sinuses regardless of head position, although tilting the head forward 90° was particularly effective in delivery to the frontal sinus after extended frontal sinus procedures.

Intraosseous infusion has become a key tool in the resuscitation of critically ill or injured patients, both in pre-hospital settings and in emergency departments. Intraosseous access is obtained through the percutaneous placement of a needle into the medullary space of a bone, thereby allowing access into the systemic venous circulation via the medullary space, which is essential to treat patients in shock, cardiac arrest, airway compromise, or major trauma. This becomes critically important when obtaining conventional intravenous access is difficult or impossible. Few cases of iatrogenic fracture have been reported for intraosseous access in the tibia and no case to-date has been reported of iatrogenic fracture secondary to humeral access. We report a case of a 55-year-old patient being resuscitated emergently with proximal humeral intraosseous infusion for cardiac and respiratory arrest secondary to status epilepticus. After successful resuscitation and removal of the intraosseous cannula, the patient noted new-onset shoulder pain. The patient was ultimately diagnosed with an iatrogenic fracture of the anatomic neck of the humerus through the intraosseous needle tract when the appropriate history was obtained in conjunction with cross-sectional imaging. As the use of intraosseous access expands, such fractures may well be seen more frequently. Intraosseous access is limited to the period of resuscitation and the cannula is often not present at the time of imaging. It is important for radiologists to recognize the findings related to intraosseous access as well as this complication with its characteristic locations and morphology.

OBJECTIVE. The purpose of this study is to assess the use of cross-sectional imaging to qualitatively and quantitatively categorize trochlear dysplasia as low grade (type A) or high grade (types B-D) according to the Dejour classification. MATERIALS AND METHODS. A retrospective review of CT and MRI knee examinations performed before patients underwent deepening trochleoplasty was independently conducted by two musculoskeletal radiologists. Each case of trochlear dysplasia was qualitatively assigned a Dejour type. Subsequently, quantitative measurements of the sulcus angle, distance from the tibial tubercle to the trochlear groove, trochlear depth, lateral trochlear inclination, trochlear facet asymmetry, and degree of patellar lateralization were performed. RESULTS. A total of 35 patients (29 female patients and six male patients; mean age, 21.1 years) with 39 affected knees (17 right knees and 22 left knees) were included. Readers had exact qualitative agreement using Dejour classification for 30 of 39 knees (77% [κ = 0.77; 95% CI, 0.62-0.91]) and agreement on classification of low-grade versus high-grade dysplasia for 36 of 39 knees (92%). For these 36 knees, the mean differences in measurements of low- versus high-grade dysplasia, respectively, were as follows: for sulcus angle, 153° versus 168° ( p < 0.001); for trochlear depth, 4 versus 1 mm ( p < 0.001); for lateral trochlear inclination, 12 versus 7 mm ( p < 0.02); and for decreased trochlear facet asymmetry, 13% versus 92% ( p < 0.001). Trochlear depth, lateral trochlear inclination, and trochlear facet asymmetry were also different in comparisons of knees with Dejour type B and C trochlear dysplasia versus those with Dejour types B and D (all p < 0.05). No quantitative measurement differentiated between trochlear dysplasia of Dejour types C and D. The distance from the tibial tubercle to the trochlear groove and the degree of patellar lateralization were not statistically different between low- and high-grade dysplasia. CONCLUSION. Qualitative use of the Dejour classification accurately categorizes trochlear dysplasia as low grade or high grade in 92% of cases, with exact agreement reached in 77% of cases. Furthermore, the trochlear depth, lateral trochlear inclination, trochlear facet asymmetry, and sulcus angle can differentiate between low-grade and high-grade dysplasia, with trochlear depth, lateral trochlear inclination, and trochlear facet asymmetry useful for differentiating between Dejour types B and C and Dejour types B and D.

OBJECTIVE. We undertook this study to determine the radiologic features of desmo-plastic fibroblastoma. MATERIALS AND METHODS. We reviewed available radiologic images for 29 pathologically confirmed desmoplastic fibroblastomas, including images from MRI, radiography, ultrasound (US), and CT. RESULTS. The patient population included 14 women and 15 men (mean age, 60 years; range, 23-96 years). Typically, lesions were oval or lobulated and relatively small (mean, 5.6 cm). In 14 of the 22 cases that included patient histories, lesions had grown slowly, with two eventually causing pain. The remaining eight were discovered incidentally. All lesions involved or were below the deep fascia. Lesions were well-defined and associated with muscle (45%), deep fascia (28%), joint (21%), or tendon (7%). MR images were available in 26 cases; 14 included unenhanced and contrast-enhanced studies. On MRI imaging all lesions were well-defined and adjacent to dense connective tissue. On T1-weighted images, lesions showed varying amounts of low and intermediate signal intensity similar to that of tendon and skeletal muscle, respectively. On fluid-sensitive images, lesions were more heterogeneous, generally showing a wider spectrum of decreased to intermediate signal intensity. On contrast-enhanced MR images, enhancement was characteristically peripheral and septal with patchy areas of homogeneity. In the 10 cases with radiographs, images showed negative findings or a nonmineralized mass. The 10 available ultrasound studies showed mixed echogenicity. In eight patients, unenhanced CT showed lesions having attenuation similar to that of skeletal muscle. CONCLUSION. Desmoplastic fibroblastoma is an uncommon neoplasm with a relatively characteristic MRI appearance.

Acute injuries to the foot are frequently encountered in the emergency room and in general practice settings. This publication defines best practices for imaging evaluations for several variants of patients presenting with acute foot trauma. The variants include scenarios when the Ottawa rules can be evaluated, when there are exclusionary criteria, and when suspected pathology is in anatomic areas not addressed by the Ottawa rules. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment., (Copyright © 2020 American College of Radiology. Published by Elsevier Inc. All rights reserved.)

Purpose: The purpose of this investigation is to assess the incidence of rotator cuff tears in cases of calcific tendonitis and evaluate for differences in the incidences of rotator cuff tears by magnetic resonance imaging (MRI) between calcific lesions of different morphology, size, or location., Methods: This single-center study involved a retrospective chart review searching for patients from January 2010 to April 2017 with a diagnosis of calcific tendonitis of the shoulder based on review of all MRI reads done on patients with shoulder pain. Anteroposterior radiographic and MRI studies were reviewed by a musculoskeletal radiologist to assess calcific tendonitis morphology, size, distance from cuff insertion, and any rotator cuff tear. An additional radiologist evaluated calcific tendonitis size, morphology, and location to evaluate the reliability of these variables., Results: In the final cohort of 318 shoulders with calcific tendonitis, the incidence of concomitant rotator cuff tears was 56%. Of all 177 tears, 164 (93%) were partial-thickness and 13 (7%) were complete. Type III calcification morphology (cloudy with soft contour) was most frequently associated with rotator cuff tears and demonstrated an increased odds of tear by a factor of 1.8 (CI 95% 1.1-2.9).There was no statistical difference regarding calcification size or location prognosticating rotator cuff tears or tear thickness. Intraclass correlation coefficients for calcification size, morphology, and location were 0.78, 0.30, and 0.50, respectively., Conclusions: The incidence of rotator cuff tears in cases of calcific tendonitis in this cohort of patients who underwent MRI is higher than previously reported. Cloudy-appearing calcified lesions showed a significant association with rotator cuff tears with an odds ratio of 1.8. Specific locations or sizes of calcified lesions do not appear to be reliable factors to predict concomitant rotator cuff tears. Interobserver agreement for these radiographic variables ranged from fair to substantial and prompt a cautious interpretation of these results., Level of Evidence: IV Retrospective Case Series., (Copyright © 2019 Arthroscopy Association of North America. Published by Elsevier Inc. All rights reserved.)

Objective: Report the incidence, pattern, and severity of equestrian-related injuries presenting to a rural level 1 trauma center and detail the total radiation dose, imaging, and hospital charges related to those injuries., Methods: An IRB-approved retrospective review of patients presenting to our facility following equine-related trauma was conducted. Demographics, mechanism of injury, types and number of imaging exams, approximate radiation dose administered, imaging findings, Injury Severity Score (ISS), rate/length of hospitalization, and approximate cost of care were recorded., Results: A total of 222 patients (161 F:61 M; mean age 38.5 years (range 4-79)) presented to our emergency department following horse-related injury. Mechanisms of injury included the following: fall (n = 186), kick (n = 18), stepped on (n = 9), and other (n = 9). Body part injured included extremity (26.1%), torso (26.6%), spine (25.7%), and head/neck (18.5%). Longer hospital admission, higher expenditure, increased CT/MR imaging, higher ISS, and radiation dose were noted in older patients and those injured by a fall or kick. Head injuries were more frequent following a horse kick (p = 0.006). Spinal and torso injuries were more common in patients older than 54 years (p = < 0.001) and those with falls (p < 0.04). Extremity injuries were more common in older patients (p < 0.001)., Conclusion: Patient age greater than 54 years and mechanism of injury are strong predictors of the ISS, injury localization, healthcare expenditure, and mean hospital stay. With the exception of obvious minor wounds, full trauma work-ups (CT chest/abdomen/pelvis and cervical spine) are encouraged for equestrian-related injuries in older patients and those injured by a fall.

We report a case of a 41-year-old male who presented to our institution with a large groin mass. CT, MRI and PET imaging was performed and was concerning for a soft tissue abscess likely originating in the lumbar spine. Differential considerations included infection, with atypical infections such as tuberculosis strongly considered. Biopsy revealed fungal elements preliminarily reported as consistent with Cryptococcus neoformans but later revealed to be Blastomyces dermatitidis. The patient responded positively following the introduction of appropriate treatment. This case illustrates the imaging similarities between spinal blastomycosis, spinal tuberculosis, and other fungal infections as well as the need for biopsy to differentiate.

Objective: Image-guided percutaneous bone biopsy may be requested by clinicians to guide antibiotics management decisions in patients with extremity osteomyelitis. Much of the clinical literature describes a high rate of bone biopsy culture positivity in patients with osteomyelitis, but anecdotally biopsy is felt to be fairly low yield in many musculoskeletal radiology practices. The objective of the study is to determine the culture positivity rate and clinical utility of bone biopsy in guiding the management of patients with osteomyelitis., Materials and Methods: All image-guided bone biopsy procedures of the pelvis or foot performed at a single institution were identified by a retrospective report search, and only those with a clinical suspicion for infection were included. Cases were included based on convincing imaging findings of osteomyelitis on retrospective review. Microbiology results were reviewed in the clinical chart, as were antibiotics management decisions and response to antibiotics therapy., Results: A total of 60 bone biopsies met the inclusion criteria, 25 within the foot and 35 biopsies of the pelvis. Overall, 11 out of 60 core biopsies (18%) yielded positive cultures. Antibiotics management was altered in only 27% patients with a positive culture; thus, only 5% of patients with MRI findings of osteomyelitis undergoing biopsy had an impact on management., Conclusion: Percutaneous bone biopsies may have a low rate of culture positivity, and even when positive, frequently do not have an impact on antibiotics choice. These data differ from much of the clinical literature, which describes a very high rate of culture positivity.

Objective: To determine how often patients with surgically proven labral tears have labral signal on shoulder MR arthrography (MRA) that is not equal to gadolinium or fluid on T1- and T2-weighted images, respectively., Materials and Methods: Consecutive patients with surgical repair of a SLAP or Bankart labral tear within 95 days of an MRA were included. Using cartilage signal as an internal reference, two musculoskeletal (MSK) radiologists retrospectively categorized labral signal as T1-hyperintense, T1-gadolinium, T2-hyperintense, or T2-fluid. In patients without T1-gadolinium or T2-fluid labral signal, secondary findings such as the orientation, extent, shape, and width of the abnormal signal was recorded. Statistical analyses were performed using Fisher's test and ANOVA., Results: Sixty-one labral tears (36 SLAP and 25 Bankart) in 54 patients (mean age, 30.7; F:M 8:46) met the inclusion criteria. In 67% and 76% of SLAP and Bankart labral tears, T1-gadolinium signal was present (p = 0.43). T2-fluid signal was present in 50% and 92% of these same labral tears (p = 0.001). The absence of T1-gadolinium or T2-fluid signal was more common in SLAP tears (33%) compared to Bankart tears (8%) (p = 0.02). In the SLAP cases, at least two secondary findings of a SLAP tear were present in 92% (11/12)., Conclusions: Lack of surfacing T1-gadolinium or T2-fluid labral signal is unusual in Bankart tears but relatively common in SLAP tears. However, a SLAP tear was diagnosed in 92% of these 12 cases when two secondary findings were present.

Background: The American Academy of Orthopedic Surgeons clinical practice guideline currently recommends repeat joint aspiration when workup of periprosthetic joint infection (PJI) reveals conflicting data. This guideline is based on a single study of 31 patients published 25 years ago. We sought to determine the correlation between first and second aspirations and factors that may play a role in variability between them., Methods: Sixty patients with less than 90 days between aspirations and no intervening surgery were identified at our institution and classified by Musculoskeletal Infection Society (MSIS) criteria as infected, not infected, or not able to determine after both aspirations. Culture results from both aspirations were recorded. The rates of change and correlation in clinical diagnosis and culture results between aspirations were determined., Results: Repeat aspiration changed the diagnosis in 26 cases (43.3%, 95% confidence interval 31.6-55.9, kappa coefficient 0.32, P < .001), and the culture results in 25 cases (41.7%, 95% confidence interval 30.1-54.3, kappa coefficient 0.27, P < .01). Among patients initially MSIS negative, the proportion who changed to MSIS positive was greater for those with a history of prior PJI compared to those without (66.7% vs 0%, P < .05), and the first aspiration mean volume was higher for those changed to MSIS positive compared to those that remained MSIS negative (12.0 vs 3.0 mL, P < .01). Among patients initially MSIS positive, the proportion of patients who changed to MSIS negative was greater for those with a history of adverse local tissue reaction (ALTR) to metal debris compared to patients without suspicion of ALTR (100% vs 7.7%, P < .05)., Conclusion: Repeat aspiration is particularly useful in patients with conflicting clinical data and prior history of PJI, suspicion of ALTR, or with high clinical suspicion of infection., (Published by Elsevier Inc.)

Harvesting can induce rapid evolution in animal populations, yet the role of ecological change in buffering or enhancing that response is poorly understood. Here, we developed an eco-genetic model to examine how ecological changes brought about by two notorious invasive species, zebra and quagga mussels, influence harvest-induced evolution and resilience in a freshwater fish. Our study focused on lake whitefish (Coregonus clupeaformis) in the Laurentian Great Lakes, where the species supports valuable commercial and subsistence fisheries, and where the invasion of dreissenid (zebra and quagga) mussels caused drastic shifts in ecosystem productivity. Using our model system, we predicted faster rates of evolution of maturation reaction norms in lake whitefish under pre-invasion ecosystem conditions when growth and recruitment of young to the population were high. Slower growth rates that occurred under post-invasion conditions delayed when fish became vulnerable to the fishery, thus decreasing selection pressure and lessening the evolutionary response to harvest. Fishing with gill nets and traps nets generally selected for early maturation at small sizes, except when fishing at low levels with small mesh gill nets under pre-invasion conditions; in this latter case, evolution of delayed maturation was predicted. Overall, the invasion of dreissenid mussels lessened the evolutionary response to harvest, while also reducing the productivity and commercial yield potential of the stock. These results demonstrate how ecological conditions shape evolutionary outcomes and how invasive species can have a direct effect on evolutionary responses to harvest and sustainability., (© 2018 The Authors. Ecological Applications published by Wiley Periodicals, Inc. on behalf of Ecological Society of America.)

Chronic knee pain is a condition that is frequently encountered. Imaging often plays an important role in narrowing down the potential causes and determining the most effective next steps. The ACR Appropriateness Criteria for Chronic Knee Pain provides clinicians with the best practices for ordering imaging examinations. The following narrative and accompanying tables should serve as useful guides to any clinician. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment., (Copyright © 2018 American College of Radiology. Published by Elsevier Inc. All rights reserved.)

Background and Purpose: The effectiveness of facet injections is unclear in the literature. Our objective was to determine the immediate and short-term efficacy of intra-articular and periarticular steroid/anesthetic injections for facet-mediated lumbar pain., Materials and Methods: All outpatient fluoroscopically guided facet injections at a single institution during a 54-month period were retrospectively and independently reviewed by 2 musculoskeletal (MSK) trained radiologists. All intra-articular, all periarticular, and partial intra-/periarticular injection locations were determined. Periarticular and partial peri-/intra-articular injections were combined for analysis. Preinjection, immediate, and 1-week postinjection numeric pain scores, patient age, sex, anesthetic/steroid mixture, fluoroscopic time, and physician performing the procedure were recorded., Results: Seventy-seven patients (mean age, 51.1 years) had 100 procedures with 205 total facet joints injected. All intra-articular, all periarticular, and partial peri-/intra-articular injections constituted 54%, 20%, and 26% of the cases, respectively. The immediate and 1-week postprocedural change in pain was -3.7 (95% CI, -4.5 to -2.8; P < .001) and -1.4 (95% CI, -2.2 to -0.6; P = .001) for the all intra-articular and -3.6 (95% CI, -4.4 to -2.9; P < .001) and -1.2 (95% CI, -1.9 to -0.4; P = .002) for the combined group. Changes in immediate pain were significantly associated with the prepain level ( P < .001) and patient age ( P = .024) but not with the anesthetic used. Analyses revealed no significant difference in pain reduction between the groups either immediately or 1 week postinjection. Intra-articular injections required less fluoroscopic time (geometric mean, 39 versus 52 seconds) ( P = .005)., Conclusions: Intra-articular and periarticular fluoroscopically guided facet injections provide statistically significant and similar pain relief both immediately and 1 week postinjection., (© 2018 by American Journal of Neuroradiology.)

Chronic ankle pain is a common clinical problem whose cause is often elucidated by imaging. The ACR Appropriateness Criteria for chronic ankle pain define best practices of image ordering. Clinical scenarios are followed by the imaging choices and their appropriateness. The information is in ordered tables with an accompanying narrative explanation to guide physicians to order the right test. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment., (Copyright © 2018 American College of Radiology. Published by Elsevier Inc. All rights reserved.)

Providing parental care is potentially costly. Costs can arise through elevated energy expenditure or from an increased risk of mortality. A cost of parental care can also occur because a parent is compromised in their ability to forage. We used pumpkinseed Lepomis gibbosus, a fish with an alternative male mating strategy, to test whether parental males differed in their feeding in comparison with females and cuckolder males. To address this question, we examined the stomach contents of female, cuckolder male, and parental male pumpkinseed during the breeding season over an entire diel cycle. We showed that parental males had a lower total weight of food in their stomachs in comparison with females, while cuckolder males did not. Parental males also had a lower weight and number of chironomids in their stomachs. The temporal pattern of feeding of parental males diverged from that of females, and they had a lower probability of pupal chironomids in their stomachs, which implies spatial segregation in foraging. Parental males had a greater probability of conspecific eggs in their stomachs than females, while the probability of egg cannibalism did not differ between cuckolder males and females. Overall, these finding meet predictions in accordance with an assumption that parental care and territoriality can compromise feeding.

Primary synovial chondromatosis is a rare benign condition of uncertain etiology manifested by synovial proliferation. In the radiology literature, there is only 1 prior case report of primary synovial chondromatosis involving the subtalar joint with only partial description of the imaging appearance. We present a 28-year-old female with primary synovial chondromatosis of the subtalar joint and conduct a literature review of the imaging features of primary synovial chondromatosis presenting in the feet.

Peer-reviewed abstracts presented at the 2017 Society of Skeletal Radiology (SSR) Annual Meeting were reviewed following oral presentation. Topics felt to be of potential interest to musculoskeletal (MSK) investigators and practicing clinicians are highlighted in this compilation and analysis of the meeting. New concepts regarding MSK imaging and intervention, MSK protocols and techniques and quality improvement are included. ePoster highlights are also presented.

Total knee arthroplasty (TKA) is the most commonly performed joint replacement procedure in the United States and annual demand for primary TKA is expected to grow by 673% by 2030. The first part provides an overview of imaging modalities (radiographs, CT, MRI, ultrasound, and various nuclear medicine studies) and discusses their usefulness in the imaging evaluation of TKA. The second part focuses on evidence-based imaging and imaging-guided intervention algorithms for the workup of TKA and its complications, including routine follow-up, component wear, periprosthetic infection, aseptic loosening, granulomas/osteolysis, conventional and rotational instability, periprosthetic fracture, patellar complications, and a variety of periprosthetic soft tissue abnormalities. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment., (Copyright © 2017 American College of Radiology. Published by Elsevier Inc. All rights reserved.)

Stress fractures, including both fatigue and insufficiency types, are frequently encountered in clinical practice as a source of pain in both athletes and patients with predisposing conditions. Radiography is the imaging modality of choice for baseline diagnosis. MRI has greatly improved our ability to diagnose radiographically occult stress fractures. Tc-99m bone scan and CT may also be useful as diagnostic tools. Although fatigue and insufficiency fractures can be self-limited and go onto healing even without diagnosis, there is usually value in initiating prompt therapeutic measures as incomplete stress fractures have the potential of progressing to completion and requiring more invasive treatment or delay in return to activity. This is particularly important in the setting of stress fractures of the femoral neck. Accuracy in the identification of these injuries is also relevant because the differential diagnosis includes entities that would otherwise be treated significantly different (ie, osteoid osteoma, osteomyelitis, and metastasis). The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer-reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment., (Copyright © 2017 American College of Radiology. Published by Elsevier Inc. All rights reserved.)

Chronic hip pain is a common clinical problem whose cause is often elucidated by imaging. The ACR Appropriateness Criteria for chronic hip pain define best practices of image ordering. Clinical scenarios are followed by the imaging choices and their appropriateness. The information is in ordered tables with an accompanying narrative explanation to guide physicians to order the right test. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer-reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment., (Copyright © 2017 American College of Radiology. Published by Elsevier Inc. All rights reserved.)

Osteoporosis is a considerable public health risk, with 50% of women and 20% of men >50 years of age experiencing fracture, with mortality rates of 20% within the first year. Dual x-ray absorptiometry (DXA) is the primary diagnostic modality by which to screen women >65 years of age and men >70 years of age for osteoporosis. In postmenopausal women <65 years of age with additional risk factors for fracture, DXA is recommended. Some patients with bone mineral density above the threshold for treatment may qualify for treatment on the basis of vertebral body fractures detected through a vertebral fracture assessment scan, a lateral spine equivalent generated from a commercial DXA machine. Quantitative CT is useful in patients with advanced degenerative bony changes in their spines. New technologies such as trabecular bone score represent an emerging role for qualitative assessment of bone in clinical practice. It is critical that both radiologists and referring providers consider osteoporosis in their patients, thereby reducing substantial morbidity, mortality, and cost to the health care system. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment., (Copyright © 2017 American College of Radiology. Published by Elsevier Inc. All rights reserved.)