Download SSR 2006 Annual Meeting At-a-Glance

Society of Skeletal
Radiology
36th Annual Meeting
March 17 – 20, 2013
Hyatt Regency Hill Country
Resort and Spa
San Antonio, TX
0
Table of Contents
Welcome from the Program Chair ..........................................................................................................2
2012 – 2013 Committees........................................................................................................................3
Program Schedule Overview ..................................................................................................................5
Educational Needs & Objectives.............................................................................................................6
Accreditation...........................................................................................................................................7
Industry Sponsored Events .....................................................................................................................8
SSR Paper Award Winners ....................................................................................................................9
Young Investigator Award Winners .......................................................................................................10
Thank You to Our 2013 Promotional Partners ......................................................................................11
Plan to Attend .......................................................................................................................................11
Thank You to Our 2013 Exhibitors ........................................................................................................12
SSR Past Presidents ............................................................................................................................12
Ultrasound Workshop Instructors ..........................................................................................................13
Research, Education and Development (RED) Fund ............................................................................13
Sunday Schedule .................................................................................................................................14
Monday Schedule .................................................................................................................................24
Tuesday Schedule ................................................................................................................................38
Wednesday Schedule ...........................................................................................................................52
Focus Session / SAMs Slides ...............................................................................................................66
ePosters .............................................................................................................................................150
Ultrasound Workshop .........................................................................................................................195
Map of Hotel Facilities ................................................................................................. Inside Back Cover
1
Welcome
Society of Skeletal Radiology
36th Annual Meeting
March 17 – 20, 2013
Hyatt Regency Hill Country Resort and Spa
San Antonio, TX
Welcome to the 36th Annual SSR Scientific Meeting at the Hyatt Hill Country Resort in San Antonio,
Texas.
From our early beginnings as the Southeastern Skeletal Radiology Society, we have grown to an
organization with almost 1,000 members now known as the SSR.
This meeting is possible only though the tireless efforts of our committee chairs, the executive
committee, and our friends at WJ Weiser & Associates. Although the meeting is the visible reward of
that work, activities of the society leadership occur year round.
A special thank you goes to Donna Blankenbaker and Adam Zoga for coordinating this year’s SAMS.
Thanks also to Jon Jacobson and Yoav Morag for coordinating the Ultrasound Hands-On Session
and to Laura Bancroft for coordinating the Case-of-the-Day.
This year, a record breaking 113 abstracts were submitted for 44 podium slots. The inclusion of
ePosters now allows us to invite more participants. The selection process is arduous, but our goal is
to present an entertaining and educational mix and I hope we have accomplished this.
I have always wanted to come back to San Antonio, after spending four years here with the Air Force
protecting America from foreign and domestic radiological pathology. They have all three food groups
here: steak, BBQ and Tex-Mex. While dining you can enjoy both types of music: country AND
western. Please give back to the local economy and buy cowboy hats, hot sauce, etc. And do have a
margarita – you won’t find a better one anywhere; Texas has recently acquired ice-making technology
from the north, so ask for it ‘frozen’ (Yankee style), and have fun!!
The program committee invites you to relax and enjoy what we hope will be our best meeting ever.
Cheers,
William B. Morrison, MD
2013 Program Committee Chair
2
2012– 2013 Committees
EXECUTIVE COMMITTEE
President
Kenneth A. Buckwalter, MD
President-Elect
William Morrison, MD
Secretary
Andrew H. Sonin, MD
Treasurer
Laura W. Bancroft, MD
Past President
Carol L. Andrews, MD
AUDIT COMMITTEE
David G. Disler, MD; Richmond, VA
Devon A. Klein, MD, MPH; New York, NY
Richard Kijowski, MD; Madison, WI (Network Chair)
ELECTRONIC COMMUNICATIONS COMMITTEE
Jeffrey M. Brody, MD; Barrington, RI
Felix S. Chew, MD; Seattle, WA
Amilcare Gentili, MD; La Jolla, CA
Perry J. Horwich, MD; Elmira, NY
Daniel M. Walz, MD; Port Washington, NY
Michael L. Richardson, MD; Seattle, WA (Chair)
FINANCE COMMITTEE
Eric A. Brandser, MD; Cincinnati, OH
Jon A. Jacobson, MD; Ann Arbor, MI
Laura W. Bancroft, MD; Winter Park, FL (Chair)
MEMBERSHIP COMMITTEE
James M. Evans, MD; Nichols Hills, OK
Kathleen C. Finzel, MD; Fort Salonga, NY
Troy F. Storey, MD; Gainesville, FL
Donna G. Blankenbaker, MD; Madison, WI (Chair)
NOMINATING COMMITTEE
Kenneth A. Buckwalter, MD; Indianapolis, IN (President)
David C. Salonen, MD, FRCPC; Toronto, ON Canada
Donald J. Flemming, MD; Hershey, PA (Network Chair)
PRACTICE GUIDELINES AND
TECHNICAL STANDARDS COMMITTEE
Jonathan S. Luchs, MD; Woodbury, NY
Barbara N. Weissman, MD; Boston, MA
James Neal Wise, MD; Bentonville, AR
J. H. Edmund Lee, MD; Davis, CA (Chair)
3
PROGRAM COMMITTEE
Andrew H. Sonin, MD; Highlands Ranch, CO
Lawrence M. White, MD; Toronto, ON Canada
William B. Morrison, MD; Philadelphia, PA (Chair)
RESEARCH COMMITTEE
Jenny T. Bencardino, MD; New York, NY
John E. Madewell, MD; Houston, TX
Ken L. Schreibman, MD, PhD; Madison, WI
Sandra L. Moore, MD; Astoria, NY (Chair)
RESIDENCY AND FELLOWSHIP EDUCATION COMMITTEE
Stephanie Bernard, MD; Hummelstown, PA
William F. Conway, MD, PhD; Charleston, SC
Joseph G. Craig, MBChB; Detroit, MI
Srinivasan Harish, FRCPC; Hamilton, ON Canada
Brian D. Petersen, MD; Denver, CO
Jorge A. Vidal, MD; San Juan, PR
Corrie M. Yablon, MD; Ann Arbor, MI
Lynne S. Steinbach, MD; Tiburon, CA (Chair)
RULES COMMITTEE
Laura W. Bancroft, MD; Winter Park, FL
Eric B. Callaghan, MD; Marshfield, WI
Kirkland W. Davis, MD; Madison, WI
David C. Salonen, MD, FRCPC; Toronto, ON Canada (Network Chair)
SOCIOECONOMIC AFFAIRS COMMITTEE
Christopher J. Hanrahan, MD, PhD; Salt Lake City, UT
John Pan, MD, MPH; Boston, MA
Michael P. Recht, MD; New York, NY
Robert K. Gelczer, MD; Oklahoma City, OK (Chair)
SSR REPRESENTATIVES TO OTHER SOCIETIES
Robert K. Gelczer, MD; Oklahoma City, OK (ACR Councilor)
Mark J. Kransdorf, MD; Scottsdale, AZ (ISS Liaison)
Richard H. Daffner, MD, FACR; Pittsburgh, PA (ACR Alternate Councilor)
Timothy J. Mosher, MD; Elizabethtown, PA (Academy of Radiology Research (ARR))
Donald J. Flemming, MD; Hershey, PA (RSNA Physics Education Work Group)
EXECUTIVE OFFICE
Two Woodfield Lake ♦ 1100 E Woodfield Road, Suite 350
Schaumburg, IL 60173 ♦ www.skeletalrad.org
Phone: (847) 517-3302 ♦ Fax (847) 517-7229
Executive Director: Wendy J. Weiser
Managing Director: Sue O’Sullivan
Associate Director: Katie Scheck
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Program Schedule Overview
Program Schedule Overview
*General Sessions located in Hill Country D – G
Sunday, March 17, 2013
7:00 a.m. – 7:55 a.m.
7:00 a.m. – 1:00 p.m.
7:00 a.m. – 4:30 p.m.
7:00 a.m. – 4:30 p.m.
7:45 a.m. – 8:45 a.m.
9:00 a.m. – 10:00 a.m.
10:00 a.m. – 10:30 a.m.
10:30 a.m. – 12:10 p.m.
12:10 p.m. – 1:30 p.m.
1:30 p.m. – 3:00 p.m.
3:00 p.m. – 3:10 p.m.
3:10 p.m. – 4:50 p.m.
4:50 p.m. – 5:10 p.m.
CONTINENTAL BREAKFAST
EXHIBIT HALL OPEN
REGISTRATION / INFORMATION DESK OPEN
EPOSTER SESSION
ANNUAL BUSINESS MEETING
EDUCATION/CLINICAL PRACTICE SESSION
BREAK – VISIT EXHIBIT HALL
BASIC RESEARCH SESSION
LUNCH
FOCUS SESSION / SELF ASSESSMENT MODULE: “CONTROVERSIES & EVOLVING
CONCEPTS IN HIP IMAGING”
BREAK
FOCUS SESSION / SELF ASSESSMENT MODULE: “FOOT TO THE GROIN: POSTOPERATIVE IMAGING OF THE LOWER EXTREMITY”
SAM Exam
Monday, March 18, 2013
7:00 a.m. – 7:55 a.m.
7:00 a.m. – 12:30 p.m.
8:00 a.m. – 12:30 p.m.
8:00 a.m. – 12:30 p.m.
8:00 a.m. – 10:00 a.m.
10:00 a.m. – 10:05 a.m.
10:05 a.m. – 10:30 a.m.
10:30 a.m. – 12:30 p.m.
12:30 p.m. – 12:35 p.m.
1:00 p.m. – 3:00 p.m.
6:30 p.m. – 7:00 p.m.
7:00 p.m. – 10:00 p.m.
INDUSTRY SPONSORED BREAKFAST
REGISTRATION / INFORMATION DESK OPEN
EXHIBIT HALL OPEN
EPOSTER SESSION
KNEE SESSION
CASE OF THE DAY
BREAK – VISIT EXHIBIT HALL
HIP / LOWER EXTREMITY SESSION
CASE OF THE DAY
MUSCULOSKELETAL ULTRASOUND HANDS-ON WORKSHOP: SHOULDER
*Separate Registration Required
SSR NEW MEMBERS’ RECEPTION
ANNUAL BANQUET
Tuesday, March 19, 2013
7:00 a.m. – 7:55 a.m.
INDUSTRY SPONSORED BREAKFAST
7:00 a.m. – 12:30 p.m.
8:00 a.m. – 12:30 p.m.
8:00 a.m. – 12:30 p.m.
8:00 a.m. – 10:00 a.m.
10:00 a.m. – 10:05 a.m.
10:05 a.m. – 10:30 a.m.
10:30 a.m. – 12:30 p.m.
12:30 p.m. – 12:35 p.m.
REGISTRATION / INFORMATION DESK OPEN
EPOSTER SESSION
EXHIBIT HALL OPEN
SHOULDER / UPPER EXTREMITY SESSION
CASE OF THE DAY
BREAK – VISIT EXHIBIT HALL
SPINE / INTERVENTION SESSION
CASE OF THE DAY
Wednesday, March 20, 2013
7:00 a.m. – 7:55 a.m.
7:00 a.m. – 10:30 a.m.
7:00 a.m. – 10:30 a.m.
7:00 a.m. – 12:30 p.m.
8:00 a.m. – 10:00 a.m.
10:00 a.m. – 10:05 a.m.
10:05 a.m. – 10:30 a.m.
10:30 a.m. – 12:30 p.m.
CONTINENTAL BREAKFAST
EXHIBIT HALL OPEN
EPOSTER SESSION
REGISTRATION / INFORMATION DESK OPEN
TUMOR SESSION
CASE OF THE DAY
BREAK – VISIT EXHIBIT HALL
MISCELLANEOUS SESSION
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Educational Needs & Objectives
Annual Meeting
Educational Needs
The need for this year’s SSR SAMs has been established from a review of written meeting evaluation surveys from
individual attendees from prior meetings, an analysis of a needs questionnaire completed at the completion of last year’s
meeting, as well as personal interviews of the Executive and Program Committees, discussions with meeting attendees
and Society members and detailed discussions with the Program Committee membership. Scientific papers were graded
and selected for presentation based on averaged score, being divided into sessions reflecting anatomy (ie, “knee”) or
pathology (ie, “tumor”).
As a result, this year’s program will focus on providing sessions to meet the identified needs. The first SAM will address
imaging of the hip and groin with an emphasis on MR imaging which has revolutionized the evaluation and management
of sport related injuries. This is a complicated and challenging field for general as well as subspecialty radiologists,
pathologists, and clinicians involved in the evaluation and treatment of musculoskeletal disease. Individual lectures have
been coordinated around hip injuries, femoroacetabular impingement and approaches to diagnosis and treatment, new
technique/basic science concepts related to imaging of joint derangement and sport injury, and interventional image
guided treatment/therapy. The other SAM will focus on imaging the post-operative patient including arthritis, degenerative
disease, trauma, and tumors. Imaging of the post-operative patient is one of the most challenging and rapidly evolving
areas within musculoskeletal radiology and updating the attendees on this was the most requested on prior years’
surveys. Lectures in this course will cover the lower extremity including groin and hip, knee and foot/ankle – from
arthroscopic surgery to imaging and techniques in joint replacement. Such sessions were coordinated to provide a better
understanding of optimal evaluation of MSK disease/conditions that can lead to earlier diagnosis and better patient
outcomes. Additionally, five “case of the day” sessions will present challenging clinical cases to provide a forum to discuss
difficult cases and combine expert approaches to improve the learning experience, and overall understanding and
evaluation of the MSK system.
Educational Objectives
1. Apply real life situations to clinical practice.
2. Integrate knowledge and performance in the assessment and diagnosis of musculoskeletal sports injury, tumors,
trauma and degenerative disease.
3. Identify the anatomy of normal MSK tissues, variants and mimicker of disease.
4. Identify morphologic, histologic and imaging characteristics of MSK disease
5. Describe the specific pathology that accounts for the appearance of osseous and soft tissues in the setting of
trauma, overuse, degeneration, inflammatory/autoimmune and neoplastic conditions on various imaging
modalities.
6. Recognize the relationship of specific biomechanical activities, injuries and treatments to the appearance of joints,
bone, and soft tissues on imaging, arthroscopic, and pathologic assessment.
7. Review the optimal role of imaging, surgery and histopathology in the diagnosis and management of
musculoskeletal disease and health.
8. Identify the complementary role of emerging imaging techniques, modalities, and interventional/therapeutic
procedures in the diagnosis and management of specific musculoskeletal conditions.
9. Illustrate competency in Ultrasound, MRI, and therapeutic approaches in the assessment and management of the
musculoskeletal system.
Musculoskeletal Ultrasound Hands-On Workshop: Shoulder
Educational Needs
Achieving competence in shoulder ultrasound not only depends on knowledge of anatomy and pathology, but also
familiarity with various techniques of shoulder ultrasound. The success of shoulder ultrasound is largely dependent on the
skills of the individual performing the ultrasound. One of the most effective learning formats is a hands-on workshop
supervised by experienced instructors.
Educational Objectives
At the completion of the ultrasound workshop, the participant will able to:
• Explain and perform a shoulder ultrasound examination.
6
Accreditation
Accreditation Statement
This activity has been planned and implemented in accordance with the Essential Areas and policies
of the Accreditation Council for Continuing Medical Education through the joint sponsorship of the
American College of Legal Medicine and the Society of Skeletal Radiology (SSR). The American
College of Legal Medicine is accredited by the ACCME to provide continuing medical education for
physicians.
The American College of Legal Medicine designates this live activity for a maximum of 18.25 AMA
PRA Category 1 CreditsTM. Physicians should claim only the credit commensurate with the extent of
their participation in the activity.
Conflict Resolution Statement
The American College of Legal Medicine CME Office has reviewed this activity’s speaker and planner
disclosures and resolved all identified conflicts of interest, if applicable.
General Disclaimer
The statements and opinions contained in this program are solely those of the individual authors and
contributors and not of the SSR. The appearance of the advertisements is not a warranty,
endorsement, or approval of the products or services advertised or of their effectiveness, quality, or
safety. The content of this publication may contain discussion of off-label uses of some of the agents
mentioned. Please consult the prescribing information for full disclosure of approved uses. The SSR
disclaims responsibility for any injury to persons or property resulting from any ideas or products
referred to in the abstracts or advertisements.
Special Assistance
We encourage participation by all individuals. If you have a disability, advance notification of any
special needs will help us better serve you. Call (847) 517-3302 if you require special assistance to
fully participate in the meeting.
7
Industry Sponsored Events
MONDAY, MARCH 18, 2013
7:00 a.m. – 7:55 a.m.
Apriomed Sponsored Breakfast and Hands-On Intervention
Presentation
Location: Hill Country A – C
"Hands-on Demonstration of the Bonopty Biopsy Needle and New
Interventional Radiology Devices"
Catherine C. Roberts, MD
Professor of Radiology, Assoc. Dean
Mayo School of Heal Sciences
Mayo Clinic, Scottsdale, AZ
William B. Morrison, MD
Professor, Thomas Jefferson University Hospital
Philadelphia, PA
Director, Musculoskeletal/General Diagnostic Radiology
TUESDAY, MARCH 19, 2013
7:00 a.m. – 7:55 a.m.
National Institute of Health Sponsored Breakfast
Location: Hill Country A – C
"Morphological and Quantitative Imaging Research Using Data from
the Osteoarthritis Initiative"
Gayle E. Lester, PhD
Program Director
Clinical Osteoarthritis & Diagnostic Imaging
Bethesda, MD
Hamza Alizai, MD
Radiology Program Resident
Department of Radiology – Residency Program
The University of Texas Health Science Center at San Antonio
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SSR Paper Award Winners
2012
Meredith Hayes, MD
“Phosphaturic Mesenchymal
Tumors Imaging Features of a
Rare Entity With Clinicopathologic
Correlation”
Selected for presentation at ISS
Srinivasan Harish, FRCPC
“MRI of the Spine and Sacroiliac
Joints for Spondyloarthropathy:
Influence on Clinical Diagnostic
Confidence and Patient
Management”
Selected for presentation at RSNA
2011
Tal Laor, MD
"Juvenile Osteochondritis
Dissecans (JOCD): Is It a Growth
Disturbance of the Secondary
Physis of the Epiphysis?"
Selected for presentation at ISS
Donna Blankenbaker, MD
“MR Arthrographic Appearance of
the Post-Operative Acetabular
Labrum”
Selected for presentation at RSNA
2010
Maxime Freire, MD
“MR Evaluation of Repair Tissue in
Osteochondral Defects Following
Treatment with Acellular Scaffolds:
High Resolution MR-Histological
Correlation in a Goat Model”
Selected for presentation at ISS
Peter MacMahon, MD
“Injectable Corticosteroid
Preparations: An Embolic Risk
Assessment by Static and
Dynamic Microscopic Analysis”
Selected for presentation at RSNA
2009
Christopher J. Hanrahan, MD,
PhD
"Temporal Evolution of MRI
Findings After Rotator Cuff Repair"
Selected for presentation at ISS
Kevin Johnson, MD
"Contrast-Enhanced Ultrasound
Characterization of the Vascularity
of the Repaired Rotator Cuff"
Selected for presentation at RSNA
2008
Stephanie A. Bernard, MD
“Cartilage Cap Thickness
Measurement on T2-Weighted MR
Imaging and the Risk of Secondary
Chondrosarcoma in
Osteochondromas”
Selected for presentation at ISS
Kelley W. Marshall, MD
“Osteochondral Lesions of the
Lateral Trochlea in the Pediatric
Athlete with Elbow Pain”
Selected for presentation at RSNA
2007
Adam Zoga, MD
“The Sports Hernia: What Is It?
How Do I image It? What Are Its
Confounders?”
Selected for presentation at ISS
Tal Laor, MD
“The Effect of Childhood Growth
on the Anterior and Posterior
Cruciate Ligaments”
Selected for presentation at RSNA
2006
Eric T. Chou, MD
“Bifurcated Distal Biceps Brachii
Tendon: Magnetic Resonance
Imaging Appearances and
Prevalence”
Selected for presentation at ISS
Lawrence M. White, MD
"Direct MR Arthrographic
Assessment of Recurrent
Symptoms Post Shoulder
Instability Repair: Correlation With
Second Look Surgical Evaluations
in 40 Patients"
Selected for presentation at RSNA
9
2005
Steven S. Gerguis, MD
“Review of the Secondary Signs of
Femoracetabular Impingement and
Correlation with the Head-neck
Angle Measured on the Frog-Leg
Lateral View”
Selected for presentation at ISS
Suzanne E. Anderson, BMed
“Computer-assisted Software for
Accurate Determination of
Acetabular Coverage with
Conventional Radiography”
2004
Mihra Taljanovic, MD, MS
“Bone Marrow Edema in Hip
Osteoarthritis: Quantitative
Assessment with MRI and
Correlation with Clinical Exam,
Radiographic Findings and
Histopathology”
2003
Joseph R. DeMartini, MD
“Effects of MR Gradient CoilInduced Vibration Artifacts and
Inherent Pulse Sequence
Imperfections on Phase”
2002
Derek R. Armfield, MD
“MRI of Posterior Medial Meniscal
Root Avulsion”
2001
Patrick T. Liu, MD
“Improved Imaging of Osteoid
Osteoma with Dynamic
Gadolinium-Enhanced MRI”
2000
Timothy G. Sanders, MD
“MRI at Different Time Intervals
following Hamstring Harvest for
ACL Reconstruction”
Patrick T. Liu Innovation In Research Award Recipient
SSR Excellence Award
2012
Joshua M. Polster, MD
“Single Energy Post – Processing Technique for Bone
Marrow Imaging on CT”
2011
Luis Beltran, Jason Mayo, Jenny Bencardino,
Zehava Rosenberg, Luis Neto Pecci, Maria Diaz de
Tuesta, Olga Ruiz
“Diagnostic Evaluation of Hip Dysplasia in the Young
Adult – Emphasis on Cross-Sectional Imaging”
2011
Kenneth Lee, MD
"Treatment of Chronic Lateral Epicondylosis Using
Hyperosmolar Dextrose Solution:
CanAcoustoelastography Monitor Tissue Healing?"
Young Investigator Award Winners
2013
Gyftopoulos, Soterios, MD
“Correlation of MIR with Arthroscopy for the Diagnosis of Subscapularis Tendon Tears”
Raghavan, Meera, MD, BS
“Radiomics of Soft tissue Sarcoma-Comuter-Aided Image Analysis and Characterization of Tumor Heterogeneity”
Rantiolu Aro, Michael, MD
“Anatomic Variations of Femoral Nerves on High Resolution 3 Tesla Magnetic Resonance Neurography and Their
Relation to Abnormal Nerve and Muscle Imaging Findings”
2012
Bethany Casagranda, DO
“Coronal Oblique Imaging of The Knee: Can It Increase Radiologists’ Confidence in Diagnosing Posterior Root Meniscal
Tears?”
Glenn Gaviola, MD
“Assessment of Fellowship Trainee Clinical Competency and Growth with an Objective Standardized Clinical Examination
Within the Musculoskeletal Fellowship Program: Initial Experience”
Jonelle Petscavage, MD, MPH
“Magnetic Resonance Imaging Findings of Adverse Reactions to Metallic Debris (ARMD) of Metal-On-Metal Total Hip
Replacements”
Naveen Subhas, MD
“Metal Artifact Reduction Using a Monoenergetic Dual Energy CT Technique”
2011
Avneesh Chhabra, MD
“High Resolution 3T MR Neurography in Sciatic Neuropathy”
Kenneth Lee, MD
“Treatment of Chronic Lateral Epicondylosis Using Hyperosmolar Dextrose Solution: Can Acoustoelastography Monitor
Tissue Healing?”
Brian Petersen, MD
“Injury of the Soleus Muscle Origin – Mimicker of Posterolateral Corner Injury in ACL Tears?”
“Prevalence of Intraforaminal Vertebral Artery Loops”
Andres Rahal, MD, PhD
“Ultrasound in Early Rheumatoid Arthritis: How to Perform a Hand and Wrist Ultrasound Examination and Common
Imaging Findings”
“Shoulder Glenoid Version on CT Scan: Using a Plane Axial to the Scapula is Critical for a Precise Measurement”
Andrew Zbojniewicz, MD
“Focal Periphyseal Edema (FOPE): A Potentially Painful Manifestation of Physeal Fusion?”
2010
Humberto G. Rosas, MD
“Acoustoelastography of the Achilles Tendon: A Pilot Study Evaluating a New Noninvasive Ultrasound Technique to
Determine the Tensile Properties of the Achilles Tendon in Both the Normal and Pathologic States”
10
Thank You to Our 2013 Promotional Partners
Gold Level
Apriomed, Inc.
GE Healthcare
Silver Level
BioMarin Pharmaceutical, Inc.
Laurane Medical
MR Instruments, Inc.
Plan to Attend
Society of Skeletal Radiology
37th Annual Meeting
March 16 – 19, 2014
Hard Rock Hotel San Diego
San Diego, CA
11
Thank You to Our 2013 Exhibitors
Special thanks to the following companies for their support
to the Society of Skeletal Radiology in 2013.
Exhibitors
Apriomed, Inc.
BioMarin Pharmaceutical, Inc.
GE Healthcare
Laurane Medical
Lippincott Williams & Wilkins
MR Instruments, Inc.
Vidacare Corporation
SSR Past Presidents
William Bonner Guilford, MD
July 1978 – June 1980
William Bonner Guilford, MD
July 1994 – June 1996
Jeremy J. Kaye, MD
July 1980 – June 1982
Terry M. Hudson, MD
July 1996 – June 1998
William F. Conway, MD, PhD
July 1998 – June 2000
Cosmo L. Haun, MD
July 1982 – June 1984
Arthur A. De Smet, MD
July 2000 – June 2002
William W. Daniel, MD
July 1984 – June 1986
B.J. Manaster, MD, PhD
July 2002 – June 2004
Anne C. Brower, MD
July 1986 – June 1988
Arthur H. Newberg, MD
July 2004 – June 2006
Jeno I. Sebes, MD
July 1988 – June 1990
Cheryl A. Petersilge, MD
July 2006 – June 2008
Murali Sundaram, MD
July 1990 – June 1992
Mark J. Kransdorf, MD
July 2008 – March 2010
Charles S. Resnik, MD
July 1992 – June 1994
Carol L. Andrews, MD
April 2010 – March 2012
12
Ultrasound Workshop Instructors
Co-Moderators/Organizers:
Jon A. Jacobson, MD - University of Michigan Medical Center, Ann Arbor, MI
Yoav Morag, MD - University of Michigan Medical Center, Ann Arbor, MI
Instructors:
Mary M. Chiavaras, MD, PhD - McMaster University, Ancaster, ON, CAN
Joseph G. Craig, MB ChB - Henry Ford Hospital, Detroit, MI
Gina A. DiPrimio, MD - The Ottawa Hospital, Ottawa, ON, CAN
David P. Fessell, MD – University of Michigan, Ann Arbor, MI
Katrina N. Glazebrook, MD - Mayo Clinic, Rochester, MN
Kenneth Lee, MD - University of Wisconsin, Madison, WI
Suzanne Long, MD - Thomas Jefferson University, Philadelphia, PA
Jonathan S. Luchs, MD - Metropolitan Diagnostic Imaging Group, Woodbury, NY
Mihra S. Taljanovic, MD - University of Arizona, Tucson, AZ
Corrie M. Yablon, MD - University of Michigan Medical Center, Ann Arbor, MI
Research, Education and Development (RED) Fund
2012 – 2013 Member Contributions
Paul M. Aitchison, MD
Laura W. Bancroft, MD
George T. Bolton, MD, DVM
Jeffrey M. Brody, MD
Eric B. Callaghan, MD
Felix S. Chew, MD
Daniel C. Davis, MD
Sukhvinder S. Dhillon, MB
ChB, MRCP, FRCR
John H. Doumanian, MD
William Rhey Dunfee, MD
Timothy R. Enright, MD
Peter T. Evangelista, MD
Donald J. Flemming, MD
Jason Ford, MD
Angel A. Gomez, MD, MPH
Christopher J. Hanrahan, MD,
PhD
Srinivasan Harish, FRCPC
Perry J. Horwich, MD
Rachel B. Hulen, MD
James S. Jelinek, MD
Aron M. Judkiewicz, MD
Yazan Kaakaji, MD
Leo Kallarackel, MBBS,
MRCPCH, FRCR
Mark J. Kransdorf, MD
Jonathan S. Luchs, MD
David A. May, MD
Jorge M. Medina, MD
Lacey F. Moore, MD
Sandra L. Moore, MD
William B. Morrison, MD
Kambiz Motamedi, MD
Seth O'Brien, MD
Brian D. Petersen, MD
13
Cheryl A. Petersilge, MD
Jeffrey J. Peterson, MD
Andres Rahal, MD, PhD
Michael L. Richardson, MD
Mark R. Robbin, MD
Lee F. Rogers, MD
Hamid Salamipour, MD
Leanne L. Seeger, FACR
Stephen A. Sevigny, MD
Gary E. Simmons, MD
Andrew H. Sonin, MD
Gregory S. Stacy, MD
Jason W. Stephenson, MD
Troy F. Storey, MD
D. Dean Thornton, MD
Jeffrey D. Towers, MD
Jorge A. Vidal, MD
Sunday, March 17, 2013
General Sessions located In Hill Country D – G unless otherwise noted.
7:00 a.m. – 7:55 a.m.
Continental Breakfast
Location: Hill Country A – C
7:00 a.m. – 1:00 p.m.
Exhibit Hall Open
Location: Hill Country A – C
7:00 a.m. – 4:30 p.m.
Registration / Information Desk Open
Location: Hill Country Foyer
7:45 a.m. – 8:45 a.m.
Annual Business Meeting
7:00 a.m. – 4:30 p.m.
ePoster Session*
Location: Hill Country A – C
(See page 150 for full information)
*As this session is not moderated, ePosters are not CME accredited
9:00 a.m. – 10:00 a.m.
Education / Clinical Practice Session
Moderators: Kirkland W. Davis, MD
Corrie M. Yablon, MD
9:00 a.m.
#1
DATA DRIVEN DESIGN OF A NEW FOURTH YEAR MSK ELECTIVE
Flemming D., Penn State Hershey Medical Center; Mosher T., Walker E., Bernard S.,
Brian P., Petscavage J.
(Presented by: Donald Flemming, MD)
9:20 a.m.
#2
UTILIZATION PRACTICES AND CURRENT AWARENESS OF NON TRADITIONAL
IMAGING TECHNOLOGIES IN MSK RADIOLOGY- WHAT WE NEED TO KNOW IN
ORDER TO STAY AHEAD OF THE GROWING TURF WARS IN IMAGING AND
WHERE ARE WE HEADED
Smith S.E., Brigham and Women's Hospital, Harvard Medical School
(Presented by: Stacy Smith, MD)
9:40 a.m.
#3
“FOOL ME TWICE”: DELAYED DIAGNOSES IN RADIOLOGY WITH AN EMPHASIS
ON PERPETUATED ERRORS
Mansfield L.T., Brooke Army Medical Center, Kim Y.
(Presented by: Liem Mansfield, MD)
10:00 a.m. – 10:30 a.m.
Break – Visit Exhibit Hall
Location: Hill Country A – C
10:30 a.m. – 12:10 p.m.
Basic Research Session
Moderators: Catherine C. Roberts, MD
Lawrence M. White, MD
10:30 a.m.
#4
*NOVEL CT METAL ARTIFACT REDUCTION PROTOTYPE FOR EVALUATION OF
SHOULDER ARTHROPLASTIES: PRELIMINARY RESULTS
Subhas N. Shiraj S., Primak A.N., Schils J.P., Krauss A., Polster J.M., Ilaslan H., Iannotti
J.P.
(Presented by: Naveen Subhas, MD)
*Not CME Accredited
10:50 a.m.
#5
*3DMR OSSEOUS RECONSTRUCTIONS OF THE SHOULDER USING A GRADIENTECHO BASED 2-POINT DIXON RECONSTRUCTION: A FEASIBILITY STUDY
Gyftopoulos S., NYU Langone Medical Center; New York, NY; Yemin A., Mulholland T.,
Bloom M., Storey P., Geppert C., Recht M.P.
(Presented by: Soterios Gyftopoulos, MD)
*Not CME Accredited
14
Sunday, March 17, 2013
11:10 a.m.
#6
UTILITY OF POSTCONTRAST SUBTRACTION MR IMAGING IN THE EVALUATION
OF PERIPROSTHETIC PSEUDOTUMOR IN PATIENTS WITH METAL-ON-METAL HIP
PROSTHESES
Otto T.M., Mayo Clinic; Bestic J.M., Peterson J.J., Garner H.W., Dave H.K.
(Presented by: Tara Otto, MD)
11:30 a.m.
#7
PRE-OPERATIVE EVALUATION OF PATIENTS UNDERGOING KNEE ARTICULAR
CARTILAGE DEFECT REPAIR: MRI 3D THICKNESS MAPS DERIVED FROM A
VALIDATED, AUTOMATED SEGMENTATION PLATFORM - INITIAL RESULTS
Brandser E., Radiology Association of N KY; Farber J., Tamez-Pena J., Holladay B.,
Larkin J., Heis F.
(Presented by: Eric Brandser, MD)
11:50 a.m.
#8
CARPAL KINEMATICS FROM DYNAMIC WRIST MRI DURING ACTIVE RANGE OF
MOTION
Boutin R.D., UC Davis, Sacramento, CA; Ashwell Z., Immerman I., Szabo R., Sonico
G.J., Buonocore M., Chaudhari A.
(Presented by: Robert Boutin, MD)
S
12:10 p.m. – 1:30 p.m.
Lunch
Location: Lukenbach Pavillion
1:30 p.m. – 3:00 p.m.
Focus Session / Self Assessment Module:
“Controversies & Evolving Concepts in Hip Imaging”
Moderator: Donna G. Blankenbaker, MD
1:30 p.m. – 1:50 p.m.
Imaging and Treatment of the Snapping Hip
Donna G. Blankenbaker, MD
1:50 p.m. – 2:10 p.m.
MRI of the Painful Hip Arthroplasty
Theodore T. Miller, MD
2:10 p.m. – 2:30 p.m.
Conundrums in Hip Imaging
Kirk Davis, MD
2:30 p.m. – 3:00 p.m.
Controversies and Challenges in Imaging of Femoroacetabular Impingement (FAI)
Michael Recht, MD
3:00 p.m. – 3:10 p.m.
Break
3:10 p.m. – 4:50 p.m.
Focus Session / Self Assessment Module:
“Foot to the Groin: Post-Operative Imaging of the Lower Extremity”
Moderator: Adam Zoga, MD
3:10 p.m. – 3:35 p.m.
Postoperative Hip/Pelvis
Adam Zoga, MD
3:35 p.m. – 4:00 p.m.
Postoperative Imaging of Knee Meniscus and Cartilage
Daniel M. Walz, MD
4:00 p.m. – 4:25 p.m.
The Postoperative Knee Ligaments and Extensor Mechanism
Bethany U. Casagranda, DO
4:25 p.m. – 4:50 p.m.
Postoperative Imaging of the Ankle and Foot
Imran M. Omar, MD
4:50 p.m. – 5:10 p.m.
SAM Exam
15
Podium #1
DATA DRIVEN DESIGN OF A NEW FOURTH YEAR MSK ELECTIVE
Flemming D., Penn State Hershey Medical Center; Mosher T., Walker E., Bernard S., Brian P., Petscavage J.
(Presented by: Donald Flemming, MD)
Purpose: The new ABR exam has forced programs to consider implementing focused clinical experiences in the fourth
year of residency. The premise is that these experiences will improve the quality of radiologic service in future practice.
The purpose of this presentation is to discuss designing a fourth year elective experience using an organized and data
driven approach.
Method: Former residents that are currently in practice were surveyed to determine what skill sets or diagnoses are most
useful for day−to−day interpretation. The frequency of current and past resident interpretation of exams and specific
diagnoses was obtained from the RIS. This data was then used to determine the goals and objectives of the curriculum.
The goals and objectives were then used to create a curricular template.
Results: Former residents overwhelmingly stated that interpretation of joint based MRI and procedure experience were
the two most important skill sets that were needed for success in private practice. The diagnosis category that former
residents felt should be reinforced before practice was evaluation of arthritis. Information from the RIS showed that
residents have relatively low exposure to cross−sectional MSK examinations, procedures and arthritis diagnoses.
Conclusion: The current MSK curriculum is driven by the need to pass the American Board of Radiology examination
rather than the needs of the average person in private practice. A needs assessment and data from resident clinical
experience may help guide educators with the development of a fourth year curriculum that addresses practical
competencies needed in everyday private practice.
16
Podium #2
UTILIZATION PRACTICES AND CURRENT AWARENESS OF NON TRADITIONAL IMAGING TECHNOLOGIES IN
MSK RADIOLOGY- WHAT WE NEED TO KNOW IN ORDER TO STAY AHEAD OF THE GROWING TURF WARS IN
IMAGING AND WHERE ARE WE HEADED
Smith S.E., Brigham and Women's Hospital, Harvard Medical School
(Presented by: Stacy Smith, MD)
Purpose: Turf wars in radiology have become more prevalent, most predominantly in vascular and cardiovascular
imaging, with progressive interest and growth in the neuroradiology and musculoskeletal arenas. In particular, there are
widely popular technologists, particularly CT or US, initially intended for radiologists which have achieved success with
surgeons and radiation oncologists across the world. The aim of this project was to assess the current state of MSK
radiologist’s awareness and utilization of such technologies and their opinions regarding this issue.
Materials and Methods: This topic is ripe for discussion among the SSR membership. In order to best access the current
state of MSK radiologists’ awareness and utilization of such technologies and this issue, both an online survey as well as
a real time audience response survey presentation at the SSR meeting are utilized. The real time audience response
survey entails smart phone technologies or other audience response technologies (dependent on availability at the time of
the meeting) with anonomized answers available for display and discussion immediately during the presentation. Survey
questions were formulated to extract the following information: the current understanding and use of nontraditional
radiology technologies in radiology (radiology owned and used, radiology and surgery shared owned and use (hybrid
situation), surgery owned and radiology shared use for example) with note of specific examples and positive or negative
feedback if currently in use; the SSR membership's interest or disinterest in using nontraditional mobile technologies in
MSK radiology and for what procedures or studies, as well as their evaluation of what may be an upcoming increase in
turf wars with surgeons and radiation oncologists who use these instruments and their perception of this situation and
potential stop gaps. The live audience response system with its real time interaction and discussion is crucial to the
overall outcome of this study which is also evaluating the utility of audience response systems with regards to
membership/societal issues and hot topics.
Results: Initial pilot survey of 25 MSK radiologists across the country showed increased concern (80%) regarding the
increased use of utilization of nontraditional imaging technologies by surgeons or other physicians with regards to
decreased utilization of their radiology services and radiologist specific expertise and patient outcomes (most
predominantly ultrasound utilization by non radiologists). 10% showed a positive interaction resulting from shared
nontraditional imaging resources between radiology and surgery with a combined (hybrid) educational experience (Mobile
CT technology).
Conclusion: The use of nontraditional imaging technologies by non radiologists is growing. MSK radiologists need to be
aware of the current status and resulting outcomes of this issue. Potential future goals include greater involvement of
radiologists in the utilization of and or education involving these technologies.
17
Podium #3
“FOOL ME TWICE”: DELAYED DIAGNOSES IN RADIOLOGY WITH AN EMPHASIS ON PERPETUATED ERRORS
Mansfield L.T., Brooke Army Medical Center, Kim Y.
(Presented by: Liem Mansfield, MD)
Purpose: Our hypothesis is that delayed diagnoses in radiology are often not recognized on subsequent radiological
examinations and are due to multiple types of diagnostic errors.
Material and Methods: 656 radiological exams with delayed diagnoses were collected from July 2002 to January 2010 at
our institution. Each case was reviewed by two radiologists and the diagnostic errors were classified according to our
modified scheme. When appropriate, more than one type of error was assigned to each case. Data collected include the
number of days elapsed between the initial exam on which the diagnosis was missed and the subsequent exam on which
the correct diagnosis was made, imaging technique on which the diagnosis was missed, imaging technique on which the
correct diagnosis was made, and whether the diagnosis was missed on subsequent radiologic exams.
Results: There were a total of 1279 errors. The range of days elapsed was 0−4611 days, with an average of 251 days.
The number of errors as a percentage of total errors was type 1, 11 (1%); 2, 110 (9%); 3, 39 (3%); 4, 535 (42%); 5, 1 (~
0%); 6, 29 (2%); 7, 69 (5%); 8, 20 (2%); 9, 92 (7%); 10, 288 (22%); 11, 6 (~ 1%); and 12, 79 (6%). The imaging
techniques on which the diagnosis was initially missed were radiography, 354 (54%); CT, 200 (31%); MR, 75 (11%);
nuclear medicine, 18 (3%); and US, 9 (1%). The diagnoses were not recognized on subsequent radiological exams in 196
cases (30%). The imaging techniques on which the diagnosis was subsequently missed were radiography, 118 (60%);
CT, 46 (23%); MR, 17 (9%); nuclear medicine, 13 (7%); and US, 2 (1%). The imaging techniques on which the correct
diagnosis was made were CT, 218 (33%); MR, 205 (31%); radiography, 188 (29%); nuclear medicine, 30 (5%); and US, 8
(1%). In five cases (1%), the correct diagnoses were made at surgery. The errors were found in the following sections:
musculoskeletal, 434 (66%); body imaging, 96 (15%); thoracic, 74 (11%); neuroradiology, 43 (7%); nuclear medicine, 5
(1%); and ultrasound, 4 (1%). 84 of the missed findings (13%) were serendipitous, not expected based on clinical history.
Conclusion: Nearly one−third of delayed diagnoses in radiology were not recognized on subsequent radiological exams.
Under−reading, satisfaction of search, faulty reasoning, and location are the most common types of errors. 7% of missed
findings were found in the “corner”of the film and 13% were serendipitous.
18
Podium #4
*NOVEL CT METAL ARTIFACT REDUCTION PROTOTYPE FOR EVALUATION OF SHOULDER ARTHROPLASTIES:
PRELIMINARY RESULTS
Subhas N., , Shiraj S., Primak A.N., Schils J.P., Krauss A., Polster J.M., Ilaslan H., Iannotti J.P.
(Presented by: Naveen Subhas, MD)
Purpose: Frequency splitting metal artifact reduction (FSMAR) is a new fully automatic and computationally inexpensive
method to reduce metal artifact by combining several techniques including metal segmentation, inpainting, frequency
splitting and spatial weighting. The purpose of this study was to compare FSMAR to standard filtered back projection
(FBP) in the evaluation of patients with shoulder arthroplasties.
Materials and Methods: 5 patients (mean age 56, 4 males, 1 female) with 6 shoulder arthroplasties were scanned on a
Definition Flash CT (Siemens Healthcare, Forchheim, Germany) with a standard clinical protocol (140 kVp, 300 reference
mAs, 0.6 mm collimation, pitch 0.35 − 0.8). Images were reconstructed using FBP at the scanner and FSMAR on a
standalone workstation with the same reconstruction kernel (B30 − smooth) and slice thickness (0.6 mm). 3
musculoskeletal radiologists reviewed blinded images of the two techniques placed side−by−side comparing the image
quality in the bones and soft tissues adjacent to the hardware using a 5 point scale (left image definitely better, left image
slightly better, no difference, right image slightly better, right image definitely better). The degree of streak artifact was
quantified as the absolute difference between the mean within a region of interest (ROI) in the soft tissue and bone on a
slice adjacent to hardware from the mean within an ROI containing similar tissue on a slice without hardware.
Results: In all 6 cases, all the readers graded the soft tissue image quality near the hardware as definitely better with
FSMAR. 2 readers also graded the bone image quality as definitely better with FSMAR in all the cases. 1 reader graded
the bone image quality as definitely better with FSMAR in 5 cases and slightly better with FSMAR in 1 case. The degree
of streak artifact in the soft tissue ranged from 5 HU to 18 HU (10 HU mean) with FSMAR compared to 54 HU to 909 HU
(319 HU mean) with FBP. The degree of streak artifact in the bone ranged from 19 HU to 166 HU (85 HU mean) with
FSMAR compared to 220 HU to 709 HU (383 HU mean) with FBP.
Conclusion: FSMAR technique was superior to the standard FBP technique in the evaluation of shoulder arthroplasties
both qualitatively, in terms of image quality, and quantitatively, in terms of streak artifact, in all cases. A larger, prospective
study is currently underway to validate these preliminary findings.
*Not CME Accredited
19
Podium #5
*3DMR OSSEOUS RECONSTRUCTIONS OF THE SHOULDER USING A GRADIENT-ECHO BASED 2-POINT DIXON
RECONSTRUCTION: A FEASIBILITY STUDY
Gyftopoulos S., NYU Langone Medical Center; New York, NY; Yemin A., Mulholland T., Bloom M., Storey P., Geppert C.,
Recht M.P.
(Presented by: Soterios Gyftopoulos, MD)
Purpose: To create 3DMR osseous models of the shoulder that are similar to 3DCT models using a gradient−echo based
2−point/Dixon sequence.
Materials/Methods: CT/3TMR examinations of 7 cadaveric shoulders were obtained. Glenoid defects were surgically
created in four of the cadaveric shoulders. Each MR study included an axial Dixon 3D dual echo−time T1W FLASH
acquisition. The water−only image data from the Dixon sequence and CT data were post−processed using 3D software.
The following measurements were obtained on the shoulders: surface area, height and width of the glenoid and humeral
head, and transverse width of the biceps groove. The glenoid defects were measured on imaging using the circle method
and compared to measurements made on digital images of the glenoids using a revised glenoid bare spot method
(reference standard). Paired T−tests/ANOVA were used to assess the differences between the imaging modalities.
Results: The average differences between the glenoid and humeral measurements were not statistically significant (cm):
glenoid surface area 0.12±0.04(p=0.45) and glenoid width 0.13±0.06(p=0.06) with no difference in glenoid height
measurement; humeral head surface area 0.07±0.12(p=0.42), humeral head height 0.03±0.06(p=0.42), humeral head
width 0.07±0.06(p=0.18), and biceps groove width 0.02±0.01 (p=0.07).
The mean/standard deviation difference between the reference standard and 3DMR measurements of the glenoid defects
was 0.25 ± 0.96%/0.30±0.14 mm. The mean/standard deviation difference between the reference standard and 3DCT
measurements of the glenoid defects was 0.25±0.96%/0.75±0.39 mm. There was no statistical difference between the
measurements obtained on 3DMR and 3DCT (%, p= 0.45; mm, p= 0.20).
Conclusion: Accurate 3D osseous models of the shoulder can be produced using a 3D 2−point/Dixon sequence and can
be added to MR examinations with a minor increase in imaging time. The 3DMR model can be used to quantify glenoid
loss and may eliminate the need for pre−surgical CT examinations.
*Not CME Accredited
20
Podium #6
UTILITY OF POSTCONTRAST SUBTRACTION MR IMAGING IN THE EVALUATION OF PERIPROSTHETIC
PSEUDOTUMOR IN PATIENTS WITH METAL-ON-METAL HIP PROSTHESES
Otto T.M., Mayo Clinic; Bestic J.M., Peterson J.J., Garner H.W., Dave H.K.
(Presented by: Tara Otto, MD)
Purpose: To describe the utility of postcontrast subtraction MR imaging for the evaluation of periprosthetic pseudotumors
in patients with metal−on−metal hip prostheses.
Materials and Methods: Postcontrast subtraction MR examinations of a total of 11 hips in 9 patients with
metal−on−metal hip prostheses who underwent imaging for clinically suspected periprosthetic pseudotumor were
retrospectively reviewed. The review was performed in consensus by three fellowship trained musculoskeletal
radiologists. Subtraction images were generated by digitally subtracting precontrast from postcontrast T1−weighted
sequences utilizing commercially available postprocessing software. Imaging features of pseudotumors on subtraction
images were compared with those of standard pre− and postcontrast sequences employing metal artifact reduction
techniques. The size, location, capsular thickness and enhancement characteristics of the pseudotumors were recorded,
as was the presence/extent of associated devitalized soft tissue or bone.
Results: MR examinations including subtraction images were available in a total of 9 patients (5 male, 4 female). Patient
ages ranged from 48−72 years (mean 63.2). Bilateral hips were evaluated in 2 patients for a total of 11 hips. All 11 hips
evaluated for metal−on−metal prosthesis related pseudotumor demonstrated evidence of abnormal periprosthetic
collections on both standard and subtraction MR sequences. All pseudotumors were centered at the level of the neck of
the femoral component, with 8 of 11 (73%) collections extending into the surrounding soft tissues, most often into the
posterior or lateral tissues. Pseudotumors ranged in size from 3.1 cm – 23.3 cm (mean 11.0 cm). Enhancement was
evident in all cases, although confined to a peripheral rind/capsule. Capsular thickness ranged from 2 mm − 6 mm (mean
3.3 mm). Subtraction images revealed periprosthetic soft tissue necrosis in 8 (73%) cases and bone necrosis in 2 (18%)
cases. Subtraction images confirmed the avascular nature of internal nodularity/debris, which was present in 4 (36%)
cases. The full extent of periprosthetic pseudotumor was subjectively better depicted on subtraction images in comparison
with routine sequences in 6 (55%) cases.
Conclusion: Postcontrast subtraction MR imaging is useful in the characterization of periprosthetic pseudotumors,
particularly in defining the full extent of the lesion and in assessing for devitalized soft tissue and bone.
21
Podium #7
PRE-OPERATIVE EVALUATION OF PATIENTS UNDERGOING KNEE ARTICULAR CARTILAGE DEFECT REPAIR:
MRI 3D THICKNESS MAPS DERIVED FROM A VALIDATED, AUTOMATED SEGMENTATION PLATFORM - INITIAL
RESULTS
Brandser E., Radiology Association of N KY; Farber J., Tamez-Pena J., Holladay B., Larkin J., Heis F.
(Presented by: Eric Brandser, MD)
Objectives: To present a robust, automated MR imaging methodology that generates 3D articular cartilage (AC)
thickness maps of the knee, and which delineates the size and location of AC defects, as well as the thickness and
integrity of the defect walls, to serve as an accurate pre−operative guide for AC defect repair.
Methods: A sagittal 3D FSE FS sequence (TR−2300; TE−20) is obtained on all patients undergoing routine 1.5T MRI
(Optima 450W, GE, Milwaukee) of the knee at our facility. These 3D FSE data sets are sent to a dedicated work station
(Qmetrics Technologies, Rochester, NY), which automatically segments the knee AC. The segmented images are then
reviewed by a radiologist for accurate fit with the source images. If necessary, edits can be made on the dedicated work
station to ensure proper segmentation. The methodology of this process has been validated (1). From the segmented
data sets, 3D AC thickness maps are generated automatically. These thickness maps are then reviewed by the radiologist
for accuracy, compared to the source images. In patients who underwent subsequent AC defect repair, intra operative
measurements and images were obtained of the AC defect size and location. The intra operative, gold standard data were
then compared with the prospectively obtained thickness maps to assess accuracy of lesion size and location.
Results: Initial results (N=9) validate the accuracy of the thickness maps in delineating AC defect size and location(MR
and sx images and charts available). In addition, the thickness maps accurately delineated the integrity of the AC defect
walls, allowing for acurate surgical debridement and pre−operative planning for graft material allocation. In no case to
date did the thickness maps miss an AC defect of the segmented regions.
Conclusion: In our initial experience, 3D thickness maps of knee AC defects accurately detect and delineate AC defects,
and are a clinically useful pre−operative tool. In addition, these automatically generated maps,, which canbe displayed
along any axis, are useful in patient−physician discussions when discussing treatment options. Further work is required to
obtain statistical validation. Further work will include also the use of T2 maps, with the thickness maps as a
template(images avaiable), to further assess the health of the AC surrounding a defect (2), to optimize further intra
operative wall debridement and graft material allocation.
22
Podium #8
CARPAL KINEMATICS FROM DYNAMIC WRIST MRI DURING ACTIVE RANGE OF MOTION
Boutin R.D., UC Davis, Sacramento, CA; Ashwell Z., Immerman I., Szabo R., Sonico G.J., Buonocore M., Chaudhari A.
(Presented by: Robert Boutin, MD)
Purpose: Carpal instability is defined by loss in normal bone alignment, and is a common clinical problem that can be
challenging to diagnose. Our goal was to investigate the use of dynamic MRI during active wrist motion in order to assess
carpal kinematics. Specifically, our objectives were to measure distal radioulnar joint (DRUJ) congruity, extensor carpi
ulnaris (ECU) tendon location, scapholunate (SL) gap, radiolunate (RL) angle, and lunocapitate (LC) angle during active
wrist motion, using dynamic MRI techniques.
Materials and Methods: 10 wrists (6 right, 4 left) of 6 asymptomatic volunteers (4 women, 2 men; mean age of 35 years)
were scanned on a 3−T MRI system [Trio Trim, Siemens], utilizing a TrueFISP pulse sequence during active
supination/pronation, radial/ulnar deviation, a dynamic “clenched fist”maneuver, and volarflexion/dorsiflexion. Each
TrueFISP series of 60 images were acquired during real time wrist motion over 28.5 seconds, with a temporal resolution
of 475 ms per image and an in−plane resolution of 0.94 x 0.94mm2. Two experienced observers (fellowship−trained
musculoskeletal radiologist and orthopedist subspecializing in hand/wrist surgery, by consensus) recorded multiple
measurements, including: [i] DRUJ congruity (determined by subluxation ratio method) and translation of the ECU tendon
on axial images in neutral, pronation and supination; [ii] the SL gap on coronal images in neutral, clenched fist, radial and
ulnar deviation positions; and [iii] the RL and LC angles on sagittal images in neutral and dorsiflexion.
Results: The mean DRUJ subluxation ratios were 0.11 (range 0.056−0.17) in neutral, 0.16 (0.095−0.21) in pronation, and
0.054 (0−0.17) in supination for the right wrist. For the left wrist, these values were 0.08 (range 0.06−0.13) in neutral, 0.1
(range 0.05−0.125) in pronation, and 0.05 (range 0−0.06), respectively. The ECU tendon was perched or translated out of
its groove in the right and left wrist of 5/6 and 3/4 hands respectively in supination and 2/6 and 1/4 hands respectively in
pronation. The mean SL gap was 1.4 mm for both wrists in the neutral position (range 1−2mm), with unchanged results
during clenched fist, radial deviation, and ulnar deviation. The mean RL angle measured 0 degrees in neutral and 22
degrees in dorsiflexion for the right wrists, while the mean LC angle was 9 degrees in neutral and 21 degrees in
dorsiflexion.
Conclusion: The TrueFISP pulse sequence allowed for real time image acquisition during active wrist motions. We
conclude that dynamic MRI is capable of measuring parameters associated with wrist kinematics during active motion,
and postulate that such metrics may supplement the static images acquired during a routine wrist MRI exam when
evaluating for carpal instability.
23
Monday, March 18, 2013
General Sessions located In Hill Country D – G unless otherwise noted.
7:00 a.m. – 7:55 p.m.
Industry Sponsored Breakfast
Location: Hill Country A – C
7:00 a.m. – 12:30 p.m.
Registration / Information Desk Open
Location: Hill Country Foyer
8:00 a.m. – 12:30 p.m.
Exhibit Hall Open
Location: Hill Country A – C
7:00 a.m. – 12:30 p.m.
ePoster Session*
Location: Hill Coutnry A – C
(See page 150 for full information)
*As this session is not moderated, ePosters are not CME accredited
8:00 a.m. – 10:00 a.m.
Knee Session
Moderators: David C. Salonen, MD, FRCPC
William B. Morrison, MD
8:00 a.m.
#9
MRI CHARACTERISTICS OF HEALED AND UNHEALED PERIPHERAL VERTICAL
MENISCAL TEARS
Kijowski R., University of Wisconsin; Rosas H., Cheung A., Lee K., Munoz del Rio A.,
Graf B.
(Presented by: Richard Kijowski, MD)
8:20 a.m.
#10
THE MENISCAL OSSICLE: IS IT RELATED TO MENISCAL ROOT TEAR?
Palisch A., Thomas Jefferson University; Khan W., Long S., Zoga A., Khoury V., Morrison W.
(Presented by: Andrew Palisch, MD)
8:40 a.m.
#11
JUVENILE OSTEOCHONDRITIS DISSECANS: CORRELATION OF FINDINGS ON
HISTOLOGY AND MRI
Zbojniewicz A.M., Cincinnati Childrens Hospital Medical Center; Laor T., Stringer K.F.,
Wall E.J.
(Presented by: Andrew Zbojniewicz, MD)
9:00 a.m.
#12
ABNORMALITIES OF THE QUADRICEPS CONTINUATION ON MRI:
DIFFERENTIATING PATHOLOGIC FROM AGE RELATED FINDINGS
Umans H., Lenox Hill Radoilogy & Imaging Associates, PC; Leb J., Wilde G.
(Presented by: Hilary Umans, MD)
9:20 a.m.
#13
RADIOGRAPHIC DIAGNOSIS OF TRANSIENT LATERAL PATELLAR DISLOCATION:
WHAT HAVE WE BEEN MISSING?
Mansfield L.T., Brooke Army Medical Center; Chabak M., O'Brien S.D., Chen D.C.
(Presented by: Liem Mansfield, MD)
9:40 a.m.
#14
TT-TG DISTANCE MEASUREMENTS ON KNEE MRI: ERROR ANALYSIS AND
CORRECTION
Boutin R.D., UC Davis, Sacramento, CA; Yao L.
(Presented by: Robert Boutin, MD)
10:00 a.m. – 10:05 a.m.
Case of the Day
55-Year-Old Man with Bilateral Ankle Pain and Swelling
Lien Senchak, MD
24
Monday, March 18, 2013
10:05 a.m. – 10:30 a.m.
Break – Visit Exhibit Hall
Location: Hill Country A – C
10:30 a.m. – 12:30 p.m.
Hip / Lower Extremity Session
Moderators: Hilary R. Umans, MD
Suzanne Long, MD
10:30 a.m.
#15
GLUTEAL MUSCLE ATROPHY: NATURAL HISTORY AND ASSOCIATION WITH HIP
FRACTURE IN OLDER INDIVIDUALS
Long S.S., Thomas Jefferson University Hospital; Chi A.S., Zoga A.C., Morrison W.B.
(Presented by: Suzanne Long, MD)
10:50 a.m.
#16
CORRELATION OF ULTRASOUND-GUIDED CORTICOSTEROID INJECTION OF THE
QUADRATUS FEMORIS WITH MRI FINDINGS OF ISCHIOFEMORAL IMPINGEMENT
Backer M.W., University of Wisconsin School of Medicine and Public Health, Madison,
WI; Lee K.S., Blankenbaker, D.G., Kijowski R., Keene J.S.
(Presented by: Matthew Backer, MD)
11:10 a.m.
#17
RAPIDLY PROGRESSIVE OSTEOARTHRITIS: A REVIEW OF CLINICAL AND
IMAGING FEATURES IN 23 PATIENTS
Ganson G., Penn State Hershey Medical Center, Hershey, PA; Bernard S.A., Walker
E.A., Petscavage J.M., Brian P.M., Flemming D.J., Mosher T.J.
(Presented by: George Ganson, MD)
11:30 a.m.
#18
ANATOMIC VARIATIONS OF FEMORAL NERVES ON HIGH RESOLUTION 3 TESLA
MAGNETIC RESONANCE NEUROGRAPHY AND THEIR RELATION TO ABNORMAL
NERVE AND MUSCLE IMAGING FINDINGS
Aro M.R., JHU; Chhabra A.
(Presented by: Michael Aro, MD)
11:50 a.m.
#19
*MRI EVALUATION OF CONCURRENT CHRONIC EXERTIONAL COMPARTMENT
SYNDROME OF THE LOWER EXTREMITY AND POPLITEAL ARTERY
ENTRAPMENT
Haas J.P., Mayo Clinic, Rochester, MN; Howe B.M., Litwiller D.V., Felmlee J.P., Young
P.M., Ringler M.D., Amrami K.K.
(Presented by: John Haas)
*Not CME Accredited
12:10 p.m.
#20
MAGNETIC RESONANCE IMAGING OF SECOND METATARSOPHALANGEAL
JOINT PLANTAR PLATE TEAR AND ITS RELATIONSHIP TO LESIONS IN THE
SECOND INTERMETATARSAL SPACE
Umans H., Lenox Hill Radiology & Imaging Associates, PC; Elsinger E., Srinivasan R.,
Wilde G.
(Presented by: Hilary Umans, MD)
12:30 p.m. – 12:35 p.m.
Case of the Day
27-Year-Old Man with Progressive Knee Pain
Christopher J. Hanrahan, MD, PhD
1:00 p.m. – 3:00 p.m.
Musculoskeletal Ultrasound Hands-On Workshop: Shoulder
*Separate Registration Required
(See page 194 for full information)
Co-Moderators/Organizers: Jon A. Jacobson, MD, Yoav Morag, MD
Instructors: Meg Chiavaras, MD, PHD, Joseph Craig, MB, ChB, Gina DiPrimio, MD,
David Fessell, MD, Katrina Glazebrook, MB, ChB, Kenneth Lee, MD, Suzanne Long, MD,
Jonathan Luchs, MD, Mihra Taljanovic, MD, Corrie Yablon, MD
Location: Bandera
7:00 p.m. – 10:00 p.m.
Annual Banquet
Location: The Lawn
25
Podium #9
MRI CHARACTERISTICS OF HEALED AND UNHEALED PERIPHERAL VERTICAL MENISCAL TEARS
Kijowski R., University of Wisconsin; Rosas H., Cheung A., Lee K., Munoz del Rio A., Graf B.
(Presented by: Richard Kijowski, MD)
Purpose: To determine the magnetic resonance imaging (MRI) characteristics of surgically confirmed healed and
unhealed peripheral vertical meniscal tears (PVMT).
Methods: The study group consisted of 64 patients who had 86 PVMT diagnosed prospectively by a musculoskeletal
radiologist during the official interpretation of the MRI examination and retrospectively confirmed by two additional
musculoskeletal radiologists. All patients had a history of knee injury, had subsequent arthroscopic knee surgery
performed within 6 months of their knee injury, and had no recurrent episodes of knee injury or instability between the
time of MRI examination and surgery. The MRI examinations of all 64 patients were retrospectively reviewed by 2
musculoskeletal radiologists to identify the following MRI characteristics of the PVMT: 1) location of tear (at or not at the
meniscocapsular junction), 2) width of tear on intermediate−weighted images (1 mm or less or greater than 1 mm), 3)
number of consecutive intermediate−weighted images on which tear was visualized, 4) tear extending through one or both
surfaces of meniscus on intermediate−weighted images, 5) tear visualized on intermediate−weighted images only or both
intermediate and T2−weighted images, 6) T2 signal of tear (intermediate, bright, or fluid signal), and 7) presence of
strands of low T2 signal bridging tear. Chi−square tests and logistic regression tests were used to compare patient age
and gender, time between injury and MRI examination, and time between injury and surgery for healed and unhealed
PVMT. Multivariate logistic regression models were used to determine whether MRI characteristics of the PVMT could
help distinguish between healed and unhealed tears at surgery taking into account the potential confounding factors of
patient age and gender, time between injury and MRI examination, and time between injury and surgery.
Results: There were 32 healed and 54 unhealed PVMT at surgery. There was no significant difference between healed
and unhealed PVMT in patient age (p=0.18) or gender (p=0.24), time between injury and MRI examination (p=0.64), and
time between injury and surgery (p=0.20). Tear location was the most significant factor (p<0.001) distinguishing between
healed and unhealed PVMT with almost all tears (94%) located at the meniscocapsular junction being healed and most
tears (77%) not located at the meniscocapsular junction being unhealed. For PVMT not located at the meniscocapsular
junction, the MRI characteristics that were significantly associated with healed tears included strands of low T2 signal
bridging tear (p<0.001), width of tear less than 1 mm (p=0.02), tear visualized only on intermediate−weighted images
(p=0.04), and intermediate or bright T2 signal of tear (p=0.07).
Conclusions: Almost all PVMT at the meniscocapsular junction spontaneously heal, while most PVMT not located at the
meniscocapsular junction do not heal. The MRI characteristics of PVMT not located at the meniscocapsular junction can
help distinguish between healed and unhealed tears with the presence of strands of low T2 signal bridging the tear being
the most useful predictor of healing.
26
Podium #10
THE MENISCAL OSSICLE: IS IT RELATED TO MENISCAL ROOT TEAR?
Palisch A., Thomas Jefferson University; Khan W., Long S., Zoga A., Khoury V., Morrison W.
(Presented by: Andrew Palisch, MD)
Purpose: The purpose of this study was to characterize meniscal ossicles and their association with posterior meniscal
root tears on MRI.
Materials and Methods: A retrospective study was performed by searching a database of all MRIs performed at a single
institution over a five year period for the term ‘meniscal ossicle’. Images were evaluated by two reviewers in consensus to
confirm the presence of a meniscal ossicle and associated features including location, presence and type of meniscal
tear, extrusion, and cartilage loss.
Results: Database search revealed 24 knee MRIs with the presence of a meniscal ossicle. Three cases were excluded
from the study as they did not represent meniscal ossicles in retrospective evaluation. The mean patient age was 55
(range 23−82) with nearly equal sex distribution (F:M 11:10). All meniscal ossicles were located in the posterior horn, with
the medial meniscus involved in nearly all cases (medial:lateral 20:1). All meniscal ossicles were associated with tears of
the posterior horn (complex:radial 12:9). The meniscal ossicles were located either at the tear site (10/21) or adjacent to
the tear site in the meniscus (11/21). Nearly all meniscal tears were associated with medial extrusion (19/21 with an
average distance of 4.7mm) and cartilage loss (17/21). One patient in our study (age 23) presented with an ACL tear and
posterior root tear without a meniscal ossicle. However, three years later on a follow−up MRI the patient had developed a
meniscal ossicle adjacent to the tear, suggesting post traumatic ossification as the origin.
Conclusions: A meniscal ossicle is a rare finding on knee MRIs. However, all were associated with posterior root
meniscal tears in this study. If a meniscal ossicle is seen on a knee MRI then a search for a posterior root tear should be
undertaken.
27
Podium #11
JUVENILE OSTEOCHONDRITIS DISSECANS: CORRELATION OF FINDINGS ON HISTOLOGY AND MRI
Zbojniewicz A.M., Cincinnati Childrens Hospital Medical Center; Laor T., Stringer K.F., Wall E.J.
(Presented by: Andrew Zbojniewicz, MD)
Purpose: To correlate MRI findings with histologic specimens from children diagnosed with juvenile osteochondritis
dissecans (JOCD).
Materials and Methods: Five patients (age range 11−16 years) with JOCD of the medial femoral condyle (MFC)
underwent core biopsy by one orthopedic surgeon (EJW) during surgical treatment. Time interval between MRI and
biopsy ranged from 1 month to 5 months. Site of biopsy within each JOCD lesion was determined by consensus through
review by the orthopedic surgeon and two radiologists (one pediatric musculoskeletal radiologist and one
fellowship−trained musculoskeletal radiologist) (AMZ, TL) of subsequent imaging studies (CT, MRI) showing the site
and/or by review of arthroscopic pictures, videos, and intraoperative fluoroscopic images.
Two radiologists blinded to the histologic findings described below, reviewed the magnetic resonance imaging (MRI)
findings at the site of biopsy and recorded: a) thickness of articular and unossified epiphyseal cartilage, b) presence of a
thin fluid signal layer between unossified epiphyseal cartilage and subchondral bone, c) presence of cyst−like foci, d)
thickness of a high T2 signal layer in subchondral bone. A single pathologist (KFS) independently reviewed the biopsy
specimens and recorded: a) thickness of core sample, b) thickness of cartilage from the articular surface, c) presence and
location (relative to cartilage and bone) of any cleft, d) presence and length of fibrous tissue layer. Comparison was made
between the MRI and histologic findings.
Results: Histologic analysis revealed abnormal thickening of articular and unossified epiphyseal cartilage with
chondrocyte cloning. Loose fibrovascular tissue was often present directly beneath the cartilage layer. Focal separation
was present between bone and cartilage in several specimens. Thickening of cartilage on histology of the JOCD sample
had direct correlation with findings at MRI. Additionally, areas of loose fibrovascular tissue corresponded to areas of high
signal on T2−weighted images in the subchondral bone. Bone necrosis and acute inflammation was not a major
component in the specimens.
Conclusion: Distinct correlation is observed between findings on histology and findings at MRI in JOCD lesions of the
knee.
28
Podium #12
ABNORMALITIES OF THE QUADRICEPS CONTINUATION ON MRI: DIFFERENTIATING PATHOLOGIC FROM AGE
RELATED FINDINGS
Umans H., Lenox Hill Radoilogy & Imaging Associates, PC; Leb J., Wilde G.
(Presented by: Hilary Umans, MD)
Purpose: To report variations in morphologic distortion of the Quadriceps Continuation (QC) as identified by MRI and
differentiate between abnormalities that are age related and those which are not.
Materials and Methods: 36 knee MRI with abnormalities of the QC were compiled prospectively from one PACS
database (7/10−8/12). 70 additional consecutive knee MRI studies were retrospectively compiled, blinded to findings and
clinical indication (6−9/12). 58 males and 48 females were included (13−71 years old, mean = 42, median=43). All MRI
(1.5 or 3.0T) included Sagittal PD, T2−Fat Saturated (fs) and Axial T2fs images. Images were assessed qualitatively for
QC thickening, delamination, contour defects +/−extension of these abnormalities into adjacent structures including: the
superficial quadriceps tendon, patellar tendon and patellar retinaculum. A grading system was introduced to group cases
with similar patterns of morphologic distortion of the QC. The electronic medical record was reviewed. Pearson's
chi−squared test, Student's t−test and Fisher’s exact test were used to analyze the data.
Results: There is significant association between anterior knee pain and any contour defect in the QC (P< 0.001,
chi−squared test) without a confounding association with CMP or patellar maltracking. A borderline association between
anterior knee pain and extension into the patellar tendon +/− contour defect was noted (P=0.07, Fisher’s exact test).
Although extension into the quadriceps tendon, simultaneous extension into both the quadriceps and patellar tendon, and
extension into the patellar retinaculum did not show statistical associations, this may be due to small sample size causing
limited power. There is significant association between advancing age and isolated delamination of the QC without
contour defect in those older than the median age of 43 (P=0.01, t−test). Those with isolated QC delamination without
contour defect were less likely to present with anterior knee pain (P=0.04, Fisher’s exact test). A normal appearing QC
was significantly associated with younger age (P= 0.006, t−test) and were on average 7.6 years younger than those with
distortion of the QC. There was no association demonstrated between gender and any grade.
Conclusions: Morphologic distortion of the QC is common. Isolated delamination of the QC appears age related and
likely degenerative, not significantly associated with anterior knee pain. Contour defects along the course of the QC occur
independent of advancing age and should be reported as they correlate with anterior knee pain. Extension into the
patellar tendon is presumably also pathologic and may correlate with anterior knee.
29
Podium #13
RADIOGRAPHIC DIAGNOSIS OF TRANSIENT LATERAL PATELLAR DISLOCATION: WHAT HAVE WE BEEN
MISSING?
Mansfield L.T., Brooke Army Medical Center; Chabak M., O'Brien S.D., Chen D.C.
(Presented by: Liem Mansfield, MD)
Purpose: Our hypothesis is that transient lateral patellar dislocation (TLPD) is often not recognized on radiography.
Materials and Methods: We retrospectively reviewed the initial knee radiographs of 44 patients diagnosed with TLPD by
MR (n = 39), CT (n = 1), and orthopedic surgeon (n = 4). The following data were collected: effusion, osteochondral
fracture, intraarticular body or “sliver sign”, medial patellar facet avulsion, lateral patellar translation, sulcus angle, lateral
patellofemoral angle, trochlear depth and Blackburne−Peel (B−P) index.
Results: There were 29 men and 15 women. The age ranges from 11 to 50 years with a mean of 20. The number of days
between radiographic and MR exams ranges from 0 to 892 days, mean 81 days. 37 (84%) patients had effusion greater
than 10 mm, range 0−38 mm. There were 18 (41%) osteochondral fractures, 16 (36%) intraarticular bodies and 18 (41%)
medial patellar facet avulsions. The mean lateral patellar translation was 5 mm, range 0−28 mm. 7 of 39 patients (18%)
had a sulcus angle > 1450. 2 of 38 patients (5%) had a positive lateral patellofemoral angle. The average trochlear depth
was 5 mm, range 1−10 mm. B−P index was low (patella alta) in 4, high (patella baja) in 13 and normal in 27 patients. 10
cases (23%) of TLPD were diagnosed on radiography.
Conclusions: 77% of patients with TLPD were not recognized on radiography. In the acute setting, the radiographic
diagnosis of TLPD can be suggested if there is a knee effusion greater than 10 mm and one of the following findings: an
intraarticular body or “sliver sign”, a medial patellar facet avulsion, an ostechondral fracture in the medial patellar facet or
lateral femoral condyle, or lateral patellar translation greater than 5 mm. In the absence of effusion, TLPD can be
diagnosed if there is a total of three of the other listed common findings. Using these criteria, we found that up to 82% of
cases of TLPD could have been diagnosed on knee radiographs. Although the radiographic findings of TLPD can be
subtle, close attention to these findings can lead to earlier diagnosis and prompt referral to the orthopedic surgeon or
follow up MRI for confirmation.
30
Podium #14
TT-TG DISTANCE MEASUREMENTS ON KNEE MRI: ERROR ANALYSIS AND CORRECTION
Boutin R.D., UC Davis, Sacramento, CA; Yao L.
(Presented by: Robert Boutin, MD)
Purpose: The tibial tubercle − trochlear groove (TT−TG) distance has gained popularity as a useful metric in the
assessment of patellofemoral dysfunction, and is routinely measured on axial MRI and CT scans. However, not all
“axial”images are created equal. Some facilities acquire axials aligned to the knee joint line (type 1 or “anatomic”); other
facilities acquire “straight”axials that are perpendicular to the z−axis of the scanner bore or table top, regardless of knee
positioning (type 2 or “uncorrected”). The latter technique can result in “obliqued axials”when the lower extremity is
positioned in abduction or adduction. This investigation examines the potential error in TT−TG measurements caused by
variance in lower extremity positioning for MRI, as well as potential solutions.
Methods: Isotropic 3D TSE studies of the fully extended knee (3 Tesla, 0.6 mm3 voxel size) were acquired in 12 healthy
subjects. Images for these studies were reformatted in: [i] the “anatomic”axial plane; [ii] the “uncorrected”axial plane; and
[iii] axial planes that simulate 5 degrees of hip adduction and abduction. A method for correcting the TT−TG value to
account for variable axial scan orientation was developed, based on measurements of relative abduction or adduction, the
intercondylar angle, and the vertical distance between the TT and TG landmarks.
Results: The average deviation between the “anatomic”axial plane from the “uncorrected”axial plane of the knee joint was
5 degrees abduction (sd=2.3). The TT−TG distance measured on “uncorrected”axial images was consistently greater than
the TT−TG measured on “anatomic”axial images (mean difference = 3.1 mm, sd=2.1, or 23%, sd=14%). Five degrees of
simulated hip abduction was associated with a mean increase in the TT−TG distance of +38% (sd=17%), while 5 degrees
of simulated hip adduction was associated with a mean decrease in the TT−TG distance of −50% (sd=40%). The
correction method reduced the error in the observed TT−TG distance by a median of 75% and 73% in cases of simulated
hip abduction and adduction, respectively.
Conclusion: The TT−TG measurement is potentially sensitive to small changes in knee positioning. Although
“anatomic”axial images facilitate standardized TT−TG measurements, the TT−TG metric should be interpreted with
caution if the orientation of axial image acquisition is not rigorously standardized or corrected. The potentially misleading
measurements on “uncorrected”axial images can be corrected by taking three additional measurements that enables
normalization to a standard knee orientation.
31
Podium #15
GLUTEAL MUSCLE ATROPHY: NATURAL HISTORY AND ASSOCIATION WITH HIP FRACTURE IN OLDER
INDIVIDUALS
Long S.S., Thomas Jefferson University Hospital; Chi A.S., Zoga A.C., Morrison W.B.
(Presented by: Suzanne Long, MD)
Purpose: To determine an association between fall−related fractures and gluteus medius and minimus atrophy.
Methods: A retrospective study of CT images of 64 patients with fall−related fractures and 96 age− and gender−stratified
controls was performed to evaluate for gluteal muscle atrophy. Inclusion criteria for subjects include: acute hip or pelvic
fracture, recent fall, and age > 50 years old. Exclusion criteria for subjects include: non−fall trauma, hip prosthesis, and
pathological or nonacute hip/pelvic fracture. Inclusion criteria for controls include: age > 50 years old. Exclusion criteria for
controls include: recent fall, hip or pelvic fracture, or hip prosthesis. The gluteus medius, gluteus minimus, and psoas
muscles were scored on a 0−4 scale using the Goutallier scale for fatty muscle atrophy. Unpaired 2−sided Student’s
t−test was used to analyze atrophy in the fracture versus control groups. Paired t−test was used to analyze atrophy on the
ipsilateral versus contralateral sides in the fracture group.
MR Imaging of patients with greater trochanteric bursitis and gluteus medius/minimus tendon pathology will also be
analyzed to determine the natural history of this finding.
Results: There is a significant difference (p<0.01) in mean combined atrophy scores (mean ±SD) for the gluteus
medius/minimus muscles in the fracture group (2.04 ± 0.99) versus control group (1.42 ± 1.17). Mean atrophy scores are:
gluteus medius fracture group (1.55 ± 0.81), gluteus medius control group (0.83 ±0.78), gluteus minimus fracture group
(2.52 ± 0.96), gluteus minimus control group (2.02±1.20). There is no significance difference (p=0.19) in mean psoas
atrophy scores between the fracture group (0.15 ± 0.58) versus control group (0.08 ± 0.31). In both groups, atrophy
increased with advancing age above age 60. For single−sided fractures, there is a significant difference (p<0.01) in mean
gluteus medius atrophy on the ipsilateral side (1.67 ± 0.72) versus contralateral side (1.42 ± 0.78). There is no significant
difference between ipsilateral and contralateral gluteus minimus atrophy (p=0.78) or combined gluteus medius/minimus
atrophy (p=0.06) in single−sided fractures.
Conclusion: Gluteus medius/minimus muscle atrophy increases with age above age 60. Atrophy of these hip rotators
and abductors is greater in patients with fall−related hip and pelvic fractures than in controls, suggesting that this may
predispose to falls in the elderly. Given that tendon tear is a prelude to atrophy, more aggressive therapy could potentially
be useful to prevent subsequent falls in patients presenting with gluteus medius or minimus tears.
32
Podium #16
CORRELATION OF ULTRASOUND-GUIDED CORTICOSTEROID INJECTION OF THE QUADRATUS FEMORIS WITH
MRI FINDINGS OF ISCHIOFEMORAL IMPINGEMENT
Backer M.W., University of Wisconsin School of Medicine and Public Health, Madison, WI; Lee K.S., Blankenbaker, D.G.,
Kijowski R., Keene J.S.
(Presented by: Matthew Backer, MD)
Purpose: MRI findings of ischiofemoral impingement (IFI) have been recently described, but there is little evidence for
treatment with ultrasound (US)−guided corticosteroid injection. The purpose of this study is to evaluate the effectiveness
of US−guided corticosteroid injection of the quadratus femoris muscle as a treatment for IFI syndrome and to correlate
MRI findings with injection outcome.
Materials and Methods: IRB approval was obtained. 54 patients with hip pain that had an MRI bony pelvis were
retrospectively reviewed. 15 with MRI findings and clinical confirmation of pain relating to IFI were included; 10 US−guided
corticosteroid injections of the quadratus femoris in six patients from February 16, 2011 to September 13, 2012 and nine
controls with MRI findings of IFI without US−guided injection. Quadratus femoris muscle edema and fat atrophy were each
graded from none to severe (grade 0 – 3). The distance of the ischiofemoral (IFS) and quadratus femoris space (QFS)
was also measured.
Clinical presentation was classified as typical, somewhat typical, or not typical of IFI. Injection effectiveness was
determined by reported pain reduction assessed before, immediately after, and 2−weeks post−procedure using a
standard 10 cm visual analog scale (VAS). Response to treatment was classified as good (reduction in pain level > 2),
mild/partial (reduced by 1−2), or no improvement. For unreturned pain diary sheet, injection effectiveness was determined
by qualitative assessment in clinic notes. A Kruskal−Wallis rank sum test was used to compare effectiveness of injection
between each group (p < 0.05). Fisher’s exact test was used to evaluate for association between each MRI finding and
injection outcome.
Results: 10 patients were included in the injection group (mean age 52, range 35−66) and nine patients were included in
the control group (mean age 46,range 18−62). All patients in both groups were female. For the injection group, mean IFS
was 14mm (range 10−18mm), mean QFS was 7mm (range 5−10mm), mean edema grade was 1.2 (range 1−2), and
mean atrophy grade was 1.3 (range 0−3). For the control group, mean IFS was 14mm (range 9−22mm), mean QFS was
8mm (range 4−15mm), mean edema grade was 1.8 (range 1−3), and mean atrophy grade was 1.4 (range 0−3). No
statistical difference between the two groups before treatment. Pain reduction after injection over the 2−week period was
statistically significant with a mean reduction of 1.6 (range 1−2) for the injection group and 0.7 (range 0−2) for the control
group, (p <0.02). 6/10 (60%) of the injections provided good relief, 4/10 (40%) provided mild relief, and 0/10 (0%) provided
no relief. No correlation was found between MRI findings and response to US−guided injection (p = 0.496). In the control
group, 2/9 (22%) had good relief, 2/9 (22%) had mild relief, and 5/9 (56%) had no relief (p<0.05).
Conclusion: US−guided corticosteroid injection of the quadratus femoris shows promise as an effective treatment option
for IFI syndrome. However, larger longitudinal studies are needed to help establish the role of US−guided injection in the
workup and care of patients presenting with both MRI and clinical findings of IFI.
33
Podium #17
RAPIDLY PROGRESSIVE OSTEOARTHRITIS: A REVIEW OF CLINICAL AND IMAGING FEATURES IN 23 PATIENTS
Ganson G., Penn State Hershey Medical Center, Hershey, PA; Bernard S.A., Walker E.A., Petscavage J.M., Brian P.M.,
Flemming D.J., Mosher T.J.
(Presented by: George Ganson, MD)
Purpose: Rapidly progressive osteoarthritis of the hip is a rare syndrome of unknown etiology described in case reports
and small case series in the literature. This study evaluates the clinical and radiologic features of rapidly progressive
osteoarthritis of the hip.
Materials and Methods: A retrospective review was conducted of patient demographics, clinical presentation, synovial
fluid examination, imaging features and femoral head histopathology in 23 cases clinically and radiologically diagnosed as
rapidly progressive osteoarthritis of the hip. Radiographic diagnosis was based on the prior published criteria of 2mm or
50% joint space loss in a year. Hip aspiration was performed in 39% of patients. Radiologic studies were reviewed by
consensus by 3 musculoskeletal radiologists and included radiographs (n=23), CT (n=7) and MRI (n=7).
Results: Patients with rapidly progressive osteoarthritis (RPO) of the hip included ten females and thirteen males ranging
in age from 39.6 – 93.6 years of age (mean 64.8 years). The mean BMI for the women was 30.5 Kg/m2 and for the men
was 27.5 Kg/m2. Significant hip trauma occurred in the year preceding the development of RPO in 22%. There was a
history of intra−articular injection of steroid in the year preceding RPO development in 30%. Crystals were not found in
any of the synovial fluid aspirates. Radiographically, complete joint space loss occurred over a mean interval of 198 days.
Femoral head migration was superolaterally in 61% and axial in 35%. Atrophic partial resorption of the femoral head was
present in 83% where as hypertrophic changes were present in 17%. Areas of avascular necrosis were present in femoral
head specimens in 17% but evident on imaging in <9%. On CT, resorption of bone and underlying sclerosis predominated
(86%). Joint effusions were present in 100%. On MRI, large joint effusions were present (100%). T1 signal of the femoral
head varied from reticulation of the fatty marrow with edema like signal (71%) to intermediate signal replacement on the
superior femoral head marrow (29%). Marrow was T2 hyperintense in the femoral head and neck in in 86%. T2 signal was
seen in the pericapsular soft tissues in 86%.
Conclusion: Rapidly progressive osteoarthritis of the hip represents a distinct entity from osteoarthritis in its progression
and appearance and may mimic an acute septic or neuropathic arthropathy, the diagnosis being one of exclusion based
on clinical and radiographic features.
34
Podium #18
ANATOMIC VARIATIONS OF FEMORAL NERVES ON HIGH RESOLUTION 3 TESLA MAGNETIC RESONANCE
NEUROGRAPHY AND THEIR RELATION TO ABNORMAL NERVE AND MUSCLE IMAGING FINDINGS
Aro M.R., JHU; Chhabra A.
(Presented by: Michael Aro, MD)
Purpose: Identify, describe and classify variations in formation, course and branching of the femoral nerves in the pelvis
using high resolution 3Tesla Magnetic Resonance Neurography.
Materials and Methods: 2 musculoskeletal radiologists retrospectively evaluated 147 Magnetic Resonance Neurography
(MRN) examinations of the pelvis in consensus, with 292 well−visualized femoral nerves for patterns of femoral nerve
formation, splits and their course in relation to psoas and iliacus muscles. Examinations were also assessed for presence
of signal abnormalities within the nerve and regional muscles in the femoral nerve distribution of pelvis and upper thighs.
Results: 33 Patients (22%) had nerve abnormalities or variations of the femoral nerves, including variations in course and
formation of the nerve. 9 nerves in 8 patients (5.4%) were split with intervening slips of the psoas muscle present in 7
nerves, an intervening slip of the iliacus muscle in one nerve, and one split nerve within the iliopsoas groove without
intervening muscle. 12 nerves in 10 patients demonstrated high intramuscular terminal branching within the psoas
muscle. 10 nerves in 9 patients showed a variation in course with 2 nerves pursuing sub muscular course deep to part of
the iliacus muscle, 4 nerves with extended intramuscular courses within the psoas muscle, and 4 nerves demonstrating
distal formation of the nerve and persistent roots within the distal pelvic iliopsoas muscle groove. In 3 patients, there were
formed nerves, which coursed between the iliacus and psoas muscles, not emerging onto the anterior aspect of the
muscle till just cephalad to the inguinal ring. None of the splits in the femoral nerve or variants in course had associated
muscle denervation signal abnormality or nerve signal changes. Signal abnormalities were however seen in 5 patients
related to causes, such as lumbar plexopathy, plexiform neurofibroma and prior surgery. Muscle changes in the
distribution of the femoral nerve were present in only 2 patients, and unrelated to variations in nerve course or formation.
In one patient, this was related to prior surgery. Unexplained moderate asymmetry in iliacus muscle size was present in
another patient.
Conclusion: MR Neurography demonstrates several variations in the formation, course and branching of the femoral
nerve in the pelvis as previously noted during anatomic dissections. Though these may have clinical implications with
regard to nerve therapy and may place the nerves at risk in certain pelvic procedures, these variants do not appear to be
the cause of neuropathy and should be considered as incidental findings.
35
Podium #19
*MRI EVALUATION OF CONCURRENT CHRONIC EXERTIONAL COMPARTMENT SYNDROME OF THE LOWER
EXTREMITY AND POPLITEAL ARTERY ENTRAPMENT
Haas J.P., Mayo Clinic, Rochester, MN; Howe B.M., Litwiller D.V., Felmlee J.P., Young P.M., Ringler M.D., Amrami K.K.
(Presented by: John Haas)
Purpose: To determine the relationship of chronic exertional compartment syndrome (CECS) and popliteal artery
entrapment syndrome (PAES) in a group of patients undergoing a screening MRI for exertional leg pain.
Materials and Methods: Eighty patients were referred to our practice for MRI evaluation of exertional leg pain from
2009−2012. Our protocol consists of an in−scanner screening exercise protocol for CECS which has been previously
validated, and assessment for popliteal artery entrapment using SSFP FIESTA based imaging using the same positioning
device and classical maneuvers (neutral, resisted plantarflexion and resisted dorsiflexion). Sixteen patients were
determined to have both CECS by MRI criteria and PAES (occlusion or severe attenuation of flow in the popliteal artery
and/or vein with resisted plantar flexion) as part of this protocol. Five patients were lost to follow up.
Results: All 11 of the remaining patients had definitive diagnoses of PAES by both imaging and clinical criteria. Five of
these patients had CECS by imaging and clinical criteria. Four patients had histories of prior fasciotomies for CECS, but
intracompartmental pressures at the time of our exam were negative in spite of positive MRI studies for CECS. Two
patients had positive MRI studies for CECS, but subsequent intracompartmental pressure measurements were negative.
All patients reported exertional leg pain; there were no significant differences in clinical presentations, age range or
gender between the groups.
Conclusion: Nine out of 11 patients referred for MRI screening for etiology of exertional leg pain had PAES with
coexisting current or past diagnosis of CECS. The relationship between these two conditions is not completely understood
but coexistence of these conditions in individual patients suggests the possibility of a common underlying disorder of
connective tissue. In patients with exertional leg pain, failure to screen for both conditions may result in incomplete
treatment leading to unsatisfactory results. Patients with exertional leg pain should be screened for both CECS and
PAES.
*Not CME Accredited
36
Podium #20
MAGNETIC RESONANCE IMAGING OF SECOND METATARSOPHALANGEAL JOINT PLANTAR PLATE TEAR AND
ITS RELATIONSHIP TO LESIONS IN THE SECOND INTERMETATARSAL SPACE
Umans H., Lenox Hill Radiology & Imaging Associates, PC; Elsinger E., Srinivasan R., Wilde G.
(Presented by: Hilary Umans, MD)
Purpose: To identify the variety of pathology in the 2nd intermetatarsal space (IS) with and without adjacent 2nd
metatarsophalangeal joint (mpj) plantar plate (PP) lesions, and to review the clinical treatment plan of 2nd IS lesions as it
is influenced by the presence or absence of adjacent PP tear.
Materials and Methods: 100 forefoot MRI performed in 96 patients for assessment of metatarsalgia from
9/30/11−7/21/12 using 1.5 or 3 T magnets were retrospectively reviewed in consensus by 2 MSK radiologists and 1
podiatrist (DPM) for 2nd mpj PP tear, the presence/nature of lesions in the 2nd (IS) and the presence / transverse
dimension of interdigital neuromas in the 2nd and 3rd IS. Weight bearing radiographs (XR) were reviewed. Treatment plan
was determined by the DPM at the time of image review.
Results: 33% of females and 40.5% of males had a tear of the 2nd MPJ PP in our study group. In 63 feet of 61 females
(23−80 yrs, average 49.1 yrs) there were 21 PP tears (11 complete), with 2nd IS lesions as follows: pericapsular fibrosis
(13), bursitis (4), indeterminate (3) and ganglion (1). There were 24 neuromas in the 2nd IS (3mm trans average, 2.6mm
median)and 43 in the 3rd IS (4.1mm average, 4mm median). In 37 feet of 35 males (20−68 yrs, average 48.7 yrs) there
were 15 PP tears (8 complete), with 2nd IS lesions as follows: pericapsular fibrosis (8), bursitis (5), ganglion (1), no lesion
(1). There were 9 neuromas in the 2nd IS (3.4mm average, 3.3 mm median) and 16 in the 3rd IS (4.1mm average, 3.8mm
median). 5 XR with PP tear showed: wide 2nd MPJ (4), elongation of the 2nd metatarsal (MT)(5), varus deviation of the
2nd toe (5), splaying of the 2nd and 3rd toe (3). 9 XR in those with intact PP were normal in 7; 1 each showed a wide 2nd
MPJ and elongated 2nd MT. In those individuals with 2nd MPJ PP tear a short course of conservative treatment,
excluding steroid injection, was recommended. Refractory cases would be treated with surgical repair of the PP.
Conclusions: 2nd MPJ plantar plate pathology is common in the context of metatarsalgia, accounting for more than 35%
of all of our cases. Almost all such cases in our series demonstrate accompanying non−neuromatous lesions in the 2nd
interspace that alter treatment plan in favor of surgical plantar plate repair if a short course of conservative therapy without
steroid injection fails to alleviate symptoms.
37
Tuesday, March 19, 2013
General Sessions located In Hill Country D – G unless otherwise noted.
7:00 a.m. – 7:55 a.m.
Industry Sponsored Breakfast
Location: Hill Country A – C
(See page 8 for full information)
7:00 a.m. – 12:30 p.m.
Registration / Information Desk Open
Location: Hill Country Foyer
8:00 a.m. – 12:30 p.m.
Exhibit Hall Open
Location: Hill Country A – C
8:00 a.m. – 12:30 p.m.
ePoster Session
Location: Hill Country A – C
(See page 150 for full information)
*As this session is not moderated, ePosters are not CME accredited
8:00 a.m. – 10:00 a.m.
Shoulder / Upper Extremity Session
Moderators: Gina A. Di Primio, MD
Andrew H. Sonin, MD
8:00 a.m.
#21
DISPLACED AXILLARY FLAP TEARS OF THE INFERIOR GLENOID LABRUM AT MR
ARTHROGRAPHY OF THE SHOULDER
White L.M., Joint Department of Medical Imaging, University of Toronto, Toronto, ON,
Canada; Naraghi A., Theodoropoulos J.
(Presented by: Lawrence White, MD)
8:20 a.m.
#22
CORRELATION OF MRI WITH ARTHROSCOPY FOR THE DIAGNOSIS OF
SUBSCAPULARIS TENDON TEARS
Gyftopoulos S. NYU Langone Medical Center; O'Donnell J., Rosenberg Z.S., Babb J.,
Recht M.P.
(Presented by: J. O’Donnell)
8:40 a.m.
#23
MRI APPEARANCES OF SUBSCAPULARIS INJURIES IN PROFESSIONAL
BASEBALL PLAYERS
Harkey G.L., Cleveland Clinic Foundation, Cleveland, OH; Polster J., Hakan I., Naveen
S., Mark S.
(Presented by: Gregory Harkey, MD)
9:00 a.m.
#24
FLEXOR CARPI RADIALIS TENDINOPATHY AND ITS ASSOCIATION WITH
SCAPHO-TRAPEZIO-TRAPEZOID
AND
FIRST
CARPOMETACARPAL
OSTEOARTHRITIS
Khan W., Thomas Jefferson University, Philadelphia PA; Palisch A., Okon L., Long S.,
Zoga A., Khoury V., Morrison W.
(Presented by: Andrew Palisch, MD)
9:20 a.m.
#25
HIGH-RESOLUTION ULTRASONOGRAPHY OF THE DORSAL AND PALMAR
EXTRINSIC WRIST LIGAMENTS IN CORRELATION WITH 3T MAGNETIC
RESONANCE IMAGING IN 40 NORMAL VOLUNTEERS AND 10 CADAVERIC
SPECIMENS WITH SURGICAL CORRELATION
Taljanovic M.S., University of Arizona Health Network; Holden D.A., Krupinski E.A.,
Sheppard J.E.
(Presented by: Mihra Taljanovic, MD, MSc)
9:40 a.m.
#26
ULTRASOUND OF DISPLACED ULNAR COLLATERAL LIGAMENT TEARS OF THE
THUMB: THE STENER LESION REVISITED
Melville D., University of Michigan, Ann Arbor, Michigan; Jacobson J.A., Haase S.,
Brandon C., Kalume Brigido M., Fessell D.
(Presented by: David Melville, MD)
38
Tuesday, March 19, 2013
10:00 a.m. – 10:05 a.m.
Case of the Day
64-Year-Old Man with Progressive RLE Pain and Paresthesias
Laurel Littrell, MD
10:05 a.m. – 10:30 a.m.
Break – Visit Exhibit Hall
Location: Hill Country A – C
10:30 a.m. – 12:30 p.m.
Spine / Intervention Session
Moderators: Laura W. Bancroft, MD
Joshua M. Polster, MD
10:30 a.m.
#27
DENS-BASION RELATIONSHIPS: NEW OBSERVATIONS IN THE ELDERLY
Daffner R.H., Allegheny General Hospital
(Presented by: Richard Daffner, MD, FACR)
10:50 a.m.
#28
MORPHOLOGY OF ENDPLATE CEMENT EXTRAVASATION CAN PREDICT
ADJACENT LEVEL FRACTURE IN OSTEOPOROTIC PATIENTS UNDERGOING
VERTEBROPLASTY AND KYPHOPLASTY
Jesse M., University of Colorado, Denver, CO; Petersen B.D.
(Presented by: Mary Kristin Jesse)
11:10 a.m.
#29
*TISSUE DISTRIBUTION OF CLONIDINE FOLLOWING INTRAFORAMINAL
IMPLANTATION OF BIODEGRADABLEPELLETS: POTENTIAL ALTERNATIVE TO
EPIDURAL STEROID FOR RADICULOPATHY
Beall D.P., Clinical Radiology of Oklahoma, Oklahoma City, OK; Parsons B.P., Carson
C.C., Deer T.R., Wilsey J.T., Walsh A.J., Block J.H., McKay W.F., Zanella J.M.
(Presented by: Douglas Beall, MD)
*Not CME Accredited
11:30 a.m.
#30
MAGNETIC RESONANCE IMAGING-GUIDED PERCUTANEOUS BIOPSY OF
OCCULT MUSCULOSKELETAL LESIONS: INITIAL ASSESSMENT OF FEASIBILITY,
SAFETY, AND DIAGNOSTIC YIELD
Datir A., Emory Orthopaedics & Spine Center, Atlanta, GA; Terk M.R., Monson D.K.,
Kitajima H., Carpenter W.A., Powell T.E., Nour S.G.
(Presented by: Abhijit Datir, MD)
11:50 a.m.
#31
IMAGE GUIDED CORE NEEDLE BIOPSY OF MUSCULOSKELETAL LESIONS: ARE
NONDIAGNOSTIC RESULTS CLINICALLY USEFUL?
Wu J.S., Beth Israel Deaconess Medical Center; Didolkar M., Anderson M., Goldsmith J.,
Gebhardt M., Hochman M.
(Presented by: Jim Wu, MD)
12:10 p.m.
#32
UTILITY OF PERCUTANEOUS JOINT ASPIRATION AND SYNOVIAL BIOPSY IN
IDENTIFYING INFECTED HIP ARTHROPLASY
Cross M.C., Mayo Clinic; Kransdorf M.J., Lorans R., Chivers F.S., Roberts C.C.,
Schwartz A.J., Beauchamp C.P.
(Presented by: M. Cross, MD)
12:30 p.m. – 12:35 p.m.
Case of the Day
17-Year-Old Girl with Pelvic Pain
Joanna Michele Costello, MD
39
Podium #21
DISPLACED AXILLARY FLAP TEARS OF THE INFERIOR GLENOID LABRUM AT MR ARTHROGRAPHY OF THE
SHOULDER
White L.M., Joint Department of Medical Imaging, University of Toronto, Toronto, ON, Canada; Naraghi A.,
Theodoropoulos J.
(Presented by: Lawrence White, MD)
Purpose: To investigate the incidence of displaced fibrocartilagenous flap tears, with tissue displaced into the axillary
recess of the glenohumeral articulation at MR arthrographic.
Materials and Methods: Following IRB approval, and waived consent, a retrospective review of 181 consecutive patients
who underwent MR arthrographic examination of the shoulder at one hospital site between August 2011 and January
2012 was performed. MR arthrographic studies were acquired following fluoroscopic guided intra−articular injection of
12−15ml of 2% gadolinium/saline contrast. All MR imaging was performed on a 1.5T n=90 (Aera, Siemens AG), or 3T
n=91 (Skyra, Siemens AG) system, utilizing multichannel shoulder coils. In all cases, MR imaging included coronal
oblique and axial T1 weighted fat suppressed, coronal oblique FSE T2 weighted fat suppressed, sagittal oblique FSE
intermediate weighted, and a high resolution T1 weighted three dimensional isotropic (SPACE) with fat suppressed
acquisitions. All cases were reviewed for demographic features and indication for MR arthrographic referral. All studies
were reviewed in consensus by 2 Musculoskeletal radiologists with with 18, and 10 years experience respectively. Studies
were evaluated for the presence/absence of a linear or globular low signal intensity fragment displaced into axillary recess
of glenohumeral articulation, continuous with inferior aspect glenoid labrum and/or inferior glenoid articular cartilage. Such
lesions needed to be surrounded by contrast material on all margins except for their connection to inferior labrum or
inferior glenoid articular surface. Such flap fragments were characterized as originating anterior−inferiorly, inferiorly, or
posterior−inferiorly. All cases with a displaced axillary flap fragment at imaging, were correlated to subsequent clinical
follow−up, and possible surgical findings.
Results: 181 patient exams were evaluated (31 female, 160 male), (shoulder; 81 left, 100 right). Mean patient age was
31.3 (range 14−64yrs). Clinical history at referral for MR arthrography included; evaluation of suspected SLAP tear
(n=41/181); traumatic injury rule out labral tear (n=39/181); anterior instability/dislocation (n=81/181); and postoperative
recurrent anterior instability (n=20/181). 24 cases (13.2%, n=24/181) were identified illustrating a fibrocartilagenous flap
tear displaced into the axillary recess of the joint (22 males, 2 females; mean age 24, range 16−35). Clinical referral
history in cases with an identified displaced axillary flap tear included; anterior instability/dislocation (n=17/24),
postoperative recurrent anterior instability (n=3/24), and traumatic injury rule out labral tear (n=4/24). Displaced flap tears
were assessed as originating anterior−inferiorly in 6 cases, inferiorly in 13, and posterior−inferiorly in 5. Clinical follow−up
was available in 17 (17/24) of the cases illustrating a suspected displaced axillary flap tear. Ten these 17 patients (10/17),
proceeded to arthroscopic surgery following MR arthrography. An unstable flap tear displaced into the axillary recess of
joint was specifically confirmed at surgery in 8 (8/10) cases. No specific OR notation, or intraoperative images illustrative
of a displaced flap tear was found in the additional 2 (2/10) patients.
Conclusion: Displaced flap tears of the inferior glenoid labrum are not uncommon findings at MR arthrography of the
shoulder and are commonly associated with clinical features of anterior glenohumeral instability.
40
Podium #22
CORRELATION OF MRI WITH ARTHROSCOPY FOR THE DIAGNOSIS OF SUBSCAPULARIS TENDON TEARS
Gyftopoulos S., NYU Langone Medical Center; O'Donnell J., Rosenberg Z.S., Babb J., Recht M.P.
(Presented by: J. O’Donnell)
Purpose: To determine the efficacy of MR imaging for the diagnosis of subscapularis tendon tears utilizing arthroscopy as
the gold standard.
Materials and Methods: The MR and arthroscopy reports from 150 consecutive patients were reviewed with 3 inclusion
criteria: 1) Non−contrast MRI performed at our institution, 2) The patient underwent arthroscopy within 6 months of the
MRI, and 3) No evidence of prior subscapularis surgery. 25 patients were excluded because of non−specific operative
(OR) reports (n=9) and MR arthrographic studies (n=16). The MR and OR reports were retrospectively reviewed for the
presence, degree (partial/full thickness), and location of tearing. A full thickness tear was defined as extending from the
articular surface to the bursal surface of the tendon. A partial thickness tear was defined as involving the articular surface
of the tendon without complete extension to the bursal surface. Tears that involved the intrasubstance and/or bursal
surface without extension to the articular surface on MRI were not considered positive because these areas are not
typically seen on arthroscopy. The presence of an adjacent supraspinatus tear on MRI and arthroscopy was noted. The
time interval between the date of surgery and MRI was also documented.
Fisher’s exact test was used to assess whether the accuracy of MRI for the detection of subscapularis tears was impacted
by the presence of a supraspinatus tear seen at arthroscopy. An Exact Mann−Whitney test was used to compare cases
MRI diagnosed correctly to those MRI did not diagnose correctly in terms of number of days between MRI and
arthroscopy.
Results: There were a total of 125 patients (92 men, 33 women; mean 47 yrs with a range of 15−83). There were 14 (10
partial/4 full−thickness) tears and 111 intact tendons on arthroscopy. Ten of the 14 arthroscopic tears (6/10 partial; 4/4
full−thickness) and 100/111 arthroscopic normal studies were correctly diagnosed on MRI. One tear was defined as
full−thickness on MRI, but was found to be partial thickness on arthroscopy. No distinction was made between whether
tears where characterized as full or partial tears at MRI for this analysis. Our analysis demonstrated 79% sensitivity, 90%
specificity and 89% accuracy. There were 11 false positive and 3 false negative MRI readings, resulting in 50% positive
and 97% negative predictive values. Of the false positive cases, 3 had partial tears on MRI involving the middle and
inferior thirds of the tendon while the other 8 involved the superior third. There was no instance of a subscapularis tear in
the absence of a supraspinatus tear, thus sensitivity could not be tested. Specificity of MRI could be tested for the
detection of subscapularis tears, though, and was 93.9% (46/49) in the absence of and 87.1% (54/62) in the presence of a
supraspinatus tear at arthroscopy without significant difference (p=0.341). There was no statistically significant difference
in time intervals between correctly and incorrectly diagnosed cases (p=0.589).
Conclusion: MRI is highly accurate for diagnosing full thickness tears and moderately accurate for the diagnosis of partial
subscapularis tendon tears, utilizing arthroscopy as the gold standard.
41
Podium #23
MRI APPEARANCES OF SUBSCAPULARIS INJURIES IN PROFESSIONAL BASEBALL PLAYERS
Harkey G.L., Cleveland Clinic Foundation, Cleveland, OH; Polster J., Hakan I., Naveen S., Mark S.
(Presented by: Gregory Harkey, MD)
Purpose: To describe and define the MRI appearances of subscapularis muscle injury in the spectrum of throwing injury
in professional baseball players.
Materials and Methods: From January 1, 2009 to October 1, 2012, 53 professional baseball players had shoulder MRI
performed at our institution. Two attending musculoskeletal radiologists and one musculoskeletal fellow retrospectively
reviewed these cases in consensus to identify cases with subscapularis muscle injury. Nine subscapularis injuries were
identified and evaluated for degree and location of muscle injury. Standard grading scale employed, with grade 1 (mild),
grade 2 (moderate), and grade 3 (severe). A description of the injury location is included.
Results: Nine cases of subscapularis muscle injuries were identified, graded as mild (n=4), moderate (n=3), and severe
(n=2). All nine cases were observed in the inferior half of the muscle.
Conclusion: Subscapularis muscle injury can occur as a part of the spectrum of throwing injuries in baseball players. In
our series, all of these injuries occurred in the inferior half of the muscle. We will present the imaging appearance of these
injuries, associated clinical presentation, player characteristics and outcome of these players. We will also propose a
mechanism of injury.
42
Podium #24
FLEXOR CARPI RADIALIS TENDINOPATHY AND ITS ASSOCIATION WITH SCAPHO-TRAPEZIO-TRAPEZOID AND
FIRST CARPOMETACARPAL OSTEOARTHRITIS
Khan W., Thomas Jefferson University, Philadelphia PA; Palisch A., Okon L., Long S., Zoga A., Khoury V., Morrison W.
(Presented by: Andrew Palisch, MD)
Purpose: The purpose of this study was to identify whether there is an association between flexor carpi radialis (FCR)
tendinosis and/or tears and osteoarthritis of either the scapho−trapezio−trapezoid (STT) or first carpometacarpal (CMC)
joints, as identified by magnetic resonance imaging (MRI).
Materials and Methods: A retrospective analysis was performed by searching a database from a single institution for
MRI studies of the wrist performed over a 15 month period which mentioned the term “flexor carpi radialis”. An exclusion
criterion was if reports described the tendon as normal. Two reviewers evaluated images and confirmed the presence of
FCR tendinosis and/or tears and osteoarthritis of the STT and first CMC joints.
Results: Database search revealed 26 patients with FCR tendinosis and/or tear. Male to female ratio was 10/16, with a
mean age of 57.8 years (range 14 – 80 years). The majority of patients (24/26, 92%) had either STT (20/26, 77%) and/or
first CMC (21/26, 81%) osteoarthritis. The two patients with no appreciable STT or first CMC osteoarthritis demonstrated
only mild degrees of FCR tendinosis. Fourteen of 26 (54%) patients had either partial (11) or complete (3) FCR tendon
tears. Twelve of 14 patients (86%) had tears positioned adjacent to the STT joint, including all three complete tears. The
other 2 patients (14%) had tears located adjacent to the first CMC joint. In all FCR tears, volar spurs were noted extending
from the affected joint and appeared to impinge upon the FCR.
Conclusions: Our data suggest that there is an association between FCR tendinopathy and STT or first CMC
osteoarthritis. Further, partial or complete FCR tendon tears appear to be more often positioned near an arthritic STT
joint. One should carefully assess for FCR pathology if there is evidence of osteoarthritis at either the STT or first CMC
joints associated with volar/radial sided pain.
43
Podium #25
HIGH-RESOLUTION ULTRASONOGRAPHY OF THE DORSAL AND PALMAR EXTRINSIC WRIST LIGAMENTS IN
CORRELATION WITH 3T MAGNETIC RESONANCE IMAGING IN 40 NORMAL VOLUNTEERS AND 10 CADAVERIC
SPECIMENS WITH SURGICAL CORRELATION
Taljanovic M.S., University of Arizona Health Network; Holden D.A., Krupinski E.A., Sheppard J.E.
(Presented by: Mihra Taljanovic, MD, MSc)
Purpose: To confirm that high−resolution ultrasonography (US) has comparable results with 3T Magnetic Resonance
Imaging (MRI) in visualization of the dorsal and palmar extrinsic wrist ligaments.
Materials and Methods: High−resolution US and 3T MRI of the dorsal and palmar extrinsic/capsular wrist ligaments were
performed on 10 fresh frozen cadaveric wrist specimens and on 40 wrists in normal volunteers. Eleven ligaments were
evaluated including the dorsal radiocarpal−DRCL, dorsal intercarpal−DICL, radioscaphocapitate−RSCL, long
radiolunate−LRLL,
short
radiolunate−SRLL,
radioscapholunate−RSLL,
palmar
ulnolunate−PULL,
palmar
ulnotriquetral−PUTL, ulnocapitate−UCL and palmar scaphotriquetral−PSTL. On the selected images, the ligaments were
graded by two examiners in consensus, using the following grading system: Grade 1− the ligament is completely
visualized, Grade 2− the ligament is partially visualized (< 100 % but > 50% of the ligament clearly seen) and Grade 3−
the ligament is not visualized (< 50% of the ligament clearly seen). Visibility of all ligaments on US and 3T MRI was
compared using the following grading system: A− the ligament is equally well seen on US and MRI, B− the ligament is
better seen on MRI, and C− the ligament is better seen on US. After imaging, all cadaveric wrists were dissected by an
orthopaedic hand surgeon. The results for each of the ligaments were shown in percentages. The percentage of visibility
scores and the comparison scores for MRI and US were calculated as a function of right versus left side and cadaver
versus volunteer. The summed percentage combining right and left sides was also calculated. Differences between the
distributions of percentages were tested for significance using the Chi−Squared(X2) test.
Results: Majority of the examined 550 dorsal and palmar extrinsic wrist ligaments were well−seen on the MRI and US
images and none received grade “3”. For MRI there was a significant difference in visualization of the ligaments (X2 =
143.04, p < 0.0001) with DUTL, RSCL and UCL receiving significantly more scores of “Grade 2”than the other ligaments.
For US, there was a significant difference for cadavers versus volunteers with volunteers receiving significantly more
scores of “Grade 1”(96 versus 88%) than the cadavers. There was a significant difference in visualization of the ligaments
(X2 = 143.83, p < 0.0001) with DUTL, PUTL, and PSTL receiving significantly more scores of “Grade 2”than the other
ligaments. There was a significant difference in quality of visibility between cadavers and volunteers (X2 = 8.70, p =
0.0129) with the volunteers receiving significantly more (64% versus 51%) grade “A”scores than the cadavers. There was
a significant difference (X2 = 335.72, p < 0.0001) with DUTL, PUTL, and PSTL receiving significantly more “B”scores than
the other ligaments and the other 8 ligaments receiving more “C”scores. On surgical dissections in 10 cadavers, it was
confirmed that all dorsal and palmar extrinsic wrist ligaments were intact.
Conclusion: Our study confirmed that high−resolution US enables satisfactory visualization of the dorsal and palmar
extrinsic wrist ligaments with results that are at least comparable to 3T MRI.
44
Podium #26
ULTRASOUND OF DISPLACED ULNAR COLLATERAL LIGAMENT TEARS OF THE THUMB: THE STENER LESION
REVISITED
Melville D., University of Michigan, Ann Arbor, Michigan; Jacobson J.A., Haase S., Brandon C., Kalume Brigido M.,
Fessell D.
(Presented by: David Melville, MD)
Purpose: To retrospectively characterize the ultrasound appearance of displaced ulnar collateral ligament (UCL) tears
that are proven at surgery, and then determine the accuracy of the resulting ultrasound criteria in differentiating displaced
from non−displaced UCL tears.
Materials and Methods: After institutional review board approval, 26 patients were identified from the radiology
information system over a 10 year period that had ultrasound evaluation of the thumb and surgically proven UCL tear.
Retrospective review of the displaced full−thickness tears was carried out to characterize displaced tears and to establish
ultrasound criteria for such tears. A repeat retrospective review four months later of all UCL tears applied the criteria to
determine accuracy of ultrasound in the diagnosis of displaced full−thickness UCL tear.
Results: The 26 subjects consisted of 17 displaced full−thickness UCL tears, seven non−displaced full−thickness tears,
and two partial−thickness tears at surgery. Retrospective ultrasound review of displaced full−thickness tears identified two
criteria present in all cases: non−visualization of the UCL ligament and presence of a heterogeneous mass−like area
proximal to the first metacarpophalangeal joint. Applying these criteria at the second retrospective review resulted in
100% sensitivity, specificity, positive predictive value, negative predictive value, and accuracy.
Conclusion: The ultrasound findings of absent UCL fibers and presence of a heterogeneous mass−like abnormality
proximal to the first metacarpophalangeal joint achieved 100% accuracy in differentiating displaced from non−displaced
full−thickness UCL tear of the thumb. Displaced full−thickness UCL tears most commonly were located proximal to the
adductor aponeurosis.
45
Podium #27
DENS-BASION RELATIONSHIPS: NEW OBSERVATIONS IN THE ELDERLY
Daffner R.H., Allegheny General Hospital
(Presented by: Richard Daffner, MD, FACR)
Purpose: To demonstrate alterations that occur in the dens−basion relationships in the elderly that result from
degenerative changes and do not indicate occipito−atlantal dislocation/subluxation.
Materials and Methods: 2285 patients underwent cervical CT for suspected trauma between 1/1/12 and 9/1/12. 1820
were between the ages of 16 and 75 years; 465 were age 76 and older. Each study included sagittal and coronal
reconstructed images in addition to axial images. We searched for fractures, dislocations, and any abnormalities in the
dens/basion relationships.
Results: No patients of either group had traumatic occipito−atlantal disruptions. None of the 1820 patients <age 75 had
abnormalities in the dens−basion relationships. Of the 465 patients > age 76, 22 were found with alterations in this
relationship. This was manifest as apparent posterior subluxation of the skull, reduction in the distance between the dens
and the basion (below 6−12 mm). All such patients had varying degrees of degenerative arthritis and pyrophosphate
calcification at the craniovertebral junction. The joints were otherwise "normal" on coronal and sagittal reconstructed
images.
Conclusion: Craniovertebral CT is much more sensitive in showing the relationships of the skull base to the cervical
spine than is radiography. In an elderly population, degenerative changes in this region may lead to abnormal alignment
of the dens in relation to the basion. When this abnormality is encountered, it is important to review the alignment of the
occipital condyles with the lateral masses on coronal and sagittal reconstructed images.
46
Podium #28
MORPHOLOGY OF ENDPLATE CEMENT EXTRAVASATION CAN PREDICT ADJACENT LEVEL FRACTURE IN
OSTEOPOROTIC PATIENTS UNDERGOING VERTEBROPLASTY AND KYPHOPLASTY
Jesse M., University of Colorado, Denver, CO; Petersen B.D.
(Presented by: Mary Kristin Jesse)
Purpose: There are conflicting data as to the factors that predispose patients to adjacent level fracture following
kyphoplasty or vertebroplasty. The purpose of the study is to restrospectively review the patient demographic and medical
data and radiographic metrics at a single center to guide decision making for prophylactic fixation of adjacent level to
prevent subsequent fracture.
Materials and Methods: A total of 156 fractureplasty levels in 80 patients performed in a single center over a 4 year
period were retrospectively reviewed. Thirty one levels in 20 patients were excluded based on non−osteoporotic fracture
(multiple myeloma, solid osseous metastases and trauma). An additional 11 levels (8 patients) were excluded due to
insufficient follow−up (less than 6 months of follow−up). Of the remaining 111 treated levels (in 52 patients), 15 of the
treated levels were between cemented vertebral bodies and were excluded from analysis. The remaining 96 levels were
evaluated for risk of adjacent level fracture. Demographic and medical data including age, gender, T−score and body
mass index were collected on all patients, if available. Radiographic evaluation included kyphotic angulation and location
and extent of cement intradiscal extravasation. Anterior, middle and posterior thirds of the vertebral body endplate were
used to define the location of intradiscal cement leakage. Extent of the leak was determined by the percentage of the
intervertebral disc height occupied by the extravasated cement material.
Results: Adjacent level fractures occurred in 20 of the 96 levels (21%). Of the adjacent level fractures, intradiscal cement
extravasation was observed in 9 (43%) of the cases, and occurred solely in the anterior (67%) and middle (33%) thirds of
the vertebral body. No intradiscal extravasation was witnessed in the posterior third of the vertebral body in the adjacent
level fracture group. In the non−fracture group, endplate cement extravasation was seen in 9 of the 71 non−fracture levels
(18%), with greatest cement burden in the middle third (55%) and posterior third (27%) of the vertebral body. Extent of
cement extravasation was similar between the two groups with greater than 50% involvement of the intervertebral disc
height in 67% of the fracture group and 63% of the non−fracture group. Despite ongoing data analysis to include p−value
calculations, no significant difference between the adjacent level fracture group and non−fracture group was apparent
when preliminarily analyzing body mass index, T−score, kyphotic angulation or comparing balloon augmentation to
vertebroplasty.
Conclusions: The risk of adjacent level fracture in our population correlates with the location of intradiscal cement
extravasation relative to the vertebral body endplate, offering a more sophisticated fracture risk assessment following
cement leakage.
47
Podium #29
*TISSUE
DISTRIBUTION
OF
CLONIDINE
FOLLOWING
INTRAFORAMINAL
IMPLANTATION
BIODEGRADABLEPELLETS: POTENTIAL ALTERNATIVE TO EPIDURAL STEROID FOR RADICULOPATHY
OF
Beall D.P., Clinical Radiology of Oklahoma, Oklahoma City, OK; Parsons B.P., Carson C.C., Deer T.R., Wilsey J.T.,
Walsh A.J., Block J.H., McKay W.F., Zanella J.M.
(Presented by: Douglas Beall, MD)
Purpose: To evaluate the distribution of clonidine after transforaminal placement of a biodegradable drug delivery depot
system.
Materials and Methods: A biodegradable polymer drug depot designed to provide sustained delivery of clonidine was
placed in or near a single lumbar neural foramen in 12 farm pigs. Clonidine tissue concentrations were measured at the
implant site and at incremental distances from the implant over a time period of 12 weeks. Plasma clonidine levels were
measured at 4 hours postimplantation on days 1, 2, 3, 5, and 7, and then weekly until the termination of the study.
Results: Clonidine was detectable up to 6 cm away from the drug depot. The highest concentrations of clonidine were
present within the targeted spinal nerve; the concentration decreased with increasing distance from the depot. Clonidine
was undetectable in plasma from all animals at all time points.
Conclusions: The results indicate that a biodegradable depot designed to be placed in a specific location to provide local
sustained release of an anti−inflammatory and analgesic drug may be a feasible new approach to treat radicular pain
associated with intervertebral disc pathology and other spinal conditions.
*Not CME Accredited
48
Podium #30
MAGNETIC RESONANCE IMAGING-GUIDED PERCUTANEOUS BIOPSY OF OCCULT MUSCULOSKELETAL
LESIONS: INITIAL ASSESSMENT OF FEASIBILITY, SAFETY, AND DIAGNOSTIC YIELD
Datir A., Emory Orthopaedics & Spine Center, Atlanta, GA; Terk M.R., Monson D.K., Kitajima H., Carpenter W.A., Powell
T.E., Nour S.G.
(Presented by: Abhijit Datir, MD)
Purpose: To evaluate the technical feasibility, procedure safety, and diagnostic yield of MRI−guided percutaneous
biopsies of challenging musculoskeletal lesions.
Materials and Methods: Following an IRB approved protocol, we retrospectively evaluated twelve consecutive
percutaneous musculoskeletal biopsies performed in eleven patients (7 females, 4 males; mean age 50.8 years). All
procedures were performed entirely within dedicated interventional MRI suite equipped with a 1.5−T open configuration
MRI unit (Magnetom Espree, Siemens, Germany) with a real−time guidance system. These included eight soft tissue and
three osseous sites. The selection criteria included lesions inconspicuous for biopsy on other modalities and/or prior
inconclusive conventional biopsies. The biopsy planning was performed with a variety of sequences and the needle
guidance sequence was subsequently chosen from these sequences based on lesion conspicuity. Tissue samples were
obtained using fine−needle aspiration (FNA), core−needle biopsy, or a combination of these techniques. An on−site
pathologist was available during all procedures for confirming the adequacy of the FNA samples, and to determine the
need for core biopsy samples. The data were evaluated for diagnostic yield (the proportion of biopsies yielding sufficient
material for pathological evaluation) and periprocedural complications.
Results: The osseous biopsy site was the bony pelvis in all cases (n=4) whereas the soft tissue biopsy site included
paraspinal (n=2), lower extremity (n=3), pelvis (n=2) and base of the penis (n=1) locations. The smallest lesion size was
1.1 x 0.6 x 1.6 cm with largest lesion measuring 9.8 x 6.2 x 5.3 cm. The average numbers of core and FNA samples
obtained were 3.1 and 2.8 respectively. The diagnostic yield was 100% in all the categories for both soft tissue and
osseous lesion biopsies. The final diagnoses included primary neoplasm (n=6) [soft tissue sarcoma (n=2), lymphoma
(n=2), peripheral nerve sheath tumor (n=1) and desmoid−type fibromatosis (n=1)], metastasis (n=2) [primary prostate
(n=1) and breast (n=1) malignancies], intramuscular venous malformation (n=2), and scar tissue (n=1). The surgical
excision biopsy confirmed the diagnosis in 2 patients (peripheral nerve sheath tumor and pleomorphic myxosarcoma).
Four patients were treated with chemotherapy and/or radiation therapy [pleomorphic liposarcoma (n=1), metastases (n=2)
and lymphoma] whereas 2 patients with intramuscular venous malformation were treated with MRI−guided sclerotherapy.
One biopsy showed only focal hemosiderin and necrotic myofibroblasts with lesion resolution on follow−up MRI. The
patient with desmoid fibromatosis was followed−up clinically with expected course. There were no procedure−related
complications.
Conclusion: MRI−guided percutaneous musculoskeletal biopsy is a feasible and safe alternative for sampling
inconspicuous muscular and bone marrow lesions. Initial assessment indicates a high diagnostic yield. A final analysis of
diagnostic accuracy awaits evaluation on a larger cohort of subjects.
49
Podium #31
IMAGE GUIDED CORE NEEDLE BIOPSY OF MUSCULOSKELETAL LESIONS: ARE NONDIAGNOSTIC RESULTS
CLINICALLY USEFUL?
Wu J.S., Beth Israel Deaconess Medical Center; Didolkar M., Anderson M., Goldsmith J., Gebhardt M., Hochman M.
(Presented by: Jim Wu, MD)
Purpose: To characterize musculoskeletal lesions associated with a high rate of nondiagnostic results during image
guided core needle biopsy (CNB) and to determine how nondiagnostic results affect clinical management.
Materials and Methods: Following IRB approval, a retrospective study was performed of 778 consecutive image guided
CNBs of bone (n=423) and soft tissue (n=355) lesions at a single institution. Histologic reports were reviewed and a
biopsy was considered nondiagnostic if a distinct pathologic diagnosis could not be rendered from the biopsy tissue that
explained the lesion clinically and by imaging. The reference standard was either (i) the final diagnosis at surgery or (ii)
clinical follow−up (mean 20 months). Diagnostic yield, defined as the number of diagnostic CNBs divided by the total
number of CNBs, was calculated for the most common diagnoses. Subsequently, the clinical and imaging data for 142
nondiagnostic CNBs (from the top two referring orthopedic oncologists) were re−reviewed with them to determine if the
nondiagnostic CNB result was useful in guiding clinical management. The clinical factors included (1) pain due to the
lesion, (2) history of malignancy, and (3) signs of infection. The imaging features included (1) overall lesion appearance
(aggressive/ indeterminate/nonaggressive) and (2) whether the lesion was an incidental finding. For each case, based on
the above findings prior to biopsy, the orthopedic surgeons recorded whether the lesion was either (1) “likely to be
benign”or (2) “suspicious for malignancy”.
Results: Of the 778 lesions biopsied, 55.7% (433/778) proved benign and 44.3% (345/778) were malignant. The overall
diagnostic yield was 73.9% (575/778). Benign lesions had a significantly lower diagnostic yield than malignant lesions
(58.2%, 252/433 versus 93.6%, 323/345; p<0.0001). The benign and malignant soft tissue and bone lesions associated
with the highest rate of nondiagnostic results were: BENIGN− cysts, myositis ossificans, tenosynovitis, Langerhans cell
histiocytosis, simple bone cyst, healing fractures, degenerative changes, foci of red marrow, and osteomyelitis;
MALIGNANT− Ewing sarcoma, and osteosarcoma. Of the 142 nondiagnostic biopsies assessed for clinical usefulness,
the orthopedic oncologists deemed 59.9% (85/142) of the biopsies useful in guiding clinical management. Useful
nondiagnostic CNB results occurred significantly more often in asymptomatic versus painful lesions (p=0.0067),
nonaggressive or indeterminate versus aggressive lesions (p=0.0036), and in lesions assessed as “likely to be
benign”instead of “suspicious for malignancy”prior to biopsy (p<0.0001).
Conclusions: Nondiagnostic CNBs are significantly more likely to occur in benign versus malignant lesions and bone
versus soft tissue lesions. Moreover, 60% of the nondiagnostic biopsies were helpful in guiding clinical management and
are more likely to occur in painless, nonaggressive lesions with high likelihood of benignity prior to biopsy.
50
Podium #32
UTILITY OF PERCUTANEOUS JOINT ASPIRATION AND SYNOVIAL BIOPSY IN IDENTIFYING INFECTED HIP
ARTHROPLASY
Cross M.C., Mayo Clinic; Kransdorf M.J., Lorans R., Chivers F.S., Roberts C.C., Schwartz A.J., Beauchamp C.P.
(Presented by: M. Cross, MD)
Purpose: Percutaneous synovial biopsy has recently been reported to have a high diagnostic value in the preoperative
identification of periprosthetic infection of the hip. We report our experience with this technique in the evaluation of
patients undergoing revision hip arthroplasty, comparing results of preoperative synovial biopsy with joint aspiration.
Materials and Methods: We retrospectively reviewed the results of the 108 most recent revision hip arthroplasties.
Thirteen cases were excluded due to having prior revision surgery, and 4 were excluded due to technical problems related
to processing or reporting the synovial biopsy culture; leaving a study group of 91 patients. Revision surgery for these
patients occurred during the period 19 February 2009 to 21 March 2012. Using this study group, results from preoperative
cultures were compared with preoperative laboratory studies and clinical evaluation for concordance and predictive value
in the preoperative diagnosis of hip arthroplasty infection. Synovial aspiration was done using an 18 or 20 gauge spinal
needle. Synovial biopsy was done coaxially following aspiration using a 22 gauge Chiba needle. Standard microbiological
analyses were performed on preoperative synovial fluid aspirate and synovial biopsy, as well as intraoperative tissue
biopsy. Intraoperative tissue culture results at surgical revision were accepted as the “gold standard”for the presence or
absence of infection.
Results: Nine of 91 (10%) patients had positive intraoperative tissue cultures as well as preoperative synovial biopsy and
joint aspiration performed at our institution. Of these, synovial fluid aspiration and synovial biopsy were both positive in 6
cases (sensitivity of 67%, specificity of 100%, and positive predictive value of 100%). Two cases in which synovial
aspiration and synovial biopsy were both negative showed anaerobic Propionibacterium on intraoperative tissue culture.
There was one case where the fluid aspiration was positive but the synovial biopsy culture was negative, and this was
also infected with Propionibacterium. The results of synovial aspiration alone resulted in the identification of 7 infected
joints with two false positive results (sensitivity of 70%, specificity of 98%, positive predictive value of 78%). The results of
synovial biopsy alone as compared to tissue culture showed 3 false positive results (sensitivity of 67%, specificity of 96%,
and a positive predictive value of 67%).
Conclusion: Standard microbiological analyses performed on synovial biopsy specimens during the preoperative
evaluation of patients undergoing revision hip arthroplasty did not improve detection of periprosthetic infection as
compared to synovial fluid aspiration.
51
Wednesday, March 20, 2013
General Sessions located in Hill Country D – G unless otherwise noted.
7:00 a.m. – 7:55 a.m.
Continental Breakfast
Location: Hill Country A – C
7:00 a.m. – 10:30 a.m.
Exhibit Hall Open
Location: Hill Country A – C
7:00 a.m. – 12:30 p.m.
Registration / Information Desk Open
Location: Hill Country Foyer
7:00 a.m. – 10:30 a.m.
ePoster Session
Location: Hill Country A – C
(See page 150 for full information)
*As this session is not moderated, ePosters are not CME accredited
8:00 a.m. – 10:00 a.m.
Tumor Session
Moderators: Mark D. Murphey, MD
Daniel M. Walz, MD
8:00 a.m.
#33
CYST OR CYSTIC TUMOR? THE ROLE OF QUANTITATIVE DIFFUSION WEIGHTED
IMAGING IN DIFFERENTIATING THESE ENTITIES
Subhawong T.K., University of Miami, Miami, FL; Jacobs M.A., Fayad L.M.
(Presented by: Ty Subhawong, MD
8:20 a.m.
#34
MR IMAGING ACCURACY IN DIAGNOSING MALIGNANT BONE MARROW LESIONS
Kohl C.A., Mayo Clinic; Chivers F.S., Kransdorf M.J., Roberts C.C., Lorans R.
(Presented by: Chad Kohl, MD)
8:40 a.m.
#35
*MRI LEADS TO INCREASED FALSE-POSITIVE DIAGNOSIS OF
CHONDROSARCOMA
Crim J.R., University of Utah, Salt Lake City, UT; Layfield L.J., Schmidt R., Hanrahan C.,
Liu T., Manaster B.J.
(Presented by: Julia Crim, MD)
*Not CME Accredited
9:00 a.m.
#36
IMAGING OF OSTEOBLASTOMA OF THE APPENDICULAR SKELETON WITH
PATHOLOGIC CORRELATION
Senchak L.T., American Institute for Radiologic Pathology; Murphey M.D., Mambalam
P.K.
(Presented by: Lien Senchak, MD)
9:20 a.m.
#37
IMAGING FEATURES OF SYNOVIAL CHONDROMATOSIS OF THE SPINE: A
REVIEW OF 28 CASES
Littrell L.A., Mayo Clinic, Rochester, MN; Wenger D.E., Inwards C.Y., Sim F.H.
(Presented by: Laurel Littrell, MD)
9:40 a.m.
#38
“SERIOUS” SEROUS ATROPHY OF BONE MARROW: MANY DIFFERENT CAUSES
AND ONE PARTICULAR COMPLICATION
Boutin R.D., UC.Davis, Sacramento, CA; Bredella M., Lopez R., Spitz D., Laor T.
(Presented by: Robert Boutin, MD)
10:00 a.m. – 10:05 a.m.
Case of the Day
Man with Progressive Proximal Fibular Pain and Palpable Mass
Speaker: Cooper Dean, MD, BS
10:05 a.m. – 10:30 a.m.
Break – Visit Exhibit Hall
Location: Hill Country A – C
52
Wednesday, March 20, 2013
10:30 a.m. – 12:30 p.m.
Miscellaneous Session
Moderators: Kenneth A. Buckwalter, MD
Bethany U. Casagranda, DO
10:30 a.m.
#39
SUBPUBIC CARTILAGINOUS CYST: AN UNCOMMON LESION WITH A HIGHLY
CHARACTERISTIC IMAGING APPEARANCE
Kransdorf M.J., Mayo Clinic; Murphey M.D.
(Presented by: Mark Kransdorf, MD)
10:50 a.m.
#40
POST-TRAUMATIC CYSTS FOLLOWING PEDIATRIC FRACTURE
Murphey M.D., American Institute for Radiologic Pathology, Silver Spring, MD;
Lewandowski L., Potter B.K., Senchak L.T., Mambalam P.
(Presented by: Mark Murphey, MD, FACR)
11:10 a.m.
#41
IMAGING CHARACTERISTICS OF MUSCULOSKELETAL ECHINOCOCCUS
DISEASE
Mambalam P., American Institute for Radiologic Pathology, Silver Spring, MD; Murphey
M.D., Senchak L.T.
(Presented by: Pramod Mambalam)
11:30 a.m.
#42
NODULAR FASCIITIS: CHARACTERISTIC IMAGING FEATURES ON ULTRASOUND
AND MAGNETIC RESONANCE IMAGING
Yablon C.M., University of Michigan; Khuu A., Jacobson J.A., Inyang A., Lucas D.,
Biermann J.S.
(Presented by: Corrie Yablon, MD)
11:50 a.m.
#43
RADIOGRAPHIC EVALUATION OF THE INBONE TOTAL ANKLE REPLACEMENT
Datir A., Emory Orthopaedics & Spine Center, Atlanta, GA;, Terk M.R., Labib S.A.
(Presented by: Abhijit Datir, MD)
12:10 p.m.
#44
EFFECT OF WRIST POSITIONING ON VISUALIZATION OF THE TRIANGULAR
FIBROCARTILAGE WITH MAGNETIC RESONANCE IMAGING
Dave H.K., Mayo Clinic Florida; Peterson J.J., Bestic J.M., Garner H.W., Tara O.M.
(Presented by: Heman Dave, MD)
12:30 p.m.
Meeting Adjourned
53
Podium #33
CYST OR CYSTIC TUMOR? THE
DIFFERENTIATING THESE ENTITIES
ROLE
OF
QUANTITATIVE
DIFFUSION
WEIGHTED
IMAGING
IN
Subhawong T.K., University of Miami, Miami, FL; Jacobs M.A., Fayad L.M.
(Presented by: Ty Subhawong, MD
Purpose: Musculoskeletal neoplasms may present with fluid−like T2 signal hyperintensity simulating benign cysts.
Intravenous contrast is the standard means of differentiating cysts and solid tumors, but requires intravenous access and
may be precluded by contrast allergy or poor renal function. The purpose of this study is to investigate the utility of
diffusion weighted imaging (DWI) with apparent diffusion coefficient (ADC) mapping for characterizing homogeneously
hyperintense T2 lesions as cysts or solid tumors.
Materials and Methods: This IRB−approved retrospective study included 36 subjects with 37 STMs imaged by
conventional MRI (T1−weighted, T2−weighted, contrast−enhanced T1−weighted sequences) and DWI (b−values 50, 400,
800 seconds/mm2) with ADC mapping. STMs were defined as cystic by histology or lack of internal enhancement, and as
solid, by histology and internal contrast enhancement (corresponding to neoplastic/inflammatory content). For each STM,
ADC values (range, average) were recorded by two observers. Differences between ADC values in cysts and solid STMs
were compared by Wilcoxon rank−sum and receiver−operating characteristic (ROC) analysis.
Results: There were higher minimum (1.65 vs 0.68 , p=0.003) and average ( 2.31 vs 1.45, p=0.005) ADC values in cysts
than solid STMs, respectively. Areas under the ROC for minimum and average ADC values were 0.82 and 0.81,
respectively. Using threshold ADC values of 1.8 (minimum) or 2.5 (average) yielded a sensitivity of 60% and 80%,
respectively, and a specificity of 100% for classifying a STM as a cyst; for tumors with high fluid−signal intensity, the
performance of these threshold values was maintained.
Conclusions: DWI with ADC mapping provides a non−contrast MRI alternative for the characterization of STMs as cysts
or solid masses. Threshold ADC values exist which provide 100% specificity for differentiating cysts and solid STMs, even
for tumors of high fluid−signal intensity on T2−weighted images.
54
Podium #34
MR IMAGING ACCURACY IN DIAGNOSING MALIGNANT BONE MARROW LESIONS
Kohl C.A., Mayo Clinic; Chivers F.S., Kransdorf M.J., Roberts C.C., Lorans R.
(Presented by: Chad Kohl, MD)
Purpose: To re−assess the accuracy of chemical shift MR imaging in diagnosing malignant bone marrow lesions.
Materials and Methods: We reviewed our experience with chemical shift MR imaging of the pelvis to assess the
accuracy of in−and−out of phase imaging in distinguishing benign and malignant bone lesions. Two musculoskeletal
radiologists retrospectively reviewed all osseous lesions biopsied since 2006; when chemical shift imaging was added to
our pelvic imaging protocol. Study inclusion criteria included (1) MR imaging of an indeterminate bone marrow lesion
about the pelvis and (2) subsequent CT−guided biopsy with histologic confirmation. The study group included 48 patients
(27 male, 21 female) with an average age of 67 years (range: 41−89 years). Prebiopsy diagnosis suggesting malignancy
was based on previously published criteria*; T1 hypointensity, T2 hyperintensity, and less than 20% signal loss on
opposed phase imaging. MR imaging results were evaluated using biopsy results as the “gold standard.”
Results: There were 25 malignant and 23 benign lesions. In conjunction, imaging criteria suspicious of malignancy
captured 24/25 malignant lesions and 12/23 benign lesions− yielding a 96% sensitivity, 52% specificity, and an area under
the receiver operator characteristic (ROC) curve of 0.74. The inter−rater agreement K value was 1.0.
Conclusion: Established MR imaging criteria find malignant bone marrow lesions well. But biopsies remain necessary−to
exclude malignancy−because the appearance of many benign marrow lesions overlaps that of malignant ones.
*Zajick DC, et al. Radiology 2005; 237:590−596.
55
Podium #35
*MRI LEADS TO INCREASED FALSE-POSITIVE DIAGNOSIS OF CHONDROSARCOMA
Crim J.R., University of Utah, Salt Lake City, UT; Layfield L.J., Schmidt R., Hanrahan C., Liu T., Manaster B.J.
(Presented by: Julia Crim, MD)
Purpose: Most studies of cartilage tumors suffer from incorporation and diagnostic review bias, where imaging criteria for
chondrosarcoma are evaluated and compared to a final diagnosis which is based on imaging as well as pathology criteria.
Our purpose was to assess the reliability of established and newer imaging signs of low−grade chondrosarcoma against
pure histopathologic diagnosis and outcomes.
Materials and Methods: Cartilage lesions prospectively diagnosed as enchondroma or chondrosarcoma were identified
by review of medical records. STARD initiative guidelines for evaluation of diagnostic accuracy were used. Pathology was
independently reviewed by 2 pathologists with extensive bone tumor experience. All cases had histopathologic proof
and/or a minimum of 5 years of imaging follow−up. Established imaging criteria for grade 1 chondrosarcoma as well as
new MRI criteria were reviewed via a study set. 2 MSK radiologists independently reviewed each of 60 cases, and
evaluated each of the criteria and overall diagnosis, based on radiographs alone and on radiographs plus MRI.
Findings: 60 cases met inclusion criteria, but 5 were lost to follow−up, leaving 30 enchondromas, 19 chondrosarcomas
and 6 with equivocal histologic diagnosis. At least 1 imaging finding of chondrosarcoma was found in every case of
enchondroma. Evaluation of matrix, tumor margins and gadolinium enhancement were not reliable in distinguishing
benign from malignant. Based on radiographic findings alone, a false positive diagnosis of chondrosarcoma was made in
3.3 % (reader 1) or 6.7% (reader 2) of cases of enchondroma. When MRI was added, the false positive diagnosis rate
increased to 6.7−16.7%. A false negative diagnosis of enchondroma was made based on radiographs alone in
15.8−31.6% of cases of chondrosarcoma. When MRI was added, the false negative diagnostic rate fell to 10.5%. Kappa
value for radiologist agreement of diagnosis was 0.754 (p=0.00) based on radiographs, and 0.557 based on radiographs +
MRI.
Conclusion: Based on radiographs, experienced readers identified the majority of enchondromas as benign, but there
was a significant false−negative rate for diagnosis of chondrosarcoma. Interobserver agreement decreased when MRI
was added to radiographs. MRI findings increased the rate at which both enchondromas and chondrosarcomas were
diagnosed as malignant. Gadolinium enhancement offers no additional value over conventional MRI.
*Not CME Accredited
56
Podium #36
IMAGING OF OSTEOBLASTOMA OF THE APPENDICULAR SKELETON WITH PATHOLOGIC CORRELATION
Senchak L.T., American Institute for Radiologic Pathology; Murphey M.D., Mambalam P.K.
(Presented by: Lien Senchak, MD)
Purpose of Study: Evaluate imaging appearance of osteoblastoma in the appendicular skeleton and identify
characteristic imaging features with pathologic correlation.
Materials, Methods and Procedures: We retrospectively reviewed 30 patients with pathologically confirmed
osteoblastoma in the appendicular skeleton. Radiologic studies were reviewed by two musculoskeletal radiologists with
agreement by consensus and included radiography(R)(n=28), computed tomography(CT)(n=9), magnetic
resonance(MR)(n=14) and nuclear medicine bone scan(n=6). Evaluation included patient demographics, lesion location,
size and morphology and intrinsic features on CT and MR, and radionuclide uptake. Imaging was correlated with available
gross pathology(n=5) and histology(n=2).
Results: Patient age ranged from 6 to 75 years (average age 27). There were 15 males and 9 females. Osseous location
included tibia (27%), humerus (20%), femur (17%), fibula (14%), talus (7%), clavicle (3%), phalanx (3%), calcaneus (3%),
ilium (3%) and ischium (3%). Long bone lesions were most commonly centered in the metaphysis (72%) or diaphysis
(23%). Axial location in bone were central medullary (53%), eccentric medullary (7%), intracortical (17%) and
subperiosteal (14%). Lesion size ranged from 1 − 9.7 cm in maximal dimension (average 5 cm). Pattern of bone lysis was
geographic 1a (30%), 1b (40%) and 1c (13%) and one was predominately sclerotic. A soft tissue component was seen in
28% of lesions by CT or MR. Fluid levels indicative of an aneurysmal bone cyst component were seen in 28 % of lesions
by MR. There were four lesions that demonstrated aggressive features with cortical destruction and two with rapid growth.
Characteristic findings on R/CT included nonaggressive periosteal reaction 76%, bone remodeling 63% and matrix
mineralization 53%. MR characteristics included predominantly low/intermediate signal intensity on T1−weighting in 85%
of lesions and heterogenous intermediate/high signal on T2 signal in 92% of cases. There was diffuse heterogenous
moderate to marked enhancement in 73% of cases. Surrounding edema was a prominent component on MR seen in 93%
of cases. In cases with both bone marrow edema and soft tissue edema, bone marrow edema exceeded soft tissue
edema in 72% of cases.
Conclusions: The prospective diagnosis of appendicular osteoblastoma remains difficult. However, the presence of a
lytic metadiaphyseal lesion containing matrix mineralization with prominent associated surrounding bone marrow and soft
tissue edema on MR are very suggestive imaging features.
57
Podium #37
IMAGING FEATURES OF SYNOVIAL CHONDROMATOSIS OF THE SPINE: A REVIEW OF 28 CASES
Littrell L.A., Mayo Clinic, Rochester, MN; Wenger D.E., Inwards C.Y., Sim F.H.
(Presented by: Laurel Littrell, MD)
Purpose: To describe the imaging features of synovial chondromatosis of the spine, an entity which has only been
described in sporadic case reports previously.
Materials and Methods: Imaging studies for 28 cases of pathologically−proven spinal synovial chondromatosis were
retrospectively reviewed which included 6 radiographs, 2 myelograms, 12 CTs, and 22 MRIs. Evaluation included patient
demographics, lesion size, anatomic level and compartmental location, presence of calcifications/loose bodies, relation to
facet joint, presence of bony erosion or destruction and signal and enhancement characteristics on MRI.
Results: Of the 28 patients, 16 were males and 12 females. Ages ranged from 24 to 75 years (average 44, median 42).
16 were located in the cervical, 6 in the thoracic and 6 in the lumbar spine. One patient had only postoperative imaging,
leaving 27 patients with imaging studies for review. Average lesion size was 3.4 cm with a range of 1.6 cm to 6.0cm.
Twenty−one of 27 (78%) were extradural or had an extradural component. Seventeen of 27 (63%) had a neural foraminal
component. Fifteen of 27 (56%) had a paraspinal component (anterior and/or posterior). Only 3 cases (11%) were purely
paraspinal in location. Twenty−five of the cases had cross−sectional imaging and in 24 (96%), the mass directly abutted a
facet joint. Ninety−six percent showed a normal facet joint without evidence of internal erosion. However, 21 of 27 (78%)
showed chronic indolent extrinsic bony erosion/scalloping, usually involving the surface of the facet (17 cases), vertebral
body (10 cases) or the pedicles/lamina (9). Seventeen patients had CT and/or radiographs and of these, only 7 (41%) had
calcifications as a dominant finding. Eight of 17 (47%) had no detectable calcifications and 2 (12%) had only a few tiny
faint calcifications. Of the patients that had calcifications as a dominant finding, only 4 (15%) had discrete round
calcifications of uniform size. The remaining 3 had a single densely calcified mass or dense confluent calcification.
Twenty−two of the 25 patients (88%) with either cross sectional imaging or myelogram had evidence of neural
compression, either cord/thecal sac (2), nerve roots (4) or both (16). On MRI, the majority of cases showed intermediate
or intermediate and dark signal on T1 (79%). On T2, the majority of lesions were heterogeneous with discrete areas of
dark signal (88%). Thirteen of 22 MRIs (59%) showed evidence of nodularity and/or dark foci on T1 or T2. Of 11 cases
with gadolinium, the majority showed peripheral nodular or peripheral rim enhancement (82%).
Conclusion: Synovial chondromatosis of the spine is a rare entity with unexpected imaging findings. The majority of our
cases presented as an extradural and/or neural foraminal mass, abutting a normal facet joint without clear evidence that
the mass was arising from the facet joint. Calcifications typical of synovial chondromatosis elsewhere in the body occurred
only in a minority of patients.
58
Podium #38
“SERIOUS” SEROUS ATROPHY OF BONE MARROW: MANY DIFFERENT CAUSES AND ONE PARTICULAR
COMPLICATION
Boutin R.D., UC.Davis, Sacramento, CA; Bredella M., Lopez R., Spitz D., Laor T.
(Presented by: Robert Boutin, MD)
Purpose: Serous atrophy (also referred to as gelatinous transformation) of bone marrow (SABM) is commonly associated
with weight loss and anemia, as may be seen in patients with conditions such as anorexia, cachexia, and cancer. In
practice, SABM is rarely diagnosed radiologically. Our purpose is to report the MRI features of a series of patients with
presumed SABM due to a wide variety of causes, with an emphasis on stress fractures.
Materials and Methods: Two experienced musculoskeletal radiologists retrospectively reviewed 8 patients with a
diagnosis of SABM. Radiologic studies reviewed by consensus included MRI (n=9), as well as radiography (n=5), CT
(n=2), and DEXA (n=2). Evaluation included analysis of patient demographics, clinical history (e.g., anorexia, athletics,
cancer), body part, and signal intensity on available MRI pulse sequences. Because ethical considerations did not permit
tissue sampling, the presumptive diagnosis was based on criteria established in the literature: [i] a medical history of a
severe catabolic state with [ii] imaging findings of minimal fat in the subcutis, the muscles, and the intermuscular fascial
planes and [iii] a peculiar pattern in adult bone marrow of diffusely diminished T1 signal intensity and diffusely elevated
STIR signal intensity.
Results: SABM patients included 4 males and 5 females ranging in age from 9 to 80 years (average, 38 years; median,
26 years). Pertinent medical history included: anorexia nervosa (n=4); bariatric surgery with massive weight loss (n=1);
pancreatic cancer (n=1); biliary atresia (n=1); cachexia (n=1); scurvy (n=1). 5 patients were athletes (4 female; 1 male). All
patients were symptomatic. 6 patients had fractures; 3 did not. One patient fractured a total of 10 different bones over a 6
year time period. Target sites for the 15 fractures in this series were in weight−bearing bones: the metatarsals (n=4),
calcaneus (n=5), malleoli (n=2), and proximal femurs (n=4). Non−displaced fractures in the proximal femurs were subtle
by MRI, presumably due to the lack of normal fat suppression on STIR images. Diagnosis of SABM may be important
when it influences treatment of profound catabolic conditions that are associated with bone fragility.
Conclusions: Based on this limited series of patients, we conclude that the diagnosis of SABM may be suggested as a
diagnosis when characteristic MRI findings are observed in the clinical setting of a severe catabolic state. The signal
intensity alterations in the bone marrow from SABM may go unrecognized, both because these changes can be
inconspicuous and because this condition is not widely known by physicians. SABM may be associated with increased
risk for stress fractures, and it should be emphasized that these fractures can be subtle.
59
Podium #39
SUBPUBIC CARTILAGINOUS CYST: AN UNCOMMON LESION WITH A HIGHLY CHARACTERISTIC IMAGING
APPEARANCE
Kransdorf M.J., Mayo Clinic; Murphey M.D.
(Presented by: Mark Kransdorf, MD)
Purpose: We report the imaging appearance of subpubic cartilaginous cyst.
Materials and Methods: We retrospectively reviewed the MR and CT images of four patients with subpubic cartilaginous
cysts. Detailed histories were available for three patients. The remaining patient was seen in consultation. All patients had
MR imaging with contrast and three also had CT imaging assessment. Evaluation included a review of patient
demographics, lesion size, lesion location, presence or absence or mineralization, lesion vascularity and intrinsic CT and
MR imaging characteristics.
Results: All patients were older women with average age of 81 years (range: 80−84 years). All were multiparous, having
between 2 and 6 previous parturitions (average: 4). Presenting complaints included vaginal mass and pain. The lesion
was an incidental imaging finding in one patient. All lesions were immediately inferior to the symphysis pubis and ranged
in size from 1.8 to 4.3 cm (average: 2.7 cm). On MR imaging, all lesions were well−defined, rounded masses, with sharply
marginated borders. Signal intensity on T1−weighted sequences was similar to muscle with mild heterogeneity; on fluid
sensitive sequences, lesions demonstrated a complex cystic appearance with variable amounts of irregularly shaped
low−to−intermediate signal within a cystlike mass. A rind of peripheral contrast enhancement was noted in all cases
without associated internal enhancement. Two cases showed extension through the syphysis, extending just cephalad to
the symphysis in one and extending 12 mm above the symphysis in the other. Lesions were much less conspicuous on
CT imaging, although the largest lesion was easily identified as a mass with attenuation less than that of muscle and
greater than that of water. Resected specimens showed as cystlike lesion with a collagenous capsule and associated
inflammation. The lesion was filled fibrocartilaginous tissue showing degenerative changes with mucinous/myxoid change.
Conclusion: Although uncommon, subpubic cartilaginous cysts occurs in a unique demographic (older multiparous
women), with a distinctive location (immediately below the symphysis), and a highly characteristic an imaging appearance
(complex cystic mass with an enhancing peripheral rind); features which should allow an unequivocal diagnosis.
60
Podium #40
POST-TRAUMATIC CYSTS FOLLOWING PEDIATRIC FRACTURE
Murphey M.D., American Institute for Radiologic Pathology, Silver Spring, MD; Lewandowski L., Potter B.K., Senchak
L.T., Mambalam P.
(Presented by: Mark Murphey, MD, FACR)
Background: Pediatric post−fracture cystic bone lesions are most commonly found on routine follow−up radiographs of
distal radius fractures. Following their discovery, there is often a discussion of the need for further radiologic imaging or
operative intervention.
Methods: We present four cases all of which were pediatric patients with a history of a healing fracture and had the
lesions diagnosed incidentally on average 3 months following initial injury. Radiographs were available for review in all
cases and MR in two cases.
Results: These four cases demonstrate nearly identical radiographic characteristics of post−fracture radiolucent lesions
of the distal radius. The radiographs consistently demonstrate a well−circumscribed lytic lesion without surrounding
sclerosis (geographic 1B) within the elevated periosteum or along the plane of the healing fracture. These lesions
appeared intracortical or along a plane of the fracture line without any aggressive characteristics. All of the lesions were
isointense with adipose tissue on all MR pulse sequence including T1, T2, fat−suppressed T1−weighted imaging and
showed only rim enhancement following intravenous contrast.
Conclusion: Although post−fracture pediatric cysts are rare, we feel that there is sufficient literature to support no longer
needing cross−sectional imaging to diagnose these lesions in the setting of an appropriate history without confounding
variables and classic radiographic appearance. Biopsy, in particular, is decidedly unnecessary unless the lesion
progresses on subsequent radiographs or demonstrates more overtly aggressive initial features. This allows for more
rapid diagnosis with substantially less burden on the healthcare system and decreases the stress that is placed on the
patients and families involved by requiring CT or MR with or without conscious sedation in order to arrive at the correct
diagnosis.
61
Podium #41
IMAGING CHARACTERISTICS OF MUSCULOSKELETAL ECHINOCOCCUS DISEASE
Mambalam P., American Institute for Radiologic Pathology, Silver Spring, MD; Murphey M.D., Senchak L.T.
(Presented by: Pramod Mambalam)
Purpose: To evaluate the imaging appearance of musculoskeletal Echinococcus with pathologic correlation.
Methods: We retrospectively reviewed 15 patients with pathologically confirmed musculoskeletal Echinococcus.
Radiologic studies were reviewed by three musculoskeletal radiologists with agreement by consensus and included
Radiography (XR)(n=12), Ultrasound (US)(n=2), Computed Tomography (CT)(n=8) and Magnetic Resonance Imaging
(MR)(n=11). Evaluation included patient demographics, lesion location, size, and characteristic intrinsic features in both
muscle and bone including morphology/signal, calcification, enhancement pattern, presence of daughter cysts/floating
membranes, and surrounding edema or atrophy.
Results: Patient age ranged from 32 to 82 years (M=49). There were 11 men and 4 women. The appendicular skeleton
was involved in 53% of cases. Bone alone was affected in 33% of cases, 33% muscle only, and 33% both bone and
muscle. Lesion size ranged from 4 to 39 cm in max dimension (M=14.9). On XR, lesions were intramedullary with a
predominantly mixed sclerotic/lytic appearance with expansile remodeling, no periosteal reaction, and a variable zone of
transition. US predominantly demonstrated a complex cystic lesion with internal smaller, round anechoic cystic structures.
Calcifications were present in 50% of cases by XR, CT or US. In cases with CT, MR, or US, uniformly round, peripheral
daughter cysts within a parent cyst was seen in 75% of cases. Floating membranes within the parent cyst was seen in
only 25% of cases. Mild surrounding edema was seen in 50% of cases by MR. Surrounding soft tissue atrophy was seen
in 30% of cases by MR. On MR, the predominant T1 and T2 signals were low−intermediate and high respectively, in 82%
of cases for both. Internal daughter cysts demonstrated low T1 and higher T2 signal in all cases. On CT or MR, a
peripheral/septal pattern of enhancement was seen in 78% of cases about the parent cysts but not around the daughter
cysts.
Conclusions: Imaging characteristics of musculoskeletal Echinococcus frequently suggests the diagnosis, similar to
other organ systems. These include the CT/MR appearance of multilocular parent cysts with internal, perfectly circular,
daughter cysts, often giving a “bowl of grapes”appearance. Parent cysts could demonstrate peripheral rim enhancement
and/or calcification with or without mild surrounding edema. Daughter cysts did not show enhancement. Floating
membranes are seen in only 25% of musculoskeletal Echinococcus.
62
Podium #42
NODULAR FASCIITIS: CHARACTERISTIC IMAGING FEATURES ON ULTRASOUND AND MAGNETIC RESONANCE
IMAGING
Yablon C.M., University of Michigan; Khuu A., Jacobson J.A., Inyang A., Lucas D., Biermann J.S.
(Presented by: Corrie Yablon, MD)
Purpose: Nodular fasciitis is a benign soft tissue tumor of spindle cell origin that often comes to clinical attention as a
rapidly growing mass. Imaging description of this mass has been limited to case reports. In this study we performed a
systematic retrospective review of pathologically proven cases of nodular fasciitis to characterize imaging features of
nodular fasciitis.
Materials and Methods: IRB approval was obtained and informed consent waived. We performed a retrospective records
review of both our radiology and pathology databases for the past ten years, searching the key words “nodular fasciitis.”
This initial search yielded 19 cases. We excluded cases that lacked correlative imaging or a final gross pathologic
diagnosis of nodular fasciitis, although many cases had preliminary core biopsy results of fasciitis. This exclusion criterion
yielded six cases with a final diagnosis of nodular fasciitis. Two musculoskeletal fellowship−trained radiologists with 17
and 8 years’ experience reviewed the ultrasound and MR imaging studies in consensus. At ultrasound, nodular fasciitis
was characterized with respect to: echogenicity; uniformity; shape; border; fascial tail; location; hyperemia; shadowing;
calcification; and increased through−transmission. Similarly, MR imaging features of nodular fasciitis were also
characterized: T1−weighted, fluid sensitive, and intravenous contrast sequences; shape; border; fascial tail; location; and
whether fat signal surrounded the mass. Patient records were also reviewed for information related to demographics.
Results: Six out of 19 cases yielded the final diagnosis of nodular fasciitis. Of the 13 cases that were excluded, two
lacked images, four lacked final pathology, and seven yielded the initial diagnosis of nodular fasciitis on percutaneous
core biopsy of nodular fasciitis, but these diagnoses were ultimately changed to myxoma, fibroma of the tendon sheath, or
desmoid fibromatosis on final pathology. Patients ranged in age from 8 to 33 years old; 3 male and 3 female. One patient
had MR imaging only; one patient had both MR and ultrasound imaging; and four patients had ultrasound imaging only.
Three masses were located in the subcutaneous tissue adjacent to fascia, two were at the subcutaneous/ muscular
border, and one was intramuscular; however, all were in contact with fascia and demonstrated a fascial tail on MRI and
ultrasound. All masses were ovoid in shape, with slightly ill−defined, lobulated borders with a size ranging from 2.5 – 3.0
cm. On MRI the masses were isointense to muscle on T1−weighted sequences, hyperintense to muscle on fluid−sensitive
sequences, and enhanced brightly but heterogeneously. All masses were surrounded by fat. On ultrasound, all lesions
were predominantly hypoechoic; all but the smallest demonstrated increased through transmission, and all demonstrated
variable hyperemia. None demonstrated shadowing or internal calcifications.
Conclusion: Nodular fasciitis had characteristic MR and ultrasound imaging features that included an oval or round mass
with ill−defined and lobulated margins, which was in contact with fascia and demonstrated a fascial tail. On MRI, the
nodular fasciitis was isointense to muscle on T1−weighted images and surrounded by fat with heterogeneous
enhancement. On ultrasound, all cases were hypoechoic. Percutaneous image−guided needle core biopsy yields
unreliable results; diagnosis should be made on gross resection.
63
Podium #43
RADIOGRAPHIC EVALUATION OF THE INBONE TOTAL ANKLE REPLACEMENT
Datir A., Emory Orthopaedics & Spine Center, Atlanta, GA;, Terk M.R., Labib S.A.
(Presented by: Abhijit Datir, MD)
Purpose: (1) To retrospectively evaluate post−operative radiographic appearance of INBONE total ankle replacement
(TAR) in 21 patients using validated linear and angular measurements.
(2) To identify INBONE prosthesis−specific radiographic findings that may correlate with post−operative outcome.
Materials and Methods: Twenty−one consecutive patients including 16 females and 5 males (mean age 62 years)
underwent TAR using INBONE cementless prosthesis from 2007−2010. The etiology of ankle joint arthritis was trauma
(n=15), rheumatoid arthritis (n=2) and idiopathic (n=4). A retrospective pre and post−operative radiographic analysis was
performed on anterior−posterior (AP) and lateral ankle projections using validated linear and angular measurements. The
pre−operative assessment included the tibial angle (TA), the talar angle (TAL), the talar slope (TS), and the coronal
deformity. The post−operative evaluation was performed on radiographs done at 6−month and 2−year interval follow−ups.
This included assessment of the talocalcaneal angle (TC), joint space height, the talar height, the lateral tibial component
angle (angle A), the lateral talar component angle (angle B), AP tibial component angle (angle C), in addition to the
pre−operative variables. Other post−operative assessment categorical variables included the presence or absence of
tibial or talar bone loss, talar collapse, talar subluxation, and AP positioning of the talus. The statistical analysis was
performed using two−sample t−test for assessing significance of pre and post variables with respect to the surgical
outcome as measured by the American Orthopaedic Foot and Ankle Society (AOFAS) hind−foot score. Fisher−Exact test
was also performed for categorical variables.
Results: Out of 21 patients, 18 had successful clinical outcome with intact prosthesis at 2−year follow−up and a mean
AOFAS score of 83.17 (SD=12.72). Three patients had failed arthroplasty with avascular necrosis of the talus resulting in
talar subsidence or loosening. Two patients had revisions of the talar component and one patient had deep infection that
was salvaged by prosthesis removal and fusion. Sixteen out of 21 patients had a pre−operative coronal plane deformity
(varus in 7 and valgus in 9 patients), ranging from mild (n=7, 5−10 degrees) to severe (n=1, more than 20 degrees). Out
of all the measured variables, only TC (p=0.003), angle B (p=0.003) and angle C (p<0.001) were found to be significant
(p<0.05) with regards to the post−surgical outcome. None of the categorical variables were found to have significant
correlation with the post−surgical outcome. On comparison of the pre and post−operative TA, TAL , TS and coronal
deformity variables, only TS showed significant correlation with p value of 0.002.
Conclusion: In our small case series, the radiographic measurements that may have significant correlation with surgical
outcome in INBONE TAR may include the talar slope, post−operative talocalcaneal angle, lateral talar and AP tibial
component angles. These should be routinely measured while reporting post−operative INBONE TAR radiographs. Also,
it is important to note that there was lack of significant correlation between the presence and degree of coronal deformity
(varus or valgus) with post−surgical outcome. Further research with larger number of patients and longer follow−up is
recommended.
64
Podium #44
EFFECT OF WRIST POSITIONING ON VISUALIZATION OF THE TRIANGULAR FIBROCARTILAGE WITH
MAGNETIC RESONANCE IMAGING
Dave H.K., Mayo Clinic Florida; Peterson J.J., Bestic J.M., Garner H.W., Tara O.M.
(Presented by: Heman Dave, MD)
Purpose: The triangular fibrocartilage (TFC) can be a challenge to adequately evaluate on routine non−contrast MR
examinations of the wrist. Positioning of the wrist in the MR scanner can alter the anatomic relationships of the ulnar
styloid process and surrounding structures which in turn can affect the visualization of the TFC. This can affect the ability
to visualize the entire ligament on standard MR images in the coronal plane. The purpose of this study is to ascertain how
positioning of the wrist in the MR magnet affects the imaging appearance of the TFC, and to determine which, if any, wrist
position (neutral, full pronation, full supination) results in optimal visualization of the TFC.
Materials and Methods: Coronal proton density fast spin echo fat saturated (PD FSE FS) images (TR 3500, TE 35, slice
thickness 3 mm, skip 3.3 mm, FOV 8 cm) were prospectively obtained with the wrist in pronation, supination, and neutral
positioning in 10 healthy asymptomatic volunteers (6 females and 4 males, ages 30−45). Images were obtained on either
a Siemens Avanto or Espree 1.5T magnet using a dedicated 4 channel wrist coil. Three fellowship trained
musculoskeletal (MSK) radiologists and two MSK fellows reviewed the images on a PACS workstation. Each wrist
position was graded on 2 separate data points. The first scoring parameter was the total of the number of contiguous
images each radiologist could see the entire TFC, including both the radial and ulnar attachments. The second scoring
system was graded on the radiologists’ opinion of the overall quality of the images scored from 1 (worst) to 5 (best).
Averages for both scoring scales were generated for each radiologist and each position. Data was also averaged between
radiologists to come up with a consensus.
Results: Data was fairly comparable between radiologists. In general, pronation was favored, followed by neutral and
then supination. Average numbers of contiguous slices was 2.62 for pronation, 2.18 for neutral, and 2.16 for supination.
Average scores on the quality of the images were 3.70 for pronation, 3.32 for neutral, and 3.18 for supination.
Conclusion: Our data indicates positioning of the wrist in pronation for MR examinations results in optimal visualization of
the TFC.
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ePosters*
*As these sessions are not moderated, ePosters are not CME accredited
Location: Hill Country A – C
Sunday 7:00 a.m. – 4:30 p.m.
Monday 7:00 a.m. – 12:30 p.m.
Tuesday 8:00 a.m. – 12:30 p.m.
Wednesday 7:00 a.m. – 10:30 a.m.
150
ePosters
ePoster #1
TECHNICAL STRATEGIES AND ANATOMIC CONSIDERATIONS FOR A MODIFIED
INFERIOR ENDPLATE PARAPEDICULAR ACCESS TO THORACIC AND LUMBAR
VERTEBRAL BODIES
Beall D.P., Clinical Radiology of Oklahoma, Oklahoma City, OK; Parsons B.P., Carson
C.C., Witherby J.R.
(Presented by: Douglas Beall, MD)
ePoster #2
MRI FOR SURVEILLANCE OF LOCALLY RECURRENT SOFT TISSUE SARCOMA: IS
GADOLINIUM NECESSARY?
Chou S.S., Department of Radiology, University of Washington, Seattle, WA; Ha A.S.,
Chew F.S.
(Presented by: Alice Ha, MD, MS)
ePoster #3
MR APPEARANCES OF THE TEMPORAL EVOLUTION OF SUPRAPATELLAR PLICA
SYNOVIALIS SYNDROME: SYNOVITIS, LIPOMA ARBORESCENCE AND RICE
BODIES
O'Brien S., Brooke Army Medical Center, San Antonio TX; Mansfield L.T.
(Presented by: Seth O'Brien, MD)
ePoster #4
HALLUX VALGUS: SPECTRUM OF IMAGING, SURGICAL PROCEDURES, AND
COMPLICATIONS
Scalcione L.R., University of Arizona Health Network, Tucson, AZ; Gimber L.H., Latt D.L.,
Chilvers M., Taljanovic M.S.
(Presented by: Mihra Taljanovic, MD, MSc)
ePoster #5
REFRACTORY LONG HEAD OF BICEPS TENDINOPATHY: TREATMENT WITH
ULTRASOUND-GUIDED PERCUTANEOUS TENOTOMY
Jose J., University of Miami; Greditzer H.G.
(Presented by: Jean Jose, DO, MS)
ePoster #6
ASEPTIC HIP PNEUMOARTHROSIS FOLLOWING MODULAR TOTAL HIP
ARTHROPLASTY: NOVEL CLINICAL AND IMAGING PRESENTATION OF
HARDWARE COMPLICATION
Morag Y., Weber A., Blaha J.D.
(Presented by: Yoav Morag, MD)
ePoster #7
USEFULNESS OF DUAL ENERGY COMPUTED TOMOGRAPHY IN THE
ASSESSMENT OF PATIENTS WITH ANTERIOR CRUCIATE LIGAMENT TEARS
Haas J.P., Mayo Clinic, Glazebrook KN; Brewerton L., Leng S., Carter R., Rhee P.,
Murthy N., Howe M., Ringler M., Fletcher J.
(Presented by: John Haas, MD)
ePoster #8
DOES INTRAVENOUS CONTRAST ADMINISTRATION INFLUENCE CLINICAL
COURSE IN PATIENTS WHO ARE IMAGED BY MRI FOR EVALUATION OF
OSTEOMYELITIS AND SOFT TISSUE INFECTIONS?
Ashikyan O., University of Oklahoma, Oklahoma City, OK; Riherd D.M., Attaya H.N.
(Presented by: Oganes Ashikyan, MD)
ePoster #9
COMMON MRI ARTIFACTS SIMULATING MUSCULOSKELETAL DISEASE: A CASEBASED REVIEW OF PHYSICS PRINCIPLES AND PROBLEM SOLVING
Hoang Q.L., New Orleans VA
(Presented by: Quoc Bao Hoang, MD)
151
ePosters
ePoster #10
CURRENT
CONCEPTS
REGARDING
CEMENTLESS
COMPONENTSGETTING DOWN TO THE “NITTY GRITTY”
Mollard B., USA; Morag Y., Hallstrom B., Urquhart A.
(Presented by: Yoav Morag, MD)
ePoster #11
MR IMAGING CHARACTERISTICS OF DIFFUSE-TYPE TENOSYNOVIAL GIANT
CELL TUMOR
Tarbox D., Mayo Clinic, Phoenix, AZ; Roberts C.C., Cross M.C., Kransdorf M.J.
(Presented by: D. Layne Tarbox, MD)
ePoster #12
QUALITY IMPROVEMENT PROJECT PITFALLS AND POTENTIAL TOPICS
Zell, S.I., Mayo Clinic, Phoenix, AZ; Roberts C.C.
(Presented by: Steven Zell, MD)
ePoster #13
ULTRASOUND OF THE ROTATOR CUFF INTERVAL – IMPROVED VISUALIZATION
WITH POSTERIOR SHIFT / EXTERNAL ROTATION (PSER) POSITIONING
Siegal D., Henry Ford Hospital, Detroit MI; Quenneville K., van Holsbeeck M.
(Presented by: Daniel Siegal)
ePoster #14
WITHDRAWN
ePoster #15
WITHDRAWN
ePoster #16
FEMORAL HEAD ANTEVERSION RELATIVE TO THE LINEA ASPERA :
MEASUREMENTS OF NORMAL SUBJECTS USING CT
Hyatt B., Brooke AMC, San Antonio, TX; Possley D., Hassan T., O'Brien S.
(Presented by: Seth O'Brien, MD)
ePoster #17
ASSOCIATION OF PELVIC INCIDENCE WITH PINCER TYPE
FEMOROACETABULAR IMPINGEMENT
Gililland J., University of Utah School of Medicine, Dept. Orthopedics, Salt Lake City, UT;
Harris M., Anderson L., Hanrahan C.J., Anderson A., Peters C., West H.
(Presented by: Christopher Hanrahan, MD, PhD)
ePoster #18
RADIOMICS OF SOFT TISSUE SARCOMA-COMPUTER-AIDED IMAGE ANALYSIS
AND CHARACTERIZATION OF TUMOR HETEROGENEITY
Raghavan M., Tampa, FL; Zhao M., Hall L.O., Goldgof D., Gatenby R.A.
(Presented by: Meera Raghavan )
ePoster #19
MUSCULOSKELETAL TUMOR MIMICS-CASES ENCOUNTERED AT AN NCIDESIGNATED CANCER CENTER
Raghavan M., Tampa, FL; Carter T.A.
(Presented by: Meera Raghavan )
ePoster #20
3 TESLA CHEMICAL SHIFT MR IMAGING: TECHNIQUE, CLINICAL UTILITY AND
PITFALLS FOR IMAGING THE SKELETON
Del Grande F., Johns Hopkins Hospital, Baltimore, MD; Vincenzo G., Flammang A.,
Fayad L.
(Presented by: Filippo Del Grande, MD, MBA)
ePoster #21
ANATOMIC AND FUNCTIONAL MR IMAGING OF PERIPHERAL NERVE TUMORS
AND TUMOR LIKE CONDITIONS
Chhabra A., JHU
(Presented by: Avneesh Chhabra)
152
FEMORAL
ePosters
ePoster #22
FDA RECALLED ARTICULAR SURFACE HIP REPLACEMENT (ASR): REVIEW OF
CLINICAL, RADIOLOGICAL AND SURGICAL FINDINGS
Lin C.H., SUNY Stony Brook University Hospital, Stony Brook, NY; Huang M., Nicholson
J., Gould E.S., Ragsdale M., Hoda S., Khan F.
(Presented by: Cheryl Lin, MD)
ePoster #23
DIFFUSION TENSOR IMAGING OF THE SCIATIC NERVE AT 3 TESLA: NORMATIVE
DIFFUSION VALUES
Chhabra A., JHU
(Presented by: Avneesh Chhabra)
ePoster #24
INTRANEURAL PERINEURIOMA: AN EDUCATIONAL REVIEW OF MR IMAGING
FEATURES WITH PATHOLOGIC CORRELATION
Miller T.L., Mayo Clinic, Howe B.M., Spinner R.J., Dyck P.B., Mauermann M.L., Felmlee
J.P., Amrami K.K.
(Presented by: Troy Miller)
ePoster #25
MR IMAGING MANIFESTATIONS OF GOUT: A CRYSTAL CLEAR REVIEW
Makanji R.J., University of South Florida, Tampa, FL; Kedar R., Rao N., Anderson S.,
Prakash N.
(Presented by: Rikesh Makanji, MD)
ePoster #26
MR IMAGING MANIFESTATIONS IN RHEUMATOID ARTHRITIS: AN EDUCATIONAL
REVIEW
Makanji, R.J., University of South Florida, Tampa, FL; Kedar R., Anderson S., Prakash
N., Rao N.
(Presented by: Rikesh Makanji, MD)
ePoster #27
RARE AND COMMON OSSICLES OF THE LOWER EXTREMITY: IMAGING
MANIFESTATIONS AND CLINICAL IMPLICATIONS
Makanji R.J., University of South Florida, Tampa, FL; Rao N.
(Presented by: Rikesh Makanji, MD)
ePoster #28
CORRELATION OF CT GUIDED SPINE BIOPSY AND BLOOD CULTURE RESULTS
IN PATIENTS WITH SUSPECTED SPONDYLODISKITIS
Larrison M., Birmingham, AL; Hamrick K., Frazier M.
(Presented by: Matthew Larrison, MD)
ePoster #29
AC JOINT: AN OFTEN OVERLOOKED SOURCE OF SHOULDER DISABILITY AND
PAIN
Tagoylo G., Ha A.S., Petscavage J.M.
(Presented by: Gino Tagoylo, MD)
ePoster #30
SAVING FORM AND FUNCTION: THE RADIOGRAPHIC APPEARANCE OF LIMB
SALVAGE AND TUMOR SURGERY
Britton C.A., University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania;, Chu E.
(Presented by: Cynthia Britton, MD)
ePoster #31
EVALUATION OF OSTEOARTICULAR ALLOGRAFTS: WHAT THE RADIOLOGIST
NEEDS TO KNOW
Graves H.F., Vanderbilt University Medical Center, Nashville, TN; Hartley K.G.
(Presented by: Houston Graves, MD, JD)
ePoster #32
ANALYSIS OF ISCHIAL SPINE ORIENTATION IN PATIENTS WITH PUDENDAL
COMPRESSION NEUROPATHY – A STUDY USING 3D COMPUTED TOMOGRAPHY
Chen L., Marvel R.P., Richard H.M.
(Presented by: Lina Chen)
153
ePosters
ePoster #33
TRICEPS INJURIES – ALL YOU WANTED TO KNOW!
Kumaravel M., UT Health; Proett J.
(Presented by: Manickam Kumaravel, MD, FRCR)
ePoster #34
PREMATURE LUMBAR DISC DEGENERATION - IS MINOR ENDPLATE LENGTH
DISCREPANCY A PREDICTOR?
Weatherall P.T., University of Texas Southwestern Medical Center, Dallas, TX; Graziano
V.
(Presented by: Paul Weatherall, MD)
ePoster #35
EVALUATION OF FOREFOOT PAIN: A PICTORIAL REVIEW
Yadavalli S., Beaumont Health System, Royal Oak, MI; Jain R.K.
(Presented by: Sailaja Yadavalli, MD, PhD)
ePoster #36
HIGH RESOLUTION MR IMAGING OF ELBOW ANATOMY, VARIANTS, AND
COMMON PATHOLOGIES REVISITED
Smith C.M., UTHSCSA, San Antonio, TX; Loredo R.A., Bean G., Garcia G., Humphrey J.
(Presented by: Crysela Smith, MD)
ePoster #37
FEMOROACETABULAR IMPINGEMENT (FAI): A NEW TECHNIQUE TO IDENTIFY
IMPINGEMENT MORPHOLOGY
Pandey T., UAMS, Little Rock, AR; Guidry C., Alapati S., Medarametla S., Ram R.,
Lensing S.Y., Jambhekar K.
(Presented by: Carey Guidry, MD)
ePoster #38
ULTRASOUND GUIDED POPLITEAL CYST ASPIRATION, SYMPTOM RELIEF AND
CLINICAL OUTCOME
Gomez A.M., UCLA Medical Center, Los Angeles, CA; Seeger L.I., Levine B.D., Manzoul
S., Motamedi K.
(Presented by: Ana Gomez, MD)
ePoster #39
WHERE DO WE STAND? EVALUATING RADIATION EXPOSURE TO OPERATORS
DURING CT FLUOROSCOPY
Gabel C., University of Rochester School of Medicine and Dentistry; Kheyfits V.,
Dieudonne G., Paeth T., Jeremenko N.T., Monu J.U.
(Presented by: Christopher Gabel, MD)
ePoster #40
LOW DOSE CT PANOREX IMAGING REPLACING PANOREX FILMS WITH CT
IMAGING IN A TERTIARY CARE CENTER
Moorthy M.K., University of Rochester School of Medicine and Dentistry; Dieudonne G.,
Mis F., Kheyfits V., Monu J.U., Waldman D.
(Presented by: Meena Moorthy, MD, MBA)
ePoster #41
THE LINE METHOD, A NEW TECHNIQUE TO MEASURE GLENOID BONE LOSS
USING 3D RECONSTRUCTIONS
Rios A., NYU Langone Medical Center; Bloom M., Babb J., Beltran L., Gyftopoulos S.
(Presented by: Alyssa Rios)
ePoster #42
COMPLICATIONS OF ARTHROSCOPIC FEMORAL ACETABULAR IMPINGEMENT
SURGERY: RADIOGRAPHIC FINDINGS AND CLINICAL CORRELATIONS
Mortensen W.M., University of Utah School of Medicine; Hanrahan C.J., Crim J.R.
(Presented by: Wayne Mortensen, MD)
154
ePosters
ePoster #43
ASSOCIATION OF NON-WEIGHT BEARING MEDIAL FEMORAL CONDYLE EDEMA
WITH ACUTE ACL TEAR
Eaton J., University of Colorado, Aurora, CO; Petersen B.
(Presented by: James Eaton, MD)
ePoster #44
IMAGING REVIEW OF OSTEOCHONDRITIS DISSECANS AND IRREGULAR
OSSIFICATION OF THE FEMORAL CONDYLE: IS REEVALUATION OF THE
CURRENT GRADING SYSTEM NEEDED?
Byra P., University of South Florida, Tampa, FL; Rao N.
(Presented by: Paul Byra, MD)
ePoster #45
MRI OF INFRAPATELLAR PLICA INJURY WITH SURGICAL AND CLINICAL
CORRELATION
Javery O., Brigham and Women's Hospital/Harvard Medical School, Boston, MA; Pandey
S., Han R., Gaviola G.C.
(Presented by: Omar Javery, MD)
WINDSWEPT APPEARANCE: A NEW SIGN TO DESCRIBE SUBSCAPULARIS
TENDON TEARS
Ismail A., Univ of Iowa, Iowa City, IA; Bennett D.L.
(Presented by: D. Bennett, MD, MA)
ePoster #46
ePoster #47
ePoster #48
WITHDRAWN
THE ACL ON MRI AXIAL OBLIQUE IMAGING: NORMAL ANATOMY AND MIMICS OF
PATHOLOGY
Stedman D., The University of Texas Health Science Center at San Antonio, TX; Bean
G.W., Loredo R., Garcia G.
(Presented by: Deborah Stedman, MD)
ePoster #49
THE “BALTIMORE BUBBLE” REVISITED: HIP NITROGEN AS A FINDING OF
RECENT DISLOCATION
Duffy E.J., Penn State Hershey Medical Center, Hershey, PA;, Petscavage J.M., Walker
E.A., Bernard S.A., Brian P.M., Flemming D.J., Mosher T.J.
(Presented by: Eric Duffy, MD)
ePoster #50
IMAGING OF THE ELITE ATHLETE: BEYOND THE UCL
Cordle A., Cleveland Clinic, Hanano A., Hatem S.
(Presented by: Andrew Cordle MD, PhD)
ePoster #51
ADVANCED IMAGING OF GOUT AND CALCIUM CRYSTAL DEPOSITION DISEASES
Ibrahim G.F., Cleveland Clinic Foundation, Cleveland, Ohio; Schils J., Hatem S.
(Presented by: Gehan Ibrahim, MD)
ePoster #52
WITHDRAWN
ePoster #53
CHOPART TO LISFRANC AND EVERYTHING IN BETWEEN, A REVIEW OF
MIDFOOT TRAUMA
Saade J.Y., Cleveland Clinic, Cleveland, OH; Hatem S.
(Presented by: Jimmy Saade MD)
ePoster #54
UPDATE ON GADOLINIUM CONTRAST FOR MUSCULOSKELETAL IMAGERS
Hochman M.G., Beth Israel Deaconess Medical Center; Wei J.L.
(Presented by: Mary Hochman, MD, MBA)
WITHDRAWN
ePoster #55
ePoster #56
BONE WINDOWS FOR DISTINGUISHING MALIGNANT FROM BENIGN PRIMARY
BONE TUMORS ON FDG PET/CT
Costelloe C.M., University of Texas MD Anderson Cancer Center; Chuang H.H, Chasen
B.A., Pan T., Fox P.S., Bassett R.L., Madewell J.E.
(Presented by: Colleen Costelloe, MD)
155
ePosters
ePoster #57
ePoster #58
ePoster #59
ePoster #60
IS THERE AN ASSOCIATION BETWEEN PSOAS ATROPHY AND PRIOR HIP
SURGERY IN PATIENTS WITH RECURRENT GROIN PAIN?
Hobbs G.P., Thomas Jefferson University Hospital, Philadelphia, PA; Zoga A.C., Meyers
W.C., Chi A., Horner M., Morrison W.B.
(Presented by: George Hobbs, MD)
ULTRASOUND VERSUS CT-GUIDED MUSCULOSKELETAL SOFT TISSUE MASS
BIOPSY: A COMPARATIVE EFFECTIVENESS ANALYSIS
Hanson J.A., University of Wisconsin, Madison, WI; Lee K.S., Peterson A.
(Presented by: James Hanson, MD)
WHY DO BONE CONTUSIONS MATTER?
Beaman F.D., University of Kentucky; Barker C.H., Montgomery J.R., Spicer P.J.,
Blomquist, G.A.
(Presented by: Francesca Beaman, MD)
VANISHING FEMORAL NECK: A MYSTERIOUS PROCESS
Blain Paré E., University of Montreal Hospital Center, Montreal, QC, Canada; Ehlinger
M., Dosch J., Moser T.
(Presented by: Etienne Blain Paré, MD, CM, FRCPC, dABR)
156
ePoster #1
TECHNICAL STRATEGIES AND ANATOMIC CONSIDERATIONS FOR A MODIFIED INFERIOR ENDPLATE
PARAPEDICULAR ACCESS TO THORACIC AND LUMBAR VERTEBRAL BODIES
Beall D.P., Clinical Radiology of Oklahoma, Oklahoma City, OK; Parsons B.P., Carson C.C., Witherby J.R.
(Presented by: Douglas Beall, MD)
Purpose: To investigate and illustrate a variation on the traditional percutaneous access to the vertebral body via an
extrapedicular approach.
Materials and Methods: An effective extrapedicular access technique that could safely and reliably guide the needle tip
into the center of the vertebral body was developed from cadaver dissection observations for the purpose of clinical use. A
total of 72 vertebral compression fractures from T−6 to L−4 were treated via the parapedicular access at our institution
between July 2008 and August 2012. There were 72 patients between ages 58 and 96 (mean age 70.2 years) who
underwent treatment.
Results: The cadaver dissection revealed a relatively avascular and aneural portion of the vertebral body along the
inferior margin of the vertebral body just superior to the inferior endplate. A total 102 vertebral fractures were treated using
the extrapedicular access technique without any recognized clinical complications from the needle access or the
instrumentation.
Conclusions: The thoracic and lumbar vertebral bodies may be safely, reliably and reproducibly accessed using a
percutaneous extrapedicular access technique. The technique presented represents a relatively avascular and aneural
approach to vertebral body.
ePoster #2
MRI FOR SURVEILLANCE OF LOCALLY RECURRENT SOFT TISSUE SARCOMA: IS GADOLINIUM NECESSARY?
Chou S.S., Department of Radiology, University of Washington, Seattle, WA; Ha A.S., Chew F.S.
(Presented by: Alice Ha, MD, MS)
Purpose: Local recurrence is the most common manifestation of treatment failure in soft tissue sarcomas (STS). MRI is
routinely used to monitor locally treated STS, although no consensus guideline has been published to date that describes
the optimal imaging follow−up. Our aim is to review the results of MRI studies performed in follow−up after primary
resection of STS, with an emphasis on the use of gadolinium.
Materials and Methods: Approval for a retrospective study was granted by the appropriate Institutional Review Board.
We identified 50 patients with histologically proven soft tissue sarcomas who were treated and followed with MRI at our
institution between 1995 and 2011. Medical records were reviewed for patient demographics, clinical presentation and
course, tumor features, MRI findings, and final pathologic diagnoses. We used statistical analysis to compare
non−contrast (NC) and contrast−enhanced (CE) follow−up MRI examinations.
Results: The 50 patients in our study group underwent 338 postoperative MRI examinations at our institution. The mean
number of postoperative studies per patients was 6.8 (range 1 to 34) and the mean length of follow−up was 55 months
(range 3 to 168 months). There were 32 men and 18 women, and a mean age of 52 (range 22 to 88).
Pathology−proven recurrence was identified in 23 of the 50 patients (46%). The primary tumor was located in the lower
extremity (56%), upper extremity (16%), pelvis (14%), thorax (12%), and abdominal wall (2%). Malignant fibrous
histiocytoma was the most common histologic subtype (46%), followed by liposarcoma (12%) and synovial sarcoma
(10%). Majority of the tumors were grade 2 (42%) and 3 (48%). Histologically proven recurrence developed in 23 of the 50
patients (46%).
From 1995 to 2000, 3 (14%) of the 22 studies were CE−MRI and 19 (86%) were NC−MRI. From 2001 to 2005, 99 (59%)
of the 169 studies were CE−MRI, and from 2006 to 2011, 142 (97%) of the 147 studies were CE−MRI.
A total of 58 biopsies or reoperations were performed. 43 biopsies were done following a CE−MRI, 36 (84%) of which
were positive and were detected by 28 of the 36 (78%) CE−MRIs. 15 biopsies were obtained following a NC−MRI, 9
(60%) of which were positive and were identified by 4 of the 9 (44%) NC−MRIs.
Conclusion: MRI is widely employed for surveillance of local recurrence after soft tissue sarcoma resection. Routine use
of gadolinium agent is the trend in the past decade and helps improve the detection rate of local recurrences.
157
ePoster #3
MR APPEARANCES OF THE TEMPORAL EVOLUTION OF SUPRAPATELLAR PLICA SYNOVIALIS SYNDROME:
SYNOVITIS, LIPOMA ARBORESCENCE AND RICE BODIES
O'Brien S., Brooke Army Medical Center, San Antonio TX; Mansfield L.T.
(Presented by: Seth O'Brien, MD)
Educational Goals and Teaching Points: 1. To review the anatomy of synovial plicae in the knee. 2. To review the
clinical and imaging features of plica syndrome. 3. To report the MR appearance of the temporal evolution of suprapatellar
plica syndrome of 4 patients presenting with synovitis, lipoma arborescens and rice bodies.
Description of Findings: Synovial folds or plicae around the knee are remnants of synovial membranes from the
embryologic development of the knee. They are thin vascularized folds of synovial tissue commonly seen on T2−weighted
fat suppressed images as thin bands of low signal intensity within high signal intensity joint fluid and have no known
function. There are four types of plicae: suprapatellar, medial, infrapatellar and lateral, all of which have variable
appearance and incidence on arthroscopy.
Regardless of the type, the majority of synovial plicae are asymptomatic. Rarely, plicae become pathologically thickened
and fibrosed, leading to relative inelasticity. When this occurs, the thickened plicae can snap over the femoral condyle
causing synovitis, chondral damage, and pain. These hypertrophic and fibrotic plicae are found in 3.8% of knee
arthroscopies and will be the only finding in patients with plica syndrome, which is most commonly seen with medial plica.
The suprapatellar plica has seven variations. One particular variation, the complete form, prevents communication of the
suprapatellar bursa with the knee joint and may not be recognized on arthroscopy unless the arthroscopist attempts to
identify the insertion of the articularis genu. Suprapatellar plica syndrome may therefore present with bursitis, pain or soft
tissue mass due to chronic localized inflammation. This localized inflammation cannot only affect the plicae but also the
adjacent synovium potentially leading to secondary processes including lipoma arborescence and rice body formation.
Lipoma arborescence of the knee is most commonly found in the suprapatellar recess. It is composed of hypertrophic
synovial villi distended with fat which have a branchlike or treelike appearance. Lipoma arborescence is typically a
reactive process associated with chronic synovitis, most frequently seen with osteoarthritis; however, it has been reported
in suprapatellar plica syndrome.
Rice bodies are formed as a result of chronic progressive inflammation and end−state fibrosis of synovial villi which
eventually become detached. They are named for their uncanny resemblance to polished rice grains. Rice bodies are
most commonly seen in patients with rheumatoid arthritis but are also found in other types of articular disease, including
tuberculosis. Rice bodies have not been reported in plica syndrome and can be confused with synovial
osteochondromatosis. However, radiography shows that they are not calcified, and arthroscopy confirms that the
intra−articular bodies were rice bodies.
Conclusion: We report the unique MR imaging appearance of four cases of suprapatellar plica syndrome presenting with
synovitis, lipoma arborescence and rice bodies. We hypothesize that chronic synovitis due to complete suprapatellar plica
leads to sloughing of the synovial villi into the suprapatellar bursa forming the rice bodies.
158
ePoster #4
HALLUX VALGUS: SPECTRUM OF IMAGING, SURGICAL PROCEDURES, AND COMPLICATIONS
Scalcione L.R., University of Arizona Health Network, Tucson, AZ; Gimber L.H., Latt D.L., Chilvers M., Taljanovic M.S.
(Presented by: Mihra Taljanovic, MD, MSc)
Purpose: It is the authors’ intent to reinforce the reader’s knowledge of the pathophysiology and altered biomechanics of
hallux valgus. We will review the radiographic assessment of the pre−operative and post−operative patient as well as
describe several commonly performed corrective surgical procedures and their potential complications.
Material and Methods: Utilizing predominately radiographs, CT, and MRI images for a case based approach, the reader
will review the pathophysiology of hallux valgus deformity as well as the radiologic evaluation of the pre−operative and
post−operative patient.
Results: The pathophysiology of hallux valgus will be reviewed. The inciting failure of the great toe metatarsophalangeal
medial collateral ligament and medial metatarsosesmoid ligament will be discussed followed by the subsequent sequential
osseous and soft tissue failure. The altered biomechanics responsible for further progression of hallux valgus including
asymmetric tension of the adductor hallucis muscle, lateral bowstringing of the extensor and flexor hallucis longus
tendons, lateral sesmoid uncoverage, and pronation of the metatarsal head will be discussed.
A review of pertinent radiographic measurements will include assessment of the hallux valgus angle (HVA),
intermetatarsal angle (IMA), interphalangeal angle (IPA), and distal metatarsal angle (DMAA). The surgical indications for
corrective procedures will be reviewed and several common surgical procedures including chevron osteotomies, scarf
osteotomies, and the Lapidus procedure will be explained.
The discussion will conclude with the radiographic assessment and follow−up of the post−operative patient. The surgical
complications such as osteonecrosis of the great toe metatarsal head, osteotomy malunions and non−unions, transfer
metatarsalgia, and hallux valgus recurrence will be discussed.
Conclusion: Hallux valgus is a common condition affecting as many as 16% of patients older than 60 years of age. Many
causative factors have been described including poor footware, excessive weight−bearing, age, first−ray hypermobility,
ligamentous laxity, and pes planus. It is important for a radiologist to be familiar with the pre−operative radiographic
findings and post−operative radiographic evaluation of hallux valgus. An understanding of the biomechanics of hallux
valgus, sequential soft tissue and osseous failure, and post−operative complications will aid in radiologic diagnosis.
159
ePoster #5
REFRACTORY LONG HEAD
PERCUTANEOUS TENOTOMY
OF
BICEPS
TENDINOPATHY:
TREATMENT
WITH
ULTRASOUND-GUIDED
Jose J., University of Miami; Greditzer H.G.
(Presented by: Jean Jose, DO, MS)
Background Information: Tendinopathy of the long head of the biceps brachii (LHB) encompasses a spectrum of
pathologies, ranging from inflammatory tendinitis to degenerative tendinosis. Disorders of the LHB often occur in
conjunction with other shoulder pathologies, such as rotator cuff disease, superior labral tears, and injury to the biceps
pulley system. Non−surgical management for mild disease consists of non−steroidal anti−inflammatory medications,
physical therapy, and injections of anesthetics/corticosteroids into the biceps tendon sheath. However, in patients with
refractory or severe disease, surgical management is indicated, with biceps tenotomy being one of the most commonly
performed procedures for older or less active individuals. Surgical release of the LHB tendon is usually performed with
arthroscopic guidance with both anterior and posterior ports. We report a new minimally−invasive method for LHB
tenotomy under ultrasound−guidance. Using a 3.0 mm arthroscopic hook knife, we performed the procedure via a
suprapectoral approach. After successfully cutting the LHB tendon without injury to the supraspinatus and subscapularis
tendons on a cadaver, we performed the procedure on a 58 year old male patient, who reports significant improvement in
anterior shoulder pain 15 months post−procedure.
Education Goals/Teaching Points: This exhibit will 1) Briefly describe the clinical evaluation of anterior shoulder pain 2)
Review the key sonographic and arthroscopic findings in LHB tendinopathy 3) Review LHB tendon and biceps pulley
system anatomy and pathophysiology 4) Detail minimally invasive ultrasound−guided suprapectoral approach to
performing LHB tenotomies.
Describe the key anatomic or physiologic issues, imaging findings or imaging technique the proposed exhibit will address
Arthroscopic and sonographic appearance of LHB tendinopathy, the so−called "lipstick biceps." We will detail the
suprapectoral approach to ultrasound guided tenotomy with a focus on anatomic and technical considerations.
Conclusion: Ultrasound−guided LHB tenotomy is a safe, effective and minimally−invasive alternative treament to the
traditional arthroscopic approach for patients with refractory LHB tendinopathy
160
ePoster #6
ASEPTIC HIP PNEUMOARTHROSIS FOLLOWING MODULAR TOTAL HIP ARTHROPLASTY: NOVEL CLINICAL
AND IMAGING PRESENTATION OF HARDWARE COMPLICATION
Morag Y., Weber A., Blaha J.D.
(Presented by: Yoav Morag, MD)
Purpose: Describe the clinical and imaging presentation of aseptic pneumoarthrosis in hips following Titanium/Titanium
(Ti/Ti) modular neck−stem interface Total Hip Arthroplasty (MTHA), discuss the imaging differential diagnosis, and
propose a novel underlying etiology taking into consideration the unique biomechanics of this type of hardware.
Materials and Methods: Five patients with hip pneumoarthrosis following MTHA will be presented with a discussion of
the clinical features and imaging characteristics on radiographs and CT and propose an explanation for this phenomenon.
Results: Five patients (4 male, 1 female, age 55−61 years) presented with a−traumatic acute hip pain 36−60 months
following THA with a Ti/Ti modular neck−stem interface. A large amount of gas was identified in the symptomatic hip
without systemic signs of infection in all cases. The gas was located in large pockets in the non−dependent portion of the
joint without evidence of loculation, without the presence of small entrapped gas bubbles or gas dissecting through soft
tissue planes. Joint fluid was confirmed in four cases which had undergone aspiration and air fluid levels in two cases
where CT was performed. Clinical and lab values were without sign of systemic infection. Preoperative hip aspiration
performed in four of the cases was without evidence of infection on culture/gram stain. In one of these cases, joint gas
was aspirated and on spectrometry, a large amount of hydrogen was found when compared to room air. In the following
surgery, a strong report and resultant smoke was noted upon use of the slap hammer suggesting the presence of
combustible hydrogen gas. Ti blood level obtained in 4 of the cases was found to be elevated (14−61 ng/ml). In surgery,
the modular neck showed corrosion or frank fracture at the modular neck−stem interface and was replaced in all cases.
Two of the patients were found to have spontaneous hip pneumoarthrosis of the contralateral MTHA 7 and 65 months
following initial arthroplasty presenting in a similar fashion during workup up for acute a−traumatic hip pain without
systemic signs of infection. Hip CT images performed at an outside institution were not available for evaluation in one of
these cases while a large amount of intra−articular gas was noted on radiographs in the second case.
Conclusion: Aseptic pneumoarthrosis should be considered in cases of spontaneous pneumoarthrosis following Ti/Ti
MTHA presenting with acute a−traumatic pain without signs/symptoms of infection or antecedent trauma. Intra−articular
hip joint gas is typically distributed in large pockets in a non loculated and nondependent fashion without accompanying
entrapped/ dissecting smaller gas bubbles. Crevice corrosion due to micro−motion at the modular Ti neck−stem interface
with resultant release of diatomic hydrogen accumulating near the interface is the suggested etiology. Acute hip pain may
be the result of an abrupt release of the accumulated hydrogen into the hip joint following movement and/or progressive
corrosion or due to component fracture.
161
ePoster #7
USEFULNESS OF DUAL ENERGY COMPUTED TOMOGRAPHY IN THE ASSESSMENT OF PATIENTS WITH
ANTERIOR CRUCIATE LIGAMENT TEARS
Haas J.P., Mayo Clinic, Glazebrook KN; Brewerton L., Leng S., Carter R., Rhee P., Murthy N., Howe M., Ringler M.,
Fletcher J.
(Presented by: John Haas, MD)
Purpose: Knee CT is used to evaluate for traumatic bone injury, without assessment of critical ligamentous structures.
We determine how dual energy CT (DECT) could be used to detect anterior cruciate ligament (ACL) tears and estimate its
performance.
Method and Materials: 16 patients (13 males, 3 females, aged 19−51 years) with unilateral traumatic ACL tears
confirmed by MRI, and 11 control patients with no history of trauma, underwent DECT of both knees after informed
consent in this IRB−approved prospective study. For each knee, 3 image planes were assessed with soft tissue windows:
axial, sagittal, and oblique sagittal (to the ACL). Additionally, oblique sagittal images with DECT bone removal,
threshold−based bone removal, and DECT tendon−specific color mapping were evaluated. 4 MSK radiologists randomly
evaluated the 324 DECT reconstructed series (54 knees x 6 displays) separately, evaluating for presence or absence of
an ACL tear using a 5−point scale (1=definitely not torn to 5=definitely torn ). Using ROC analysis, AUCs were calculated
for each reader for each display, with reader agreement evaluated using intraclass correlation coefficients (ICC). For
sensitivity estimates, a cutoff of 3 was used to indicate a torn tendon.
Results: Diagnostic performance for detection of ACL tears varied between techniques (p<0.01) for all but one reader
(p=0.71). With the notable exception of the tendon−specific color map images (Mean AUC: 079; Range: 0.66−0.94, ICC:
0.41), sagittal oblique displays performed best: mixed kV (Mean AUC: 0.95; Range: 0.94−0.97; ICC: 0.63), DECT bone
removal (Mean AUC: 0.94; Range: 0.93 – 0.96; ICC: 0.62) and single−energy bone removal (Mean AUC: 0.93; Range:
0.89 – 0.96; ICC: 0.69). Reader performance did not differ statistically for these three displays (p>0.25 for each), but did
differ significantly for the color map images (p<0.05). Mean sensitivity/specificity for the three best performing displays
were 94%/87%, 92%/84% and 88%/84%, respectively.
Conclusion: Oblique sagittal reconstructions of DECT images using either mixed−kV or DECT bone removal displays
performed better than the other display techniques evaluated. The high AUC, sensitivity and specificity show promise for
the detection of ACL tears using CT, adding clinical utility in the emergency room due to the more ubiquitous presence of
CT in the emergency room setting as compared to MRI.
162
ePoster #8
DOES INTRAVENOUS CONTRAST ADMINISTRATION INFLUENCE CLINICAL COURSE IN PATIENTS WHO ARE
IMAGED BY MRI FOR EVALUATION OF OSTEOMYELITIS AND SOFT TISSUE INFECTIONS?
Ashikyan O., University of Oklahoma, Oklahoma City, OK; Riherd D.M., Attaya H.N.
(Presented by: Oganes Ashikyan, MD)
Purpose: To determine differences in likelihood of undergoing drainage procedures, in number of hospital days, and in
other clinical course variables among patients who receive and do not receive intravenous gadolinium contrast material
for evaluation of suspected osteomyelitis and soft tissue infections in the extremities and osseous pelvis.
Materials and Methods: After obtaining exemption from full IRB review for this retrospective study, we reviewed reports
of 114 MR studies in 99 patients that were obtained for evaluation of infections in the extremities and osseous pelvis. We
recorded the age and sex of each patient, and obtained study date, imaged body part, presence or absence of
osteomyelitis, location of osteomyelitis, presence or absence of sinus tract, presence or absence of focal fluid collection,
size of the fluid collections, date of the study, admission date, discharge date, and absence or presence of follow up
drainage procedures.
Results: 40 MR studies in 34 patients were obtained with and without administration of contrast material. 74 studies in 65
patients were obtained without administration of contrast material. There was no statistically significant difference in
detection of osteomyelitis, detection of sinus tract, size of soft tissue fluid collection, size of intraosseous abscess,
likelihood of undergoing a drainage procedure, number of days from MRI to procedure, number of days from admission to
MRI, and number of days from procedure to discharge between the two groups. Patients who received intravenous
contrast spent fewer total days in the hospital and fewer days from MRI to discharge.
Conclusion: There is no difference in likelihood of undergoing drainage procedure between patients who receive and do
not receive intravenous contrast for evaluation of osseous and soft tissue infections by MRI. Differences in the total
number of days in the hospital and number of days from MRI to discharge may be influenced by other co−variables.
163
ePoster #9
COMMON MRI ARTIFACTS SIMULATING MUSCULOSKELETAL DISEASE: A CASE-BASED REVIEW OF PHYSICS
PRINCIPLES AND PROBLEM SOLVING
Hoang Q.L., New Orleans VA
(Presented by: Quoc Bao Hoang, MD)
Frequently encountered artifacts in musculoskeletal MRI include magic angle, truncation, pulsation, susceptibility and
aliasing (wraparound) artifacts. These artifacts are not only a cause of suboptimal image quality, but may also mimic
disease. The following presentation is a case−based review of these common artifacts, their basic physics principles and
techniques to resolve them.
ePoster #10
CURRENT CONCEPTS REGARDING CEMENTLESS FEMORAL COMPONENTSGETTING DOWN TO THE “NITTY
GRITTY”
Mollard B., USA; Morag Y., Hallstrom B., Urquhart A.
(Presented by: Yoav Morag, MD)
Purpose: Introduce the current classification of cementless femoral components, describe the guidelines for component
selection, variations in surgical technique and describe expected and unexpected findings on follow−up imaging.
Background: Cementless hip Arthroplasty has been gaining popularity because osseous overgrowth/ ingrowth are
considered potentially advantageous over the use of cement.
The femoral component has undergone numerous modifications in regard to composition and geometry in order to
minimize stress shielding, bone weakening and fracture as well as post procedure thigh pain.
Current classification of cementless femoral components is based on geometry and pattern of fixation. The selection of a
specific femoral component and the surgical technique originates from femur anatomy and the variable fixation with
different types of femoral components. The expected radiographic findings are derived from the typical osteointegration
pattern of different types of femoral components.
Methods: Current classification of cementless femoral components, the selection process and variations in surgical
technique will be described with accompanying clinical images. Examples of expected changes and hardware
complication as seen on follow up imaging will be presented and discussed based on the expected biomechanics.
Advances in knowledge: By appreciating the differences between noncemented femoral components, the radiologist will
more readily be able to discern hardware complications.
ePoster #11
MR IMAGING CHARACTERISTICS OF DIFFUSE-TYPE TENOSYNOVIAL GIANT CELL TUMOR
Tarbox D., Mayo Clinic, Phoenix, AZ; Roberts C.C., Cross M.C., Kransdorf M.J.
(Presented by: D. Layne Tarbox, MD)
Purpose: To describe the typical MR imaging characteristics of diffuse−type tenosynovial giant cell tumor (TGCT) and
compare with other histologically similar tumors including localized giant cell tumor of tendon sheath (GCTTS), pigmented
villonodular synovitis (PVNS), and nodular synovitis.
Materials and Methods: We review a case of a large diffuse−type tenosynovial giant cell tumor involving the deep soft
tissues of the distal thigh. From the basis of this case, other pathologically similar entities are presented with the
differentiating features highlighted.
Results and Conclusion: The family of synovial proliferative disease has common histologic features but a variety of
appearances on MR imaging ranging from small discrete nodules to large aggressive−appearing masses. Attention to the
sometimes subtle details of these lesions will allow successful differentiation on imaging.
164
ePoster #12
QUALITY IMPROVEMENT PROJECT PITFALLS AND POTENTIAL TOPICS
Zell, S.I., Mayo Clinic, Phoenix, AZ; Roberts C.C.
(Presented by: Steven Zell, MD)
Purpose: To review common mistakes made when performing quality improvement projects and suggest potential quality
improvement project topics for musculoskeletal radiologists.
Materials and Methods: Several years of teaching, mentoring, and grading quality improvement projects has led to
development of a list of mistakes that are commonly made when quality improvement projects are undertaken. A list of
potential project options is provided to help musculoskeletal radiologists choose projects that are pertinent to their
practice.
Results and Conclusion: Completion of quality improvement projects is required for radiologists undergoing American
Board of Radiology Maintenance of Certification and residents in ACGME accredited programs. Review of pitfalls and
potential project options will help radiologists complete these projects successfully.
ePoster #13
ULTRASOUND OF THE ROTATOR CUFF INTERVAL – IMPROVED VISUALIZATION WITH POSTERIOR SHIFT /
EXTERNAL ROTATION (PSER) POSITIONING
Siegal D., Henry Ford Hospital, Detroit MI; Quenneville K., van Holsbeeck M.
(Presented by: Daniel Siegal)
Purpose: This presentation details the posterior shifted / external rotation (PSER) technique for imaging the rotator cuff
interval (RCI), with photographic and sonographic examples.
Materials and Methods: IRB approval was obtained. Retrospective PACS review identified patients who underwent
diagnostic shoulder ultrasound within the last five years, with clinical symptoms of adhesive capsulitis. Shoulder
ultrasound examinations were performed by a single sonographer as part of routine ultrasound evaluation for shoulder
symptoms. All examinations were acquired at the same diagnostic site, using the same ultrasound equipment. Images of
the rotator cuff interval were obtained in standard positioning, and in PSER positioning. All images were interpreted by a
fellowship−trained musculoskeletal radiologist.
Photographic demonstration of patient and transducer positioning and corresponding sonographic examples were also
obtained.
Results: The posteriorly shifted, externally rotated (PSER) positioning allows clear RCI visualization, and good
delineation of the LHBT, SGHL, CHL, and adjacent support structures. Color or Power Doppler evaluation can be
performed in this area, to demonstrate presence of increased vascularity, that may be suggestive of inflammation.
Conclusion: Typical positioning for evaluation of the long head biceps tendon involves placing the arm in slight internal
rotation, with the elbow flexed to 90 degrees, and the hand fully supinated. In this position, the intra−articular portion of
the biceps and structures of the RCI tend to follow an oblique course away from the transducer, and can be difficult to
image.
By posteriorly shifting and slightly flexing the patient’s elbow, and then externally rotating the arm, while keeping the elbow
closely tucked against the side, the long head biceps tendon can be brought more anterior and lateral in position. This
posteriorly shifted, externally rotated (PER) positioning allows clearer RCI visualization, and better delineation of the
LHBT, SGHL, CHL, and adjacent support structures.
Sonographers and radiologists should be familiar with this technique to help with imaging this difficult area. Further study
is also warranted to investigate whether the PSER view is comparable or superior to other techniques for visualizing the
RCI.
165
ePoster #14
WITHDRAWN
ePoster #15
WITHDRAWN
ePoster #16
FEMORAL HEAD ANTEVERSION RELATIVE TO THE LINEA ASPERA : MEASUREMENTS OF NORMAL SUBJECTS
USING CT
Hyatt B., Brooke AMC, San Antonio, TX; Possley D., Hassan T., O'Brien S.
(Presented by: Seth O'Brien, MD)
Purpose: To define the anatomical relationship between the linea aspera and the neck of the femur in normal human
subjects. Knowledge of this angle will aid optimal positioning of proximal femur replacements and megaprostheses.
Materials and Methods: Axial images from CT scans of 35 consecutive patients (70 femora) from 2009−2011 were
independently retrospectively reviewed by 2 orthopedists and 1 fellowship trained radiologist. Examinations were
performed for other reasons usually for lower extremity angiographic purposes. Exclusion criteria were those with a
history or presence of femoral fracture or fixation. The midshaft angle between the linea aspera and the horizon was
measured using standard toolbar devices on a PACS system, as was the angle between the femoral neck and the
horizon. These angles were added to calculate the angle between the linea aspera and the femoral neck.
Results: Twenty−one patients (60%) were male. Twenty−four patients (68.6%) were over 50. The average angle between
the linea aspera and the femoral neck was 86.4° (standard deviation = 7.91). The average angle for males was 85.4°(7.7),
and for females 87.9° (8.1); p = 0.2. Patient age ranged from 21−92 years of age (mean 55.4); the average angle for
patients over 50 was 87.0 (8.1) and the average for patients under 50 was 85.1 (7.5). The angle for right femora was
87.9° (7.7) and for left femora 84.9° (7.9); p = 1.
Conclusion: The angle between the linea aspera and the femoral neck in healthy human patients is relatively uniform,
measuring 86.4°, with a standard deviation of 7.9. There was no significant difference in males compared to females or
right compared to left sides.
166
ePoster #17
ASSOCIATION OF PELVIC INCIDENCE WITH PINCER TYPE FEMOROACETABULAR IMPINGEMENT
Gililland J., University of Utah School of Medicine, Dept. Orthopedics, Salt Lake City, UT; Harris M., Anderson L.,
Hanrahan C.J., Anderson A., Peters C., West H.
(Presented by: Christopher Hanrahan, MD, PhD)
Background: Radiographic signs of acetabular retroversion have been shown to be affected by pelvic tilt and rotation.
Pelvic incidence (PI) is a growing concept in the spine literature and is a fixed radiographic measurement based upon
static pelvic geometry. It is intimately associated with the functional pelvic tilt needed to maintain overall sagittal balance.
We hypothesized that increased pelvic incidence would correlate with pincer type femoroacetabular impingement (FAI) as
these patients would have higher pelvic tilt to maintain sagittal balance and thus more functional acetabular retroversion.
Methods: We performed a retrospective radiographic review of 53 patients with FAI who had a pre−operative CT scan
and had undergone either open or arthroscopic surgery to address their impingement. Pelvic incidence, defined as the
angle between line orthogonal to the superior sacral endplate and the line connecting the center of the superior sacral
endplate body to the center of the hip axis (center of femoral heads), was measured on computed tomography (CT)
sagittal reconstructions. The patients were divided into two groups: 1) pincer or mixed, acetabular morphotype FAI, and 2)
pure cam, femoral morphotype FAI. The mean PI in each group was compared to each other and the overall FAI PI to
asymptomatic historical controls.
Results: Our groups were similar demographically, while age and gender were noted to be potential confounders. When
controlling for these potential confounders, we found similar mean pelvic incidence in the acetabular morphotype FAI
group compared to the femoral morphotype FAI group (46.1° vs. 40.5°, p=0.06). The overall PI in our entire FAI
population was similar to published asymptomatic controls from Vrtovec et al., (44.1°, SD 9° vs. 47.1°, SD 10°)(Spine
2012).
Conclusions: We found a possible trend toward increased pelvic incidence in hips with acetabular morphotype FAI
compared to pure femoral morphotype FAI. When compared to historical controls, the overall FAI population had similar
PI to published asymptomatic controls. These observations warrant further study into possible relationships between
pelvic incidence and femoroacetabular impingement.
167
ePoster #18
RADIOMICS OF SOFT TISSUE SARCOMA-COMPUTER-AIDED IMAGE ANALYSIS AND CHARACTERIZATION OF
TUMOR HETEROGENEITY
Raghavan M., Tampa, FL; Zhao M., Hall L.O., Goldgof D., Gatenby R.A.
(Presented by: Meera Raghavan )
Purpose: Apply computer−aided, spatially−explicit image analysis to MRI examinations of soft tissue sarcomas (STS) in
the extremities to quantify tumor heterogeneity and response to treatment.
Sarcomas are a heterogeneous group of mesenchymal−derived tumors comprising greater than 50 histological subtypes.
Each tumor is also typically heterogeneous containing regions of necrosis, calcification, and soft tissue. Multimodality
treatment of sarcomas often includes neoadjuvant chemotherapy and radiation. Assessment of tumor response to therapy
has mainly relied on changes in tumor size. However, tumor size alone may not accurately reflect changes in tumor
biology as responses may vary considerably within each subregion of tumor. In fact, heterogeneous response to therapy
is often seen in patients with the same tumor stage and among different sub regions within the same tumor. Thus,
treatment failure is critically influenced by tumor sub−regions that possess unfavorable functional and biological
properties, and it is crucial to identify those regions to optimize treatment. However, there is currently no available
technique to reproducibly identify, characterize and quantify these subregions. To address this, we have developed image
analysis techniques to extract quantified, mineable data from clinical imaging (termed “radiomics”) to non−invasively
characterize the biology and response to therapy STS.
Materials and Methods: Pathologically proven malignant extremity STS were identified through retrospective imaging
review. Case selection was based on tumor location in an extremity without osseous involvement and size greater than 5
cm. MRI sequences used included axial non fat suppressed T1, STIR/T2, and post gadolinium enhancement. A total of 11
cases were identified. Baseline and post treatment MRIs were reviewed. Slices most representative of the tumor were
identified across all three sequences and region of interest (ROI) drawn around the tumor as well as the area of
enhancement. Based on imaging criteria, patients response to treatment was evaluated and patient outcomes reviewed.
Utilizing fuzzy c−means clustering, a data clustering algorithm, the images were analyzed. Analysis was performed on the
entire cross section through the tumor as well as the areas of enhancement. Two−dimensional color maps were
generated from data points obtained from the clustering algorithm in three−dimensional space, based on pixel intensity
values.
Results: Our analysis found that distinct intratumoral subregions could be identified within all of the tumors although there
was considerable inter−tumoral variation in their relative abundance. Tumor response could be quantified as a change in
the percentage of each “habitat”in the cross sectional area of the tumor pre− and post−treatment.
Conclusions: Soft tissue sarcomas characteristically exhibit significant spatial heterogeneity but this is currently only
characterized subjectively. Sophisticated image analysis can define distinct sub−regions (“habitats”) within each tumor
based on combinations of imaging features from several MRI sequences and allows spatial variations within STS to be
assessed and quantified. Initial investigation indicates this technique provides novel data for assessing response to
therapy in malignant extremity STS. Characterization of tumor heterogeneity prior to initiation of treatment may have
important therapeutic and prognostic implications.
168
ePoster #19
MUSCULOSKELETAL TUMOR MIMICS-CASES ENCOUNTERED AT AN NCI-DESIGNATED CANCER CENTER
Raghavan M., Tampa, FL; Carter T.A.
(Presented by: Meera Raghavan )
Purpose: As musculoskeletal radiologists at a Cancer Center, it is of utmost importance that we are able to recognize
musculoskeletal neoplasms. However, it is also equally important that we are able to identify non−neoplastic conditions
based on imaging characteristics. The purpose of this project is to demonstrate several cases of tumor mimics referred to
our cancer center. The reader will become familiar with the key clinical and imaging characteristics of these commonly
encountered conditions. It is important for musculoskeletal radiologists to recognize these conditions, as the imaging
features can often be diagnostic, preventing unnecessary biopsy and associated risks and complications.
Material and Methods: Clinical history and imaging of cases presenting to our cancer center were reviewed at the time of
presentation and through multidisiplinary tumor board. In several cases, biopsy results were also reviewed.
Results: Cases in this series fell into one of several general categories. Post traumatic conditions such as myositis
ossificans, hematoma, and pseudoaneurysm are often encountered; less common is calcific myonecrosis. Atypical
presentation of arthropathies such as crystal deposition diseases are also commonly seen. Other conditions include
periprosthetic abnormalities and infection. For each case, clinical and imaging features, as well as differential diagnoses
are presented.
Conclusion: Tumor−like conditions of the musculoskeletal system are often encountered. Radiologists can play an
important role in mulitidisciplinary management of these patients by diagnosing these conditions through imaging, and in
many some cases, obviate unnecessary further workup including biopsy and/or surgical intervention.
ePoster #20
3 TESLA CHEMICAL SHIFT MR IMAGING: TECHNIQUE, CLINICAL UTILITY AND PITFALLS FOR IMAGING THE
SKELETON
Del Grande F., Johns Hopkins Hospital, Baltimore, MD; Vincenzo G., Flammang A., Fayad L.
(Presented by: Filippo Del Grande, MD, MBA)
Purpose: To review the technical considerations and important pitfalls of performingand interpreting chemical shift
imaging (with in−phase and opposed−phase gradient echo sequences) at 3T for the assessment of bone abnormalities.
The clinical utility of this sequence will be examined as it relates to the characterization of bone lesions.
Material and Methods: Retrospective review of several cases of in phase and out of phases imaging in bone marrow
lesions with qualitative and quantitative analysis.
Results: Technical considerations and protocol design for 3T imaging.
Clinical utility of chemical shift imaging with characterization of bone lesions:
−Differentiating pathologic from non−pathologic spine fractures
−Differentiating bone marrow infiltrative disorders and marrow replacement
−Specific pathologies amenable to evaluation by chemical shift imaging
3 Important pitfalls
−Impact of choice of time of Echo (TE) on results
−Technical acquisition errors at 3T (compared with 1.5T)
−Challenging lesions
Conclusions: Chemical shift imaging is a valuable technique for differentiating bone marrow replacement from non−bone
marrow replacement processes. However, at 3T, there are important technical factors which the radiologist must be aware
of to use chemical shift imaging correctly. In addition, the radiologist should be familiar with potential pitfalls to avoid
misleading reports.
169
ePoster #21
ANATOMIC AND FUNCTIONAL MR IMAGING OF PERIPHERAL NERVE TUMORS ANDTUMORLIKE CONDITIONS
Chhabra A., JHU
(Presented by: Avneesh Chhabra)
Purpose: To evaluate the role of 3T anatomic MR imaging and DTI in the characterization of peripheral nerve tumor and
tumorlike conditions.
Materials and Methods: Twenty−nine patients (13 men, 16 women; mean age, 41 years;
range, 11–83 years) with a nerve tumor or tumorlike condition (25 benign, 5 malignant) underwent 3T
MR imaging by using anatomic (n −29), functional diffusion, DWI (n − 21), and DTI (n − 24)
techniques. Images were evaluated for image quality (3−point scale), ADC of the lesion, tractography,
and fractional anisotropy (FA) of nerves with interobserver reliability in ADC and FA measurements.
Results: No significant differences were observed in age (benign, 40 +/− 18 versus malignant, 45 +/−19 years) and sex
(benign, male/female = 12/12 versus malignant, male/female = 3:2) (P > .05). All anatomic (29/29, 100%) MR imaging
studies received “good”quality; 20/21 (95%) DWI and 21/24 (79%) DTI studies received “good” quality. ADC of benign
lesions (1.848 +/− 0.40 x 10−3 mm2/s) differed from that of malignant lesions (0.900 +/− 0.25 x 10−3 mm2/s, P <.001)
with excellent interobserver reliability (ICC − 0.988 [95% CI, 0.976–0.994]). There were no FA or ADC differences
between men and women (P > .05). FA of involved nerves was lower than that in contralateral healthy nerves (P < .001)
with excellent interobserver reliability (ICC − 0.970 [95% CI, 0.946–0.991]). ADC on DTI and DWI was not statistically
different (P > .05), with excellent intermethod reliability (ICC − 0.943 [95% CI, 0.836–0.980]). Tractography differences
were observed in benign and malignant lesions.
Conclusions: 3T MR imaging and DTI are valuable methods for anatomic and functional evaluation of peripheral nerve
lesions with excellent interobserver reliability. While tractography and low FA provide insight into neural integrity, low
diffusivity values indicate malignancy in neural masses.
170
ePoster #22
FDA RECALLED ARTICULAR SURFACE HIP REPLACEMENT (ASR): REVIEW OF CLINICAL, RADIOLOGICAL AND
SURGICAL FINDINGS
Lin C.H., SUNY Stony Brook University Hospital, Stony Brook, NY; Huang M., Nicholson J., Gould E.S., Ragsdale M.,
Hoda S., Khan F.
(Presented by: Cheryl Lin, MD)
Purpose: FDA recalled metal−on−metal hip resurfacing arthroplasty (MoMHRA) is a popular alternative in younger
patients. In addition to the common complications, a unique entity called aseptic lymphocytic dominated vasculitis
associated lesions (ALVAL) has been described in MoMHRA. Increasing incidence of failures from complications has led
to FDA recalls on Depuy ASR since 2010. These recalls have subjected patients to closer surveillances. The purpose of
our study was to: 1) Describe imaging optimization parameters used for MR artifacts reduction. 2) Present a series of 17
cases of failed Depuy ASR from ALVAL with pre revision imaging, clinical symptoms, exams and lab results. 3) Assess
the impact of imaging on clinical management. 4) Correlate imaging findings with surgical and pathological findings.
Methods: Retrospective chart review was conducted on 15 patients with failed Depuy ASR (17 hips), all of whom
underwent acetabular revision from 1/2010 to 3/2012. Data includes demographic, physical exam, clinical
symptomatology, preoperative laboratory results, and age of the prosthesis at onset of symptoms and at time of revision.
Two attending MSK radiologists and one MSK radiology fellow reviewed 15 available hip MRI’s in conjunction with plain
films. Pathological correlation was made with operative reports and laboratory and imaging findings.
Results: The mean age of the prosthesis at time of revision is 3.5 years. All patients had groin pain of varying intensity;
with 2 patients reported pain only on exertion. 71% patients (n=12) had increased CRP levels and 76.5% patients (n=13)
had increased ESR levels. 88.2% of cases (n=15) had increased blood metal ion (cobalt and chromium) levels. One case
(5.9%) demonstrated gross acetabular osteolysis. 100% cases (n=15) had abnormal MRI findings, including
pseudocapsular or periprosthetic extracapsular collections with varying complexity. 80% (n=12) of these collections
demonstrated complex fluid with debris and 20% (n=3) showed simple fluid. All 17 cases were found to have moderate
yellowish turbid fluid (average 20 cc) with granular material at surgery. All 17 cases had pathological diagnosis of ALVAL
characterized by extensive soft tissue necrosis and a layer of macrophages parallel to the region of necrosis. All
intra−operative cultures were negative for infection.
Conclusions: The recognition and evaluation of MoMHRA is important to the radiologist and should, therefore, prompt
imaging correlation with clinical findings, laboratory data specifically including serum cobalt and chromium levels, and
orthopedic consultation.
171
ePoster #23
DIFFUSION TENSOR IMAGING OF THE SCIATIC NERVE AT 3 TESLA: NORMATIVE DIFFUSION VALUES
Chhabra A., JHU
(Presented by: Avneesh Chhabra)
Purpose: Diffusion tensor imaging (DTI) of peripheral nerves is becoming a reality, thereby opening new doors in
research and clinical work. Normative diffusion values such as fractional anisotropy (FA) and mean apparent diffusion
coefficient (ADC) should be available from subjects without symptoms of sciatic neuropathy before this technique can be
applied for the diagnosis of sciatica. The aims of this study were to determine normative diffusion values of the sciatic
nerves at 3T imaging, detect side−to−side differences, and assess interobserver variability in the measurements.
Method and Materials: In this HIPPA compliant study, 37 subjects without symptoms of sciatic neuropathy (18 females,
19 males; mean age 46, SD±13) were studied using a 3.0 T MR scanner (Verio, Trio, Siemens, Erlangen, Germany) and
a body matrix coil. DTI was performed using a single−shot echo planar imaging (EPI) sequence (TR/TE, 11300/ 77ms,
b−values−0, 800 and 1000s/mm2; 12 encoding directions). FA and ADC of the sciatic nerves on both sides were
determined in each subject by 2 trained observers with free hand drawn ROIs (at least 3 mm2 area) at two locations in
each nerve: at the level of greater sciatic notch, anterior to the piriformis muscle (point A); and outside the pelvis at the
level of the ischial spine, behind posterior column of the acetabulum (point B).
Results: The mean ADC values of the right sciatic nerve at points A and B were 1111.97±235.39 and 1172.17±207.95 x
10−3s/mm2, respectively. The respective FA values were 0.46±0.11 and 0.44±0.08. The mean ADC values of the left
sciatic nerve at points A and B were 619.39±109.55 and 1197.93±192.39 x 10−3s/mm2, respectively. The respective FA
values were 0.43±0.1 and 0.43±0.08. The only statistically significant side−to−side difference in all 4 values was in ADC
values at the right side point A (p <0.001). The inter−observer correlation as per intra−class correlation coefficient showed
substantial reliability (0.7−0.92 for ADC and 0.77−0.95 for FA).
Conclusion: Normative MR−diffusion tensor values of the sciatic nerves are different from those reported for upper
extremity nerves, such a s median nerves. For FA, there were no significant side−to−side differences and inter−observer
reliability was substantial.
172
ePoster #24
INTRANEURAL PERINEURIOMA: AN EDUCATIONAL REVIEW OF MR IMAGING FEATURES WITH PATHOLOGIC
CORRELATION
Miller T.L., Mayo Clinic, Howe B.M., Spinner R.J., Dyck P.B., Mauermann M.L., Felmlee J.P., Amrami K.K.
(Presented by: Troy Miller)
Purpose: To review the typical MR imaging features of intraneural perineurioma and correlate these features with the
histopathologic appearance. This educational review will focus on the imaging features of intraneural perineurioma and
how they differ from other peripheral nerve lesions on the differential diagnosis, including chronic inflammatory
demyelinating polyneuropathy, peripheral nerve sheath tumors, and infiltrating processes such as malignancy, lymphoma
and sarcoidosis.
Materials and Methods: Our database consists of 38 cases of pathologically proven intraneural perineurioma. Evaluation
included patient demographics, lesion size, lesion location, MR signal characteristics, and post−gadolinium enhancement
characteristics. Radiologic−pathologic correlation is used to illustrate the unique characteristics of intraneural
perineurioma which are best appreciated with high resolution 3T MRI.
Results: The typical MRI findings of intraneural perineurioma include fusiform nerve enlargement with T2−hyperintensity
and marked post−gadolinium enhancement. The intense enhancement helps distinguish perineurioma from other
hypertrophic neuropathies, such as chronic inflammatory demyelinating polyneuropathy.
Conclusion: Intraneural perineurioma is a rare disorder of the peripheral nervous system; however, knowledge of the MR
imaging features exists which should be recognized to differentiate it from more common etiologies such as non−specific
neuritis and chronic inflammatory demyelinating polyneuritis.
173
ePoster #25
MR IMAGING MANIFESTATIONS OF GOUT: A CRYSTAL CLEAR REVIEW
Makanji R.J., University of South Florida, Tampa, FL; Kedar R., Rao N., Anderson S., Prakash N.
(Presented by: Rikesh Makanji, MD)
Purpose: This presentation is mean to serve as an educational exhibit reviewing the following:
1. A brief discussion of the epidemiology, pathophysiology and clinical presentation of gout
2. A detailed review the MR imaging findings of gout with radiographic correlation when appropriate
3. A review of the differential diagnostic considerations with regards to MRI findings in gout
Materials and Methods: A total of 80 MRI studies performed on a high field 3 Tesla scanner in patients with a clinical
history of gout and associated pain were reviewed by 4 board certified radiologists. Case examples of various MR imaging
manifestations of gout were then selected to include in this educational review. These included a variety of findings in the
elbow, knee, ankle and foot and included examples of various types of tophi (soft tissue tophi, calcified tophi,
intraosseous, extra−articular and intra−articular tophi), erosions, synovitis, tenosynovitis, bursitis, and effusions.
Radiographic correlation to demonstrate calcified tophi were also obtained. A detailed literature review of gout was then
conducted to provide an up−to−date educational exhibit with both clinical and radiological relevance.
Results: The goals of this educational exhibit are sixfold. First we will provide a brief introduction of gout, discussing the
pathophysiology, epidemiology and clinical presentation. Next, a large portion of this presentation will be dedicated to
discussing the imaging manifestations of gout on MRI, with radiographic correlation when appropriate. Specifically, we will
discuss pertinent findings in the foot, ankle, knee and elbow with a focus on erosions, synovitis, tenosynovitis, bursitis,
and effusions. In addition, tophi characteristics including calcified versus soft tissue tophi and intra−articular versus
extra−articular versus intraosseous tophi will be reviewed. Imaging examples of each of these entities will be provided.
Fourth, we will briefly review differential diagnostic considerations of gout on MRI and provide hints for differentiating
those entities from gout. Fifth, we will discuss the utility of MRI in the management of patients with gout. Lastly, we hope
to summarize the exhibit with key take home points and provide a brief look at the future of imaging with respect to gout.
Conclusion: There were a variety of goals with educational exhibit as described above. However, the three major take
home points are as follows: Manifestations of gout on MRI include erosions, various types of tophi including calcified or
soft tissue predominant tophi and intra−articular, extra−articular or intraosseous predominant locations. Additional findings
include synovitis, tenosynovitis, bursitis and effusions. Second, while the 1st metatarsophalangeal joint is the most
commonly involved site for gout, many other joints may manifest gout related abnormalities on MRI including the ankle,
knee, and elbow. Third, differential diagnostic considerations include (among many other entities) rheumatoid arthritis,
pseudogout, psoriatic arthritis and septic arthritis. MRI can be helpful in differentiating these entities from gout.
174
ePoster #26
MR IMAGING MANIFESTATIONS IN RHEUMATOID ARTHRITIS: AN EDUCATIONAL REVIEW
Makanji, R.J., University of South Florida, Tampa, FL; Kedar R., Anderson S., Prakash N., Rao N.
(Presented by: Rikesh Makanji, MD)
Purpose: This presentation is meant to serve as an educational exhibit addressing the following:
1. A brief discussion of the epidemiology, pathophysiology and clinical presentation of rheumatoid arthritis
2. Common and uncommon imaging manifestations of rheumatoid arthritis on MRI with radiographic correlation when
appropriate
3. Differential diagnostic considerations with regards to the MRI findings in rheumatoid arthritis
Materials and Methods: A total of 53 MRI studies in patients with a clinical history of rheumatoid arthritis were reviewed
by 3 board certified radiologists. Relevant case examples demonstrating the various MR imaging manifestations of
rheumatoid arthritis were then selected to include in this educational review. These include a variety of findings in the
spine, shoulder, elbow, wrist, hand, knee, ankle and foot. Specifically we provide examples of erosions, pannus/synovitis,
marrow edema, rice bodies, tenosynovitis, bursitis and effusions. An in−depth literature review of rheumatoid arthritis was
conducted to provide an up−to−date educational exhibit with both clinical and radiological relevance.
Results: The goals of the educational exhibit are as follows: First we will provide a brief review of the epidemiology,
pathophysiology, and clinical presentation of rheumatoid arthritis. Next, a large portion of this presentation will be
dedicated to discussing the imaging manifestations of rheumatoid arthritis on MRI. Specifically, we will provide examples
of pertinent findings in the spine, shoulder, elbow, wrist, hand, knee, ankle, and foot concentrating on erosions,
pannus/synovitis, marrow edema, rice bodies, tenosynovitis, bursitis and effusions. Third, we will briefly review differential
diagnostic considerations of rheumatoid arthritis on MRI and provide tips for differentiating those entities from rheumatoid
arthritis. Fourth, we will discuss the utility of MRI in the management of patients with rheumatoid arthritis. Lastly, a
summary of the exhibit with key take home points will be provided in addition to a brief look at the future of imaging with
respect to rheumatoid arthritis.
Conclusion: Rheumatoid arthritis is a disease involving many different joints beyond the hands and wrists and
manifesting in many different ways beyond erosions. In this educational review we demonstrate MRI manifestations of
disease in the spine, shoulder, elbow, wrist, hand, knee, ankle, and foot with case examples of erosions,
pannus/synovitis, marrow edema, rice bodies, tenosynovitis, bursitis and effusions. We also demonstrate the clinical utility
of MRI regarding the management of patients with rheumatoid arthritis. Differential diagnostic considerations of MRI
findings are also reviewed and include many inflammatory and non−inflammatory arthritides, most notably psoriatic
arthritis, systemic lupus erythematosus and erosive osteoarthritis, among many other entities.
175
ePoster #27
RARE AND COMMON OSSICLES OF THE LOWER EXTREMITY: IMAGING MANIFESTATIONS AND CLINICAL
IMPLICATIONS
Makanji R.J., University of South Florida, Tampa, FL; Rao N.
(Presented by: Rikesh Makanji, MD)
Purpose: Review the imaging findings and clinical relevance for a variety of ossicles of the lower extremity, beginning in
the hip and ending in the foot.
Materials and Methods: Hundreds of radiologic studies were reviewed at our institution in order to find the most
radiologically interesting examples of each ossicle. A thorough review of the literature was also performed in order to
provide a current and detailed analysis of the radiographic and clinical relevance of each ossicle.
This educational exhibit has three primary goals:
1. Educate the reader regarding the imaging manifestations of common and uncommon accessory ossicles of the lower
extremity.
2. Review the pathophysiology which results in symptoms from these various ossicles.
3. Review the clinical relevance of the various ossicles with regards to common symptomatic presentations and patient
management.
Result: In all cases we address imaging findings of each ossicle in addition to clinically pertinent issues. Radiographic
appearance is discussed with CT, MRI and/or tomosynthesis correlation when available.
Entities unique to each ossicle are addressed as follows:
Os Acetabuli: Link with femoral acetabular impingement and associated pathophysiology
Os Fabella: Clinical aspects of fabella syndrome. Discuss relationship with the posterolateral corner structures,
specifically the fabellofibular ligament and arcuate ligament
Meniscal Ossicle: Differential diagnostic considerations and how to differentiate this ossicle from them.
Cyamella: Discuss imaging manifestations, differential diagnostic considerations and symptomatic presentation and
management.
Os Peroneum: Review painful os peroneum syndrome and resultant pathology within the peroneal longus tendon and
tendon sheath. Review clinical relevance of os perineum, specifically as a source of lateral plantar pain.
Os Trigonum: Association with posterior ankle impingement syndrome.
Os Naviculare: Review the 3 different types of os naviculare and association with posterior tibial tendon pathology.
Os Intermetatarseum: Review painful os intermetatarseum which may represent a rare cause of dorsal mid foot pain.
Deep peroneal nerve neuropathy as a result of impingement is also addressed.
Os Vesalianum Pedis: Potential pitfalls in misdiagnosing this os as an avulsion fracture and how to differentiate fracture
from os vesalianum pedis. Review differential diagnostic considerations including normal ossification center and Iselin's
disease.
Os Subfibulare: Discuss possible etiologies of this rare os (congenital variant versus post traumatic).
Os Subtibiale: Discuss how to avoid misdiagnosing this rare os as an avulsion fracture.
Os Supratalare: Discuss imaging findings and incidence of this rare os.
Os Supranaviculare: Review possible link between this os and navicular stress fractures as well as etiologies for such an
association.
Conclusion: Accessory ossicles are generally considered to represent normal anatomic variants. However they may
result in symptoms by a variety of different pathophysiologic mechanisms. In this exhibit we have reviewed the imaging
manifestations and clinical relevance for a variety of ossicles of the lower extremity. These include common entities such
as the os acetabuli, fabella, os peroneum, os trigonum and os naviculare to rarer entities such as the meniscal ossicle, os
intermetatarseum, os vesalianum pedis, os subfibulare, os subtibiale, os supratalare, os supranaviculare. An exceedingly
rare ossicle known as the cyamella is also discussed.
176
ePoster #28
CORRELATION OF CT GUIDED SPINE BIOPSY AND BLOOD CULTURE RESULTS IN PATIENTS WITH
SUSPECTED SPONDYLODISKITIS
Larrison M., Birmingham, AL; Hamrick K., Frazier M.
(Presented by: Matthew Larrison, MD)
Purpose: The purpose of this project is to determine which patients are likely to benefit from CT guided spine biopsy by
correlating the biopsy and blood culture results in patients with suspected spondylodiskitis.
Material and Methods: Patients who had undergone both CT Guided Biopsy for suspected spondylodiskitis and had
blood cultures within 2 days were studied, retrospectively. A total of 26 patients were selected (14 female, 12 male, age
range 38−85.) The electronic medical records of the selected patients were reviewed for biopsy results as well as blood
and biopsy culture data.
Results: 17 of the 26 patients had negative blood cultures, of which 1 had a positive biopsy culture. Among the 9 patients
that had positive blood cultures, 6 had positive biopsy cultures. This data showed that blood culture demonstrated a
sensitivity of 85.71 (p = 0.1250), specificity of 84.21(p = 0.0044), Positive Predictive Value of 66.67 (p = 0.5078) and
Negative Predictive Value of 94.12 (p = 0.0003) for the prediction of biopsy culture results.
Conclusion: The results suggest that a negative blood culture result is very likely to yield a negative biopsy culture.
Therefore, in patients with negative blood culture results, biopsy may not be warranted and that more conservative
treatment could be pursued prior to biopsy.
ePoster #29
AC JOINT: AN OFTEN OVERLOOKED SOURCE OF SHOULDER DISABILITY AND PAIN
Tagoylo G., Ha A.S., Petscavage J.M.
(Presented by: Gino Tagoylo, MD)
Background Information and Purpose: The acromioclavicular (AC) joint is important functionally for full range of
movement at the shoulder. Trauma, degenerative and inflammatory arthritis, congenital variants, and abnormal bone
contour can alter biomechanics and result in patient pain and disability. Radiologists have an important role in diagnosing
these sources on imaging studies, providing therapeutic injections, and recognizing expected and abnormal appearances
of surgical management of the AC joint. The purpose of this exhibit is to provide a review of normal, pathological, and
post−surgical imaging of the AC joint and an update of recent advances in surgical techniques.
Educational Goals and Teaching Points: Review the normal and variant anatomy of the AC joint, illustrate the normal
imaging appearance, detail the radiological diagnosis of traumatic, mechanical, and arthritic disorders of the joint, review
image guided treatment options, explain physiology of surgical methods, and provide imaging examples of
treatment−related complications. Key anatomic or pathophysiologic issues, imaging findings or imaging technique
Normal anatomy of the AC joint, including meniscus, ligaments, capsule, and osseous structure will be reviewed in
illustrations, radiographs, and cross−sectional images. Pathological conditions shown will include os acromiale syndrome,
AC joint separation, psoriatic arthritis, degenerative arthritis, type 1−4 acromion contour, subscapularis impingement, and
fracture. Fixation methods shown will include the newer techniques of tightrope and bioabsorbable biotenodesis screws.
Fluoroscopic and ultrasound guided techniques for therapeutic injection will be demonstrated.
Conclusion: The AC joint is a common source of pain and disability around the shoulder. Knowledge of normal anatomy
and imaging appearance, pathological conditions affecting the joint, and treatment options is vital to providing a
meaningful radiological contribution.
177
ePoster #30
SAVING FORM AND FUNCTION: THE RADIOGRAPHIC APPEARANCE OF LIMB SALVAGE AND TUMOR
SURGERY
Britton C.A., University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania;, Chu E.
(Presented by: Cynthia Britton, MD)
Purpose: 1. To review the most common as well as unusual limb salvage techniques used in the resection of aggressive
bone tumors.
2. To demonstrate the expected post operative radiographic appearance of extremities after resection of benign and
malignant tumors.
Material and Methods: Orthopedic oncologic cases from a large tertiary care academic hospital from the last 10 years
were retrospectively reviewed. Twelve cases were selected for presentation. Selection of each case was performed to
provide examples of common as well as unusual surgical approaches to benign and malignant skeletal tumors.
Results: Benign and malignant bone tumors requiring resection and limb salvage will be briefly discussed. Modern limb
salvage surgical techniques will be explained. Examples of common as well as unusual limb salvage surgical techniques
and tumor resection from a database of an orthopedic oncologic group at a major academic medical center for the past 10
years will be displayed. This includes rotationplasty, saddle prosthesis and combined allograft and modular posthesis
techniques.
Conclusion: Limb salvage surgery is commonly used in orthopedic oncology to maintain form and function of the
diseased limb while preserving the patient's quality of life. Understanding the types of surgical resection, the general
approach of orthopedic procedures to benign and malignant tumors, and the expected post operative appearance of
extremities after tumor resection is essential to evaluate for adequate resection of tumor and to rule out potential post
operative complications.
ePoster #31
EVALUATION OF OSTEOARTICULAR ALLOGRAFTS: WHAT THE RADIOLOGIST NEEDS TO KNOW
Graves H.F., Vanderbilt University Medical Center, Nashville, TN; Hartley K.G.
(Presented by: Houston Graves, MD, JD)
Purpose: To provide a case based, multimodality, pictorial review of osteoarticular allografts, their expected normal
appearance, and common complications.
Materials and Methods: Two musculoskeletal radiologists retrospectively reviewed the available imaging from a
maintained database of orthopaedic oncology patients who received osteoarticular allograft (OAA) reconstructions to
identify cases that illustrate normal post−operative appearance, normal incorporation of the graft, and common
complications including graft−host bone non−union, graft fracture, early osteoarthritis, and tumor recurrence. We note the
functional outcomes of the patient in each case and use illustrative examples in anatomic locations less well described in
the literature.
Conclusion: Although the appropriateness of OAA reconstruction varies depending on anatomic location, osteoarticular
allografts remain a treatment option for those undergoing limb salvage surgery. Musculoskeletal radiologists who see
oncology patients will encounter these grafts and should be familiar with expected outcomes and common complications.
178
ePoster #32
ANALYSIS OF ISCHIAL SPINE ORIENTATION IN PATIENTS WITH PUDENDAL COMPRESSION NEUROPATHY – A
STUDY USING 3D COMPUTED TOMOGRAPHY
Chen L., Marvel R.P., Richard H.M.
(Presented by: Lina Chen)
Purpose: The pudendal nerve is a predominately sensory nerve arising from S2−4 nerve roots. Pudendal neuralgia is a
compression neuropathy similar to carpal tunnel syndrome. The nerve has three branches, the inferior rectal, peroneal
and dorsal nerve of the penis/clitoris. The first branch innervates the skin around the anus. The second branch has a deep
motor portion and two sensory portions, the medial and lateral labial (scrotal) branches. The third branch runs along the
skin of the penis/clitoris, innervating the overlying skin. Pudendal neuralgia can present with pain in the distribution of
some or all of these branches. There are several potential sites of entrapment along the course of the nerve. One critical
zone of compression is adjacent to the ischial spine and sacrotuberous ligament.
We hypothesize that variation of bony anatomy of the ischial spine may predispose patients to pudendal nerve
compression. The goal of this study was to identify reliable measurement of ischial spine orientation using 3D computed
tomography (CT) that may help differentiate patients with pudendal neuralgia from control patients without neurological
symptoms.
Materials and Methods: CT scan of the bony pelvis in 32 female patients were retrospectively reviewed, including 16
patients who were diagnosed with pudendal nerve compression syndrome and underwent pudendal nerve block aged
22−78 (mean 54.3+/−15) and 16 patients who presented with trauma and no documented neurologic symptoms aged
22−94 (mean 64+/−19). The majority of patients who presented to the pain clinic with pudendal neuralgia were adult
female patients. Diagnostic criteria were: pain in the anatomic distribution of the pudendal nerve, pain worsened with
sitting and relieved by lying down, and no sensory loss on physical examination. Exclusion criteria include patients with
alternative etiologies of pain such as pure coccygeal, gluteal or hypogastric pain, diffuse pelvic pathology such as Paget
disease and metabolic bone disease, pelvic fracture, extensive calcification or ossification of the soft tissue and presence
of hardware.
Using TeraRecon 3D CT application (Foster City, CA), axial oblique CT image at the level of the tip of the bilateral ischial
spine and mid symphysis pubis was obtained. Nine methods of measurements were assessed bilaterally (total 18
measurements for each patient). Measurements were performed by one musculoskeletal radiologist with five years of
subspecialty experience. Each measurement was performed twice separated by at least one week. Student’ s T−test
(SPSS, IBM, Armonk, New York) was used to compare the diference in measurement between the two groups, and
Mann−Whitney test was used to assess intra−observer variability.
Results: Of the nine CT measurements, the difference of the angle between the ischial spine and inner pelvic wall was
found to be statistically significant between the control group and neuralgia patients. Right side: p=0.000, neuralgia group
(126+/−4.8) and control group (135+/−4.9). Left side: p= 0.001, neuralgia group (126+/−2.4), and control group
(134+/−5.4). Intra−observer variability was not significantly different.
Conclusion: Assessment of the orientation of ischial spine using 3D CT may help identify patients at risk of developing
pudendal compression neuropathy.
179
ePoster #33
TRICEPS INJURIES – ALL YOU WANTED TO KNOW!
Kumaravel M., UT Health; Proett J.
(Presented by: Manickam Kumaravel, MD, FRCR)
Purpose and Aim: Exhibit aims to
1. Detail the anatomy of the triceps, including complex trilaminar attachment and illustrate the various slips of the medial,
lateral and long head of the tendon.
2. Discuss imaging modalities to identify the triceps, including ultrasound , plain radiography and MRI
3. Elucidate various cases of triceps injury, including traumatic partial, full thickness tears, avulsion injuries and
non−traumatic causes.
4. Review treatment methods and post operative imaging evaluation for the various triceps conditions.
Content Organization:
1. Gross anatomy images of triceps components
2. Ultrasound anatomy and detailed MRI anatomy of the triceps
3. Illustrated plain radiography and MRI examples of various pathology – including infectious, traumatic (including
associates avulsion fractures) and non− traumatic (including neoplastic) conditions of the triceps.
4. Comprehensive treatment methods for triceps pathology.
Educational Objectives: On studying the exhibit the reviewer will be able to
1. Understand the anatomy of the triceps in detail
2. Recommend optimal imaging studies to evaluate the triceps
3. Have a detailed knowledge of the various pathologies involving the triceps and treatment protocols.
4. Be familiar with post−operative appearance of the triceps injuries.
ePoster #34
PREMATURE LUMBAR DISC DEGENERATION - IS MINOR ENDPLATE LENGTH DISCREPANCY A PREDICTOR?
Weatherall P.T., University of Texas Southwestern Medical Center, Dallas, TX; Graziano V.
(Presented by: Paul Weatherall, MD)
Purpose: We sought to determine whether small differences in the length of vertebral body endplates occurring at the
same disc level, correlate with premature disc degeneration. This feature is common, but subtle, as it usually occurs only
near midline posteriorly and thus is not readily apparent on non−sagittal images.
Materials and Methods: We evaluated the L4−5 and L5−S1 disc levels of 108 consecutive adult patients (216 lumbar
discs) under the age of 36, presenting for an MRI exam at a single imaging center. All patients (64 females / 44 males
18−35 years, median = 29) had a history of non−malignant low−back symptoms, with each exam performed on 1.5T or 3T
magnets. Standardized 4mm sagittal T2−weighted images were acquired with in−plane resolution of <0.7mm and
magnified prior to subsequent measurement. The anteroposterior length of L4−5 and L5−S1 discs and corresponding
vertebral endplates were carefully measured at midline. End−Plate length Discrepancy (EPD) at individual disc−levels
were recorded and correlated with presence or absence of disc pathology at that level. Discs were classified as abnormal
if there was either definite dehydration (subjective assessment = at least moderate/unequivocal T2 signal decrease) or a
bulging pattern beyond the endplates greater than 2mm. A disc pathology grading system was also used, assigning a
point for each degree of disc desiccation (0−3) and posterior disc bulging (categories = 0mm, 1−3mm, 4−6mm, >6mm).
Results: In this young patient group, minor EPD was fairly common when assessing the midline segment. In this lower
lumbosacral zone, greater than 2mm EPD was detected at 35 disc−levels (16%). Within this group, all but one (97%) had
evidence of disc disease at that level (the only exception being an 18yo with 3mm EPD). At disc−levels where EPD was
2mm or less, only 29% had abnormal discs. Using our limited disc assessment grading system, there was a very strong
correlation between disc pathology and >2mm EPD (p−value >0.000004 using student T−Test).
Conclusions: 1. In young adults, there is a very strong correlation between disc degeneration and the relatively small
discrepancy of adjacent vertebral endplate lengths at midline.
2. Although unproven in our current research, it is likely that disc degeneration accelerates when it loses >2mm of
adjacent endplate mechanical support, in combination with loading and motion stresses at this site.
3. Recognition that mild vertebral body midline endplate length discrepancies likely predict premature disc degeneration,
may allow patients and healthcare providers to improve prevention or treatment decisions.
180
ePoster #35
EVALUATION OF FOREFOOT PAIN: A PICTORIAL REVIEW
Yadavalli S., Beaumont Health System, Royal Oak, MI; Jain R.K.
(Presented by: Sailaja Yadavalli, MD, PhD)
Introduction: The forefoot is commonly evaluated for pain, especially in the region of the metatarsophalangeal joints.
Causes of forefoot pain may relate to infectious or inflammatory processes, trauma, soft tissue masses and rarely
neoplasms. When radiographs are negative, ultrasound is increasingly becoming the first line imaging choice. However,
magnetic resonance imaging (MRI) continues to be the imaging modality of choice that provides exquisite soft tissue and
osseous detail, allowing for a specific diagnosis to be made in many cases.
Goals and Objectives: 1. To review normal anatomy of the forefoot, with special attention to the metatarsophalangeal
joints
2. Familiarize the viewer with commonly seen disease processes and disorders in the forefoot causing pain and
discomfort in the region
3. Discuss causes of forefoot pain based on location, morphology of lesions and relationship to adjacent anatomic
structures
4. Review MRI signal characteristics and enhancement patterns of some commonly seen disorders in the forefoot
5. Where appropriate ultrasound imaging features will also be presented
Conclusion: Disorders of the forefoot are a common source of pain that result in imaging evaluation. Therefore it is not
only important for the radiologist to be familiar with some of the common causes but also with the imaging features of
these lesions.
ePoster #36
HIGH RESOLUTION MR IMAGING OF ELBOW ANATOMY, VARIANTS, AND COMMON PATHOLOGIES REVISITED
Smith C.M., UTHSCSA, San Antonio, TX; Loredo R.A., Bean G., Garcia G., Humphrey J.
(Presented by: Crysela Smith, MD)
Purpose: To describe basic MR imaging parameters and techniques for optimal evaluation of elbow anatomy, variants
and pathologic conditions.
Materials and Methods: An asymptomatic normal volunteer’s elbow was imaged on the 3T MRI using an 8−channel high
resolution knee coil. MR images were obtained with standard sequencing, using a 9 −10 cm field of view. The normal
anatomy of the elbow was evaluated and images of pertinent anatomy and variant development were selected for
demonstration. Patients with known common elbow pathologies who had been evaluated on 3T and 1.5 T magnets were
retrospectively reviewed, and the important diagnostic findings were assessed, documented, and compared with the
normal anatomic MR images for presentation.
Results: High resolution MR images result in detailed anatomy of the fine ligamentous, myotendinous, neural, and
capsular/bursal structures of the elbow with anatomic precision.
Conclusion: Knowledge of image optimization for delineating normal anatomy, variants and the appearance of common
pathologies is crucial in preventing diagnostic pitfalls.
181
ePoster #37
FEMOROACETABULAR IMPINGEMENT (FAI): A NEW TECHNIQUE TO IDENTIFY IMPINGEMENT MORPHOLOGY
Pandey T., UAMS, Little Rock, AR; Guidry C., Alapati S., Medarametla S., Ram R., Lensing S.Y., Jambhekar K.
(Presented by: Carey Guidry, MD)
Aim: To demonstrate utility of a novel MRI measurement technique in identification of femoral head neck offset and
Femoroacetabular Impingement (FAI).
Background: The conventional alpha angle measurement technique helps in identification of anterior femoral head−neck
junction bony abnormality. But the methodology is flawed towards identification of femoral head−neck offset. Hence most
cases of FAI are not detected accurately.
Hypothesis: We hypothesize that measurement of the femoral head neck offset using a novel technique increases
accuracy in detection of FAI.
Specific Aim: 1. Study agreement of conventional alpha angle and novel technique in detection of FAI.
2. Study the inter−observer variation between conventional alpha angle and novel measurement techniques.
Materials and Methods:
1. Study Group: Retrospective review of patients with hip MRI scans performed in our institution over the past 5 years.
a. Non FAI group: No Clinical, Radiographic and/or MRI sign of FAI. No labral or cartilage abnormality.
b. FAI group: Clinical, Radiographic and/or MRI signs of FAI (regardless of alpha angle). Morphological signs, labral
and/or cartilage changes compatible with FAI.
2. Inclusion & Exclusion Criteria: Scans from all patients with oblique axial and/or 3D axial MRI images of the hip joint
were included. Patients with severe degenerative arthritis, patients with avascular necrosis leading to remodeling of the
femoral head, pelvic deformity or suboptimal MR images were excluded.
3. Imaging: MRI scans and plain radiographs of the pelvis were reviewed.
4. Evaluation: Resident, MSK Fellow and MSK radiologist reviewed scans independently and were blinded to one another
and study groups. Clinical data was collected from review of medical records after Imaging review.
Results: Based on Clinical/MRI/Radiographic evidence (gold standard), 25 of 37 patients had FAI. The agreement
statistics between the novel MRI and conventional MRI technique is as follows:
a. Novel MRI Technique: Sensitivity 25/31 (81%), Specificity 6/6 (100%), Positive Predictive Value 25/25 (100%),
Negative Predictive Value 6/12 (50%) and Accuracy 31/37 (84%).
b. Conventional MRI Technique: Sensitivity 8/8 (100%), Specificity 12/29 (41%), Positive Predictive Value 8/25 (32%),
Negative Predictive Value 12/12 (100%) and Accuracy 20/37 (54%).
The novel and conventional methods disagreed in 23 of 37 cases where the novel technique detected an abnormality and
conventional did not. Overall, the proportion of subjects with abnormalities differed significantly between the two
approaches (p<0.001). The modified method detected abnormalities in 31/37 (84%) and the conventional in 8/37 (22%).
Additionally, the Kappa statistics significantly differed; the kappa statistic for modified vs. gold standard was 0.57 and the
kappa statistic for conventional vs. gold standard was 0.23 (p=0.043). The inter−observer agreement was good.
Conclusion: The novel measurement technique designed to measure femoral head neck offset increases the accuracy
and specificity in detecting FAI on MRI.
182
ePoster #38
ULTRASOUND GUIDED POPLITEAL CYST ASPIRATION, SYMPTOM RELIEF AND CLINICAL OUTCOME
Gomez A.M., UCLA Medical Center, Los Angeles, CA; Seeger L.I., Levine B.D., Manzoul S., Motamedi K.
(Presented by: Ana Gomez, MD)
Purpose: To investigate the clinical outcome and utility of ultrasound guided popliteal (Baker) cyst aspiration.
Materials and Methods: We retrospectively reviewed the medical records of 25 patients who underwent ultrasound
guided popliteal cyst aspiration over a 32 month period and referred to our service by both sports medicine and/or
orthopedic specialists. The records were reviewed for patients demographics, cyst size, fluid volume aspirated, needle
used and cytology evaluation. Presence of osteoarthritis and clinical follow−up was documented if available.
Results: There were 4 males and 21 females with a mean age of 56 years (range 30 – 92). The cyst size raged form 1.1
x 0.6 x 1.1 cm to 9.4 x 2.5 x 2 cm. The average volume of the popliteal cysts aspirated was 7.1 cc with a mean of 11.4 cc
of fluid aspirated. Fluid was sent to pathology for analysis in 22 patients, fluid in the remaining 3 patients was discarded.
All aspirations were performed with 18 gauge needles. All fluid sent for cytology analysis was found to be consistent with
synovial fluid with occasional inflammatory components and without malignant cells. Of the 25 patients 13 (52%)
demonstrated some degree of osteoarthritis; 11 had documented clinical follow−up and of these 7 (63%) had clinical
improvement following aspiration. The remaining 14 patients had no documented clinical follow up notes or failed to follow
up with the referring clinician. Those with symptom relief had cysts of varying sizes and relief did not correlate with cyst
size.
Conclusions: Ultrasound guided popliteal cyst aspiration may result in symptom relief and can be used as a diagnostic
tool to located patients’ source of symptoms. However, symptom relief does not seem to correlate with the size of the
popliteal cyst and/or presence of osteoarthritis.
ePoster #39
WHERE DO WE STAND? EVALUATING RADIATION EXPOSURE TO OPERATORS DURING CT FLUOROSCOPY
Gabel C., University of Rochester School of Medicine and Dentistry; Kheyfits V., Dieudonne G., Paeth T., Jeremenko
N.T., Monu J.U.
(Presented by: Christopher Gabel, MD)
Background and Objectives: Radiologists are called upon more frequently to perform imaging guided procedures and
CT fluoroscopy has gradually replaced conventional CT in many institutions for the performance of imaging guided
procedures. The result is increased risk and exposure to ionizing radiation from the CT scanners to the operators. The
purpose of this study is to determine the average radiation dose exposure to the operator at various locations in the CT
suite during a procedure and thence determine the optimal operator position during fluoroscopic exposure.
Materials and Methods: Radiation dosimeters were placed in a 16 slice CT fluoroscopy suite −1.beside the gantry, 2.
end of CT table, 3−4. in front of, and 5. behind the gantry. Typical CT fluoroscopy exposures were performed on
phantoms and readings obtained concomitantly from the dosimeters at each of the locations. Several readings were
obtained and the average radiation dose for each location was determined. Measurements were obtained at the same
locations with the dosimeter in front of and behind a mobile lead shield,
Results: The typical parameter for CT fluoroscopy is a kV of 120 and an mAs of 30. The highest radiation exposure
occurred in front of and to the right of the gantry with an exposure of 65mR/hr in front of and 0.29mR/hr behind the lead
shield. The lowest dose rate, 0.20 mR/hr, was adjacent to and in line with the CT gantry. The dose rates at other locations
in the room, even at the foot of the CT table which is approximately 6 feet from the gantry, were significantly higher,
ranging from 45 to 50 mR/hr.
Standing in line with the gantry yielded a dose rate reduction of 99.6% to 99.7%. Only a 25% dose reduction, from 0.20
mR/hr to 0.15 mR/hr, was seen without and with the mobile shield adjacent to the gantry.
Conclusions: Where we stand in the CT room during CT guided procedures significantly affect our radiation exposure..
Dose rate reductions are realized when using the mobile lead shield, however, this is cumbersome when trying to work
around the shield when it is placed between the operator and patient whereas just standing beside and in line with the
gantry yielded a dose rate reduction of 99.6% to 99.7%. Given these factors, adjacent to and in line with the gantry is the
preferred standing location during CT fluoroscopic exposure for CT guided procedures.
183
ePoster #40
LOW DOSE CT PANOREX IMAGING - REPLACING PANOREX FILMS WITH CT IMAGING IN A TERTIARY CARE
CENTER
Moorthy M.K., University of Rochester School of Medicine and Dentistry; Dieudonne G., Mis F., Kheyfits V., Monu J.U.,
Waldman D.
(Presented by: Meena Moorthy, MD, MBA)
Background: Conventional X−Ray Panorex Imaging for either dental or maxilla−facial purposes is widely used and
prevalent given its relative (practice based) availability, and low−cost; however, the ubiquity of CT, its multiplanar
reformation capabilities and latest software enhancement including curved reformations and MIP as well as increased
attention to low dose imaging, make use of CT quite appealing. Further more, CT allows for imaging of patients that are
too weak or otherwise unable to cooperate with the “erect”X−Ray Panorex examination. MIP imaging provides for a
familiar image to the clinicians used to standard Panorex X−Ray, with the added advantage that the acquired raw data
can be used for further problem solving. The relatively higher radiation exposure to various organs especially the thyroid
gland from CT is a major deterrent to its use in this fashion. The purpose of our study is to determine optimal parameters
using low dose required to obtain optimal images of the mandible and to determine the radiation exposure to the thyroid
gland.
Materials and Methods: A Phantom and lightly embalmed cadaver was used for this study. The phantom was scanned
using current standard Maxillo−facial protocol, (i.e. standard axial plane) and also in an oblique axial plane.
Following this, an instadose badge was “surgically”placed in the thyroid bed in the cadaver. Images and thyroid radiation
measurements were obtained employing progressively decreasing kVp and mA. MIP images were generated from each
CT scanning parameter used and were assessed for diagnostic quality such that 1= excellent, 2=good, 3=fair;
4=non−diagnostic quality by 4 board certified musculoskeletal radiologists.
Results: Twelve readings ranging from a kVp 120 and mAs 280 to kVp 80 and mAs 150 were obtained with shallow
radiation dose of 32.79 mGy – 5.72 mGy with the phantom. The thyroid equivalent dose was determined with a dosimeter
in the phantom and scanning with decreasing parameters from kVp/mAs of 120/280 – 100/180. The exposure rates
ranged from 459 – 161 mRem. The procedure was then repeated in a cadaver with the dosimeter embedded in the
thyroid bed. The thyroid exposure at kVp 120, mAs 280 was 1303 mRem and at kVp 100, mAs 150 the dose was 319
mRem. At lower doses the images suffered considerable loss of detail and were considered non diagnostic.
Conclusion: Diagnostic images of the mandible displayed in a panoramic format can be obtained using considerable
dose reduction techniques. This affords the multi−trauma or otherwise incapacitated patient the convenience and
advantages of one stop radiographic evaluation. There are the added advantages of real estate costs reduction in a busy
radiology department and the savings from non−duplication of equipment. This will contribute to reduction of imaging and
ultimately health care costs.
Disclosure: The cadaver used for this study was noted to be edentulous. Additional readings with cadavers with
appropriate dentition are proposed and the findings will be presented.
184
ePoster #41
THE LINE METHOD, A NEW TECHNIQUE TO MEASURE GLENOID BONE LOSS USING 3D RECONSTRUCTIONS
Rios A., NYU Langone Medical Center; Bloom M., Babb J., Beltran L., Gyftopoulos S.
(Presented by: Alyssa Rios)
Purpose: To test the accuracy of a new method of quantifying glenoid bone loss (GBL) based on the glenoid length and
gender
Materials and Methods: The imaging data from one shoulder from 75 consecutive patients undergoing CT−chest studies
were post−processed into 3D−reconstructions. Each glenoid 3D−reconstruction was reviewed for deficiency of its anterior
margin, which could represent prior impaction/instability. Ten reconstructions were excluded because of questionable
flattening/defect along their anterior margins.
The remainder of the 65 3D reconstructions (28 males/37 females; mean age 61.7 yrs/range 18−89) were then reviewed.
The glenoid length was measured with a line beginning at the superior glenoid tubercle that extended inferiorly to the
inferior margin of the glenoid, centered in the AP dimension. A best−fit circle was then drawn along the inferior glenoid. A
horizontal line was drawn through the center of the circle, perpendicular to the longitudinal line, representing the glenoid
width. Linear regression was used to construct a model to predict width using either length alone or length in combination
with age and/or gender. The association of width and age was characterized using a Pearson correlation.
A retrospective review of 7 consecutive patients (3 males/4 females; mean age 30/range 24−55) who underwent
preoperative CT/3CT or MRI/3DMR examinations and had the amount of GBL measured during arthroscopy (OR) was
conducted. The GBL was estimated using two techniques by one musculoskeletal radiologist. The initial measurements
were made using a regression model that incorporated the length of the glenoid and patient gender to predict the
estimated width (EW) of the intact glenoid. The glenoid defect was then estimated by subtracting the width of the remnant
glenoid (RG) from the EW, which was then divided by the EW to produce % of GBL [(EW−RG)/(EW)= %GBL] (aka the
line method).
A second set of measurements was made 7 days later by the same reader using the circle method. The two sets of data
were compared to the OR−measurements using paired sample t−tests.
Results: There was a statistically significant (p<0.0001), strong correlation (r=0.88) between glenoid length and width on
the intact glenoids. There was an additive effect in predicting glenoid width when considering gender in addition to length,
with females tending to have smaller widths then males. Patient age did not have a significant additive effect. The
regression equations that led to the highest probability of accurately predicting glenoid width were:
width=7.02+(0.591*length) for men; width=4.9+(0.591*length) for women (difference reflects difference in average size of
the glenoid between men/women).
Compared to the OR measurements, the average difference for the circle method technique for GBL quantification was
1.79±1.35%, and 2.79±3.51% for the line method without significant difference between the two (p=0.474). There was no
significant difference when comparing either set of measurements to those conducted during arthroscopy (circle/p=0.939,
line/p=0.262).
Conclusion: Glenoid bone loss can be accurately estimated using an equation that incorporates the glenoid length and
gender, the line method. There was no significant difference between the measurements obtained using this technique
and the current gold standard, the circle method.
185
ePoster #42
COMPLICATIONS OF ARTHROSCOPIC FEMORAL ACETABULAR IMPINGEMENT SURGERY: RADIOGRAPHIC
FINDINGS AND CLINICAL CORRELATIONS
Mortensen W.M., University of Utah School of Medicine; Hanrahan C.J., Crim J.R.
(Presented by: Wayne Mortensen, MD)
Purpose: To illustrate complications of arthroscopic treatment of femoral acetabular impingement (FAI) and associated
radiographic findings.
Materials and Methods: A two year retrospective review of cases of FAI treated arthroscopically was performed by three
musculoskeletal radiologists. Patients who had persistent pain or radiographic abnormalities after surgery were identified
and their clinical and imaging findings (radiographs, CT and MRI) were reviewed.
Results: Complications of arthroscopic FAI surgery include instability, hip dislocation, rapid progression of osteoarthritis,
stress fracture, heterotopic ossification, detachment of the rectus femoris tendon and failure of symptom relief. Failure of
symptom relief was associated with osteoarthritis, pain during activities of daily living, and pain at rest prior to surgery.
Conclusion: The radiologist has an important role in the diagnosis of postsurgical complications and can assist the
surgeon in early detection. Knowledge of the potential complications of arthroscopic surgery and their often subtle
radiologic manifestations can help identify complications early and improve patient outcomes.
ePoster #43
ASSOCIATION OF NON-WEIGHT BEARING MEDIAL FEMORAL CONDYLE EDEMA WITH ACUTE ACL TEAR
Eaton J., University of Colorado, Aurora, CO; Petersen B.
(Presented by: James Eaton, MD)
Purpose: MRI is highly sensitive for the detection of marrow edema from both traumatic and non−traumatic causes. The
marrow edema pattern resulting from multiple complex knee injuries has been extensively studied and reported. ACL
tears often occur related to a pivot−shift mechanism that results in valgus angulation and external tibial rotation. This
injury is commonly associated with a well documented “kissing contusion”pattern of edema within the anterior lateral
femoral condyle and posterior lateral tibial plateau. However, the presence of marrow edema within the non−weight
bearing medial femoral condyle has only seldom been reported and the mechanistic cause of the injury pattern has not
been postulated. The purpose of our study was to determine the prevalence of marrow edema within the non−weight
bearing medial femoral condyle in patients with acute ACL disruption and to offer a biomechanical explanation for the
finding.
Method and Materials: A retrospective review of the MRI examinations of all patients who sustained an acute ACL tear
over a 5 year period was performed to evaluate for the presence of edema within the medial femoral condyle and for
evidence of injury to the deep or superficial fibers of the MCL. Additional areas of marrow edema and any associated
internal derangement were also recorded. The medical record was reviewed to elucidate the mechanism of injury.
Results: Initial data demonstrates marrow edema in the non weight−bearing portion of the medial femoral condyle in 85
of 182 (47%) acute ACL tears. Injury to the deep MCL fibers (meniscofemoral or posterior oblique ligaments), or their
attachment, was seen in 75 of 85 (88%) of patients with this MFC edema pattern. 63 of 85 (74%) of patients also suffered
injury to the superficial MCL fibers. Mechanisms of injury included pivot, twisting, valgus forces, and hyperextension.
Conclusion: The biomechanical properties of the deep MCL fibers predispose it to injury at a lower stess than the more
superficial fibers. Bone marrow edema in the non−weight bearing medial femoral condyle may occur as a result of the
traction stress on the deep MCL fibers during the pivot shift injury in 47% of acute ACL injuries.
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ePoster #44
IMAGING REVIEW OF OSTEOCHONDRITIS DISSECANS AND IRREGULAR OSSIFICATION OF THE FEMORAL
CONDYLE: IS REEVALUATION OF THE CURRENT GRADING SYSTEM NEEDED?
Byra P., University of South Florida, Tampa, FL; Rao N.
(Presented by: Paul Byra, MD)
Purpose: To determine the incidence and review the imaging findings and grading of osteochondral abnormalities,
including osteochondritis dissecans (OCD) and irregular epiphyseal ossification, in the pediatric population.
Materials and Methods: Retrospective review by a musculoskeletal radiologist and musculoskeletal radiology fellow of
686 knee MRIs in patients 20 years of age or younger who presented with knee pain. MRIs were evaluated for the
presence of OCD and irregular ossification of the femoral condyle. PubMed review of the literature regarding OCD and
irregular ossification of the femoral condyle was performed.
Results: The incidence of OCD was 4.5% (n=31). The patient population consisted of 22 males and 9 females. The mean
and median age was 15. Incidence of OCD involving the posterior femoral condyle is 1% (n=7) with slight predominance
of the medial femoral condyle (n=4). Incidence of irregular ossification of the femoral condyle was 0.2% (n=2). Both cases
were in 9 year old males. There were four controversial cases which had the appearance of OCD however, the overlying
cartilage was normal. Literature review of irregular ossification of the femoral condyle and the MRI grading system of OCD
resulted in some controversy. The most referenced grading system is according to an article by Bohndorf, published in
1998, before the advent of 3.0 Tesla magnets and the widespread use of MRI in the pediatric population for imaging of
OCD. The current grading system does not account for lesions in which there is intrinsic signal abnormality within the
otherwise intact cartilage. Irregular ossification and grade 1 OCD lesions both demonstrate irregularity in subchondral
bone with intact overlying cartilage.
Conclusion: OCD is not uncommon in the pediatric patient population presenting with knee pain. Irregular ossification of
the femoral condyle has also been reported in the literature to be common. Reported features of irregular epiphyseal
ossification include lack of adjacent marrow edema and location at the posterior femoral condyle. With the advent of 3.0
Tesla magnets, detailed evaluation of cartilage has improved and slight signal abnormality can better be appreciated.
Controversy exists in the erroneous diagnosis of irregular ossification of the posterior femoral condyle with reactive edema
instead of a true grade 1 OCD. The clinical significance is the impact on patient lifestyle as grade 1 OCD is treated with
activity restriction and irregular ossification is not clinically significant. Modification of the current MRI grading system may
reduce confusion. We suggest dividing grade 1 lesions into normal overlying cartilage (grade 1a) and intact but
heterogeneous cartilage signal (grade 1b).
ePoster #45
MRI OF INFRAPATELLAR PLICA INJURY WITH SURGICAL AND CLINICAL CORRELATION
Javery O., Brigham and Women's Hospital/Harvard Medical School, Boston, MA; Pandey S., Han R., Gaviola G.C.
(Presented by: Omar Javery, MD)
Purpose: To evaluate the imaging characteristics of injury to the infrapatellar plica, the prevalence of injury amongst our
patient population, and the potential clinical and surgical correlate for imaging findings.
Materials and Methods: A total of 21,509 consecutive knee MRIs were retrospectively reviewed from 2004 to 2011. A
keyword search for the terms “infrapatellar plica”and/or “ligamentum mucosum”was performed to identify an overall
reporting prevalence, which was subsequently subdivided into normal and abnormal. For patients with reported
abnormalities of the infrapatellar plica and/or ligamentum mucosum, the medical record was reviewed to determine
correlative or associated surgical findings and clinical course. We are currently extending our analysis through the end of
2012, which will be completed in early 2013.
Results: Overall, the term “infrapatellar plica”and/or “ligamentum mucosum”was reported in 56 of 21,509 (0.26%) knee
MRI reports. Of these, 34 (60.7%) were reported as abnormal, while 22 (39.3%) were reported as normal. Fifteen of 34
abnormal cases had arthroscopic correlates, 5 of which made specific mention to plica abnormalities and 10 of which had
no mention of plica, though other internal abnormalities were described. Nineteen of 34 patients underwent no surgery
and were managed clinically in various ways.
Conclusion: Our preliminary results suggest that injury to the infrapatellar plica may be an under−recognized and
under−reported cause of knee pain, whether isolated or in association with other internal injuries. Increased awareness of
this entity by both radiologists and orthopedic surgeons may allow for better clinical and arthroscopic correlation for
imaging findings. Prospective trials are necessary to further evaluate true prevalence and clinical importance.
Retrospective data collection of our patient population is ongoing.
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ePoster #46
WINDSWEPT APPEARANCE: A NEW SIGN TO DESCRIBE SUBSCAPULARIS TENDON TEARS
Ismail A., Univ of Iowa, Iowa City, IA; Bennett D.L.
(Presented by: D. Bennett, MD, MA)
Purpose: Previously reported sensitivities and specificities for subscapularis tendon tears are low. We are conducting this
study to describe a new sign (wind swept appearance) to help more accurately diagnose subscapularis tears.
Materials and Methods: Consecutive shoulder MRIs (1.5 T) performed over a 2 year period were retrospectively
reviewed (396) for the windswept appearance of the subscapularis tendon by two observers that were blind to the clinical
history, surgical reports and original MRI report. Exclusion criteria included; 1)studies from external facilities, 2)MR
arthrograms, 3)shoulder MRIs obtained for indications other than evaluation of the rotator cuff; 4)no surgical correlation
present; and 5)patients with prior surgery. The medical records of the non−excluded 211 patients were reviewed and MRI
findings by the reviewers were correlated to the surgical reports (open and arthroscopic).
Results: 69 patients underwent surgery; 21 had subscapularis tendon tears (10 full−thicknesses (FT), 12
partial−thicknesses (PT). 12/69 had the MRI windswept−sign (10 FT tears, 2 PT tears, and 0 no tear). In 9 of the PT tears,
the wind swept−sign was not present on MRI. The calculated sensitivity of the windswept−sign for subscapularis tears (FT
and PT) was 57% with a specificity of 100%. For only FT tears, the sign was 100% sensitive and 97% specific; it was 18%
sensitive and 83% specific for PT tears
Conclusion: The windswept appearance is highly sensitive and specific for complete subscapularis tendon tears. This
windswept−sign of the subscapularis tendon will help improve diagnosis of complete subscapularis tears and aid
management of these patients (previously reported sensitivities of other signs for combined FT and PT tears are around
35% and for FT tears only is around 69%).
ePoster #47
WITHDRAWN
ePoster #48
THE ACL ON MRI AXIAL OBLIQUE IMAGING: NORMAL ANATOMY AND MIMICS OF PATHOLOGY
Stedman D., The University of Texas Health Science Center at San Antonio, TX; Bean G.W., Loredo R., Garcia G.
(Presented by: Deborah Stedman, MD)
Purpose: To describe the normal anatomic features of the anterior cruciate ligament (ACL) and its relationship to other
key structures of the knee in the axial oblique plane. To describe potential mimics of ACL pathology and the advantages
of using the axial oblique plane to avoid these pitfalls.
Materials and Methods: Retrospective analysis of MR images of the knee acquired in the oblique axial plane will be
performed. Images will be acquired on either a 1.5 or 3 T magnet using a T2−weighted without fat suppression sequence.
A detailed description of the anatomic appearance of the ACL will include length, width, morphology, and signal intensity.
Potential mimickers of partial thickness ACL tear include degeneration, fluid signal intensity between the anteromedial and
posterolateral bands, and ganglion cyst formation. Examples of these entities will be provided and their appearance on
the axial oblique plane will be discussed.
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ePoster #49
THE “BALTIMORE BUBBLE” REVISITED: HIP NITROGEN AS A FINDING OF RECENT DISLOCATION
Duffy E.J., Penn State Hershey Medical Center, Hershey, PA;, Petscavage J.M., Walker E.A., Bernard S.A., Brian P.M.,
Flemming D.J., Mosher T.J.
(Presented by: Eric Duffy, MD)
Purpose: To re−examine the positive predictive value of the finding of nitrogen in the hip joint of an acute trauma patient
as an indicator of recent hip dislocation and evaluate the effect of thin section axial CT imaging and the broad availability
of multiplanar reconstructions upon its reliability.
Materials and Methods: The pelvic CT examinations of 60 patients with pelvic trauma were retrospectively reviewed.
The examinations included 36 hip dislocations in 35 patients that were compared with 25 patients with pelvic fracture
without hip dislocation either documented or clinically or radiographically suspected. Nitrogen bubbles were defined as
areas of visual low attenuation on lung windows equivalent to extracorporeal air. Patient demographics, mechanisms of
injury, time from injury to imaging, fracture/diastasis patterns and soft tissue injury as well as intra−articular versus
extraarticular air and the imaging plane it was visible on were recorded.
Results: The patients without dislocation were 68% male:32% female with a mean age of 46.3 years (range 14−81years)
and those with dislocation were 77%male:23% female with a mean age of 40.8 years (range 18−82 years). Motor vehicle
accident was a cause of injury in 59% of the non dislocation pelvic trauma patients and 71% of those with dislocations.
Intra−articular nitrogen bubbles occurred in 78% of the hips with documented dislocation. The bubble was equally visible
on axial, sagittal and coronal images. Of dislocations lacking bubbles, 3 had a greater than 4 hour delay from injury to
time of CT, 2 were anterior dislocations, 1 was an inferior dislocation, 1 was a superior dislocation, and only one was a
posterior dislocation without a delay in imaging. Of the posterior dislocations without a delay in imaging, 96%
demonstrated nitrogen bubbles. No intra−articular nitrogen bubbles were seen on pelvic trauma CTs in the absence of
prior dislocation.
Conclusion: Intra−articular nitrogen bubbles are specific indicators of recent posterior hip dislocation when identified on
trauma CT examinations within 4 hours of injury. The sensitivity is less when dislocations occur in other than a posterior
direction.
ePoster #50
IMAGING OF THE ELITE ATHLETE: BEYOND THE UCL
Cordle A., Cleveland Clinic, Hanano A., Hatem S.
(Presented by: Andrew Cordle MD, PhD)
Purpose: A review of sports−related elbow injuries with an emphasis on high performance athletes will be presented. The
focus will be on complex and less well described injury patterns providing a comprehensive understanding of
sports−related elbow pathologies. While injuries to the ulnar collateral ligament will be included the primary purpose will
be to elucidate more complicated injuries of the elite athlete.
Materials and Methods: Cases from our teaching files and clinical practice, including 3 professional sports teams,
numerous collegiate programs, and an international referral base will be utilized for this educational exhibit.
Results: The range of valgus extension overload injuries in the overhand athlete (e.g., ulnohumeral osteochondral
injuries, olecranon stress fractures, ulnar collateral ligament injuries) will be reviewed. Emphasis will be placed on the
spectrum of injuries from acute to chronic with additional review of postoperative findings. Additionally, non−throwing
injuries (e.g., elbow dislocation, tendon injuries) will be presented.
Conclusion: There is wide variation in experience and comfort in interpreting elbow imaging studies, which is further
magnified in the elite athlete. While imaging finding of ulnar collateral ligament injuries have been well described, this
presentation will provide a more sophisticated understanding of the elbow injury patterns seen in high performance
athletes.
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ePoster #51
ADVANCED IMAGING OF GOUT AND CALCIUM CRYSTAL DEPOSITION DISEASES
Ibrahim G.F., Cleveland Clinic Foundation, Cleveland, Ohio; Schils J., Hatem S.
(Presented by: Gehan Ibrahim, MD)
Purpose: To describe the imaging appearance of gout and calcium crystal deposition diseases with emphasis on
advanced imaging modalities.
Materials and Methods: Advanced imaging studies of gout and calcium crystal deposition diseases from our teaching
files and ongoing rheumatology conference series are presented. Cases will illustrate both the role of advanced imaging in
known or suspected crystal arthropathy, as well as their diagnosis when presenting as a clinical mimic.
Results: The radiographic findings of gout and calcium crystal deposition diseases are well known but the appearance on
other advanced imaging modalities is less well described. We present a review of these advanced imaging findings
including magnetic resonance imaging, computed tomography, dual energy computed tomography, and high resolution
ultrasound. Cases will illustrate findings of crystal arthropathies that may not be radiographically apparent (calcific
tendinitis, capsulitis, tenosynovitis, etc.) and where imaging clarifies a confounding clinical presentation (suspected
neoplasm, septic arthritis, etc.).
Conclusion: Gout and calcium crystal deposition diseases are common entities that may present a diagnostic challenge
both clinically and upon imaging. Knowledge of findings with advanced imaging techniques can aid diagnosis both in
suspected and unsuspected cases.
ePoster #52
WITHDRAWN
ePoster #53
CHOPART TO LISFRANC AND EVERYTHING IN BETWEEN, A REVIEW OF MIDFOOT TRAUMA
Saade J.Y., Cleveland Clinic, Cleveland, OH; Hatem S.
(Presented by: Jimmy Saade MD)
Purpose: Educational review poster of midfoot trauma.
Materials: Educational review poster of midfoot trauma including radiographs, CT and MRI.
Results: In this educational poster, we review midfoot trauma. The poster begins with review of anatomy, defining the
midfoot using radiographs, computed tomography and magnetic resonance imaging. There is an emphasis on the
spectrum of Lisfranc injuries, due to the difficulty of diagnosis, clinical significance, and medical−legal implications.
Additional midfoot fractures, dislocations and anatomic variants will be reviewed, e.g. navicular, cuboid, and cuneiform
fractures, bipartite medial cuneiform, and Chopart dislocations. We use radiographs, computed tomography, and
magnetic resonance imaging to review these injuries, including findings, mechanisms, classifications, and associated
findings.
Conclusion: Educational review of midfoot trauma
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ePoster #54
UPDATE ON GADOLINIUM CONTRAST FOR MUSCULOSKELETAL IMAGERS
Hochman M.G., Beth Israel Deaconess Medical Center; Wei J.L.
(Presented by: Mary Hochman, MD, MBA)
Purpose: Recent concerns regarding the safety of gadolinium contrast agents, together with the development of new
contrast agents, have led to changes in the spectrum of gadolinium contrast agents in common clinical use at many
institutions. Musculoskeletal imagers must be familiar with the safe use of existing contrast agents and should understand
the potential implications of newly introduced contrast agents. The goal of this presentation it to review the current data
regarding many of the currently available gadolinium contrast agents, their imaging characteristics and their associated
safety concerns, particularly as they relate to musculoskeletal imaging.
Material and Methods: Recent literature regarding gadolinium contrast agents and the risk of nephrogenic systemic
fibrosis (NSF) with various formulations was reviewed. Additional patient safety concerns and recommend guidelines were
reviewed. Physiochemical characteristics of gadolinium agents in common current use were also reviewed.
Results: The results of the review outlined above will be presented. Guidelines regarding use of gadolinium in the setting
of renal failure, pregnancy, and breast−feeding will be presented. Data on the potential interaction of gadolinium with
articular cartilage will also be presented.
Conclusion: Musculoskeletal imagers oversee MRI studies using intravenous and intra−articular gadolinium contrast
agents and should be familiar with the safety profile, management guidelines, and imaging characteristics of the different
contrast agents they may encounter.
ePoster #55
WITHDRAWN
ePoster #56
BONE WINDOWS FOR DISTINGUISHING MALIGNANT FROM BENIGN PRIMARY BONE TUMORS ON FDG PET/CT
Costelloe C.M., University of Texas MD Anderson Cancer Center; Chuang H.H., Chasen B.A., Pan T., Fox P.S., Bassett
R.L., Madewell J.E.
(Presented by: Colleen Costelloe, MD)
Purpose: The default window setting on PET/CT workstations is soft tissue. This study investigates whether bone
windowing and hybrid FDG PET/CT can help differentiate between malignant and benign primary bone tumors.
Materials and Methods: Database review included 98 patients with malignant (n=64) or benign primary bone (n=34)
tumors. Reference standard was biopsy for malignancies and biopsy or >1 year imaging follow−up of benign tumors.
Three radiologists and/or nuclear medicine physicians blinded to diagnosis and other imaging viewed the lesions on CT
with bone windows (CT−BW) without and then with PET (PET/CT−BW), and separate PET−only images for malignancy or
benignity. Three weeks later the tumors were viewed on CT with soft tissue windows (CT−STW) without and then with
PET (PET/CT−STW).
Results: Mean sensitivity and specificity for identifying malignancies included: CT−BW: 96%, 90%; CT−STW: 90%, 90%;
PET/CT−BW: 95%, 85%, PET/CT−STW: 95%, 86% and PET−only: 96%, 75% respectively. CT-BW demonstrated higher
specificity than PET-only and PET/CT-BW (p=0.0005 and p=0.0103, respectively) and trended toward higher sensitivity
than CT-STW (p=0.0759). PET/CT-STW trended toward higher specificity than PET-only (p=0.0859) and higher sensitivity
than CT-STW (p=0.0662). Malignant primary bone tumors were more avid than benign lesions overall (p<0.0001) but the
avidity of benign aggressive lesions (giant cell tumors and Langerhans Cell Histiocytosis) trended higher than the
malignancies (p=0.08).
Conclusion: Bone windows provide high specificity for the identification of primary bone tumors and are recommended
when viewing FDG PET/CT.
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ePoster #57
IS THERE AN ASSOCIATION BETWEEN PSOAS ATROPHY AND PRIOR HIP SURGERY IN PATIENTS WITH
RECURRENT GROIN PAIN?
Hobbs G.P., Thomas Jefferson University Hospital, Philadelphia, PA; Zoga A.C., Meyers W.C., Chi A., Horner M.,
Morrison W.B.
(Presented by: George Hobbs, MD)
Purpose: To explore the possibility of an association between the presence of isolated, ipsilateral psoas muscle atrophy
and prior hip surgery or arthroscopy in patients presenting with recurrent or persistent hip/groin pain.
Materials and Methods: A database of patients with groin or hip pain referred for MRI by an athletic pubalgia
subspecialist was queried for those with a history of prior hip surgery. A total of 109 subjects were identified.
Demographics, surgical history, type of MR, and situs of pain were recorded. Two Society of Skeletal Radiology members
independently reviewed the MR exams retrospectively for the following: presence and degree of psoas muscle atrophy
(graded as mild for intramuscular signal abnormality only, moderate for <50% volume loss, and severe for >50% loss),
atrophy within other pelvic muscle groups, athletic pubalgia lesions, visible femoral osteotomy, and other regional
muscle/tendon injuries. In addition, a control group comprised of 135 subjects with MR for groin pain but no history of hip
surgery was also reviewed.
Results: In the study group, 24/109(22%) subjects had isolated, ipsilateral psoas atrophy with reader consensus,
whereas the control group demonstrated only 5/135(4%) with asymmetric psoas atrophy (p<0.001). Of the 24 study group
subjects with psoas atrophy, 19 (79%) were graded as moderate or severe. A small subset of patients with psoas atrophy
had an earlier MR prior to hip surgery, and all (9/9) had normal and symmetric muscle bulk on preoperative imaging. The
mean interval between hip surgery and MR imaging in study subjects with atrophy was 18.9 months. The majority (88%)
of these subjects had hip arthroscopy, while 2 had total hip replacement, and 1 had hip resurfacing. A small number
(33%) reported at least two hip arthroscopies and one reported ipsilateral psoas release. 61% of the arthroscopy subjects
had a femoral osteotomy. Other surgeries in the psoas atrophy group included spigelian repair(1), inguinal
herniorrhaphy(3), caesarian section(1) and pelvic floor (pubalgia) repair(4).
Conclusion: We have observed a significant incidence of isolated, ipsilateral psoas muscle atrophy at MR in a subset of
patients with recurrent or persistent hip/groin pain after prior hip surgery or arthroscopy. The cause and significance of this
anecdotal observation will require further investigation; however, it is possible that psoas atrophy is somehow related to
the hip surgery and may be a source of recurrent pain. While further investigation is needed, MR protocols for suspected
internal derangement of the hip should include adequate "large field of view" imaging to assess for ipsilateral psoas
muscle atrophy.
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ePoster #58
ULTRASOUND VERSUS CT-GUIDED MUSCULOSKELETAL SOFT TISSUE MASS BIOPSY: A COMPARATIVE
EFFECTIVENESS ANALYSIS
Hanson J.A., University of Wisconsin, Madison, WI; Lee K.S., Peterson A.
(Presented by: James Hanson, MD)
Purpose: The high diagnostic yield for both US and CT−guided biopsy of musculoskeletal soft tissue (ST) masses has
been well established. However, choosing which modality to use should take into account differences in biopsy location,
procedure time, cost, and radiation exposure.
Methods: IRB approval was obtained and informed consent waived for this retrospective study of 84 consecutive
musculoskeletal ST biopsies performed at a university−based hospital between August 2004 and July 2012. Student
t−test was used to determine if differences in demographic data, biopsy location, procedure time, pathologic positivity, and
need for additional diagnostic procedures were statistically significant between US− and CT−guidance groups. P < 0.05
was the criterion for statistical significance. A secondary analysis was performed to measure the additional attributable
risk of malignancy from CT radiation on a population level versus US, which was reported as “willingness to pay.”
Results: 84 musculoskeletal ST masses were biopsied in 84 patients (45 women, 37 men; mean age 55 years; age range
13−82). (54/84)64% of patients underwent US−guided biopsy and (30/84)36% of patients underwent CT−guided biopsy.
Patients with lower extremity masses were more likely to undergo US−guided biopsy (p<0.0001) while pelvis masses
were more likely to undergo CT−guided biopsy (p<0.0001). There were no other differences in biopsy site. Procedure time
averaged 27 minutes for US and 38 minutes for CT (p<0.01). Demographic data and malignancy rate were similar
between groups. There was no difference in rate of pathology positivity (p=0.38) or need for additional diagnostic
procedures (p=0.34). Total charges for US− and CT−guided biopsy were $1896 and $2688, respectively. CT−guidance
would need to be 8% better than US if one were willing to pay $10,000 to avoid one non−diagnostic pathology result, but
only 0.4% better if the willingness to pay was $200,000. The number of patients needed to cause one excess malignancy
with CT−guidance is 47,619 patients. Assuming a willingness to pay $50,000 to prevent one excess malignancy (given
CT− and US−guided biopsy are equally accurate), it would be reasonable to pay an extra $1.05 per biopsy to use US
instead of CT.
Conclusion: When factors such as procedure time, radiation exposure and cost are included in the decision making for
US versus CT−guided soft tissue biopsy, US may be the preferred modality depending on location.
ePoster #59
WHY DO BONE CONTUSIONS MATTER?
Beaman F.D., University of Kentucky; Barker C.H., Montgomery J.R., Spicer P.J., Blomquist, G.A.
(Presented by: Francesca Beaman, MD)
Background Information: The knee is a complex joint and frequently injured joint, thus representing a significant portion
of a musculoskeletal imaging practice. Magnetic resonance is the primary modality for evaluating soft tissue injuries and
marrow abnormalities and is exquisitely sensitive in depicting them. On MR, bone marrow edema has been characterized
as a region of low T1−weighted signal intensity with corresponding intermediate to high T2−weighted signal intensity.
Bone contusions (bone bruises) are visible areas of marrow edema that result from direct bone−on−bone, or an external
impact upon a bone. The bone contusion pattern not only reflects the mechanism of trauma sustained, but also provides
clues to the most likely soft tissue injuries.
Educational Goals/Teaching Points: After review of this education exhibit, the learner will be able to:
1. Recognize common bone contusion patterns.
2. Describe the mechanisms of injury that yield specific bone contusion patterns.
3. Identify the key soft tissue injuries.
Key Imaging Findings/Techniques: This exhibit presents a pictorial review of acute knee sports injury and trauma on
radiography, CT and MRI. Illustrations will aid in the understanding of traumatic mechanisms. Classic injury patterns such
as pivot shift, transient lateral patellar dislocation, dashboard, clipping and hyperextension injuries will be discussed, with
emphasis on associations between key soft tissue and osseous abnormalities.
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ePoster #60
VANISHING FEMORAL NECK: A MYSTERIOUS PROCESS
Blain Paré E., University of Montreal Hospital Center, Montreal, QC, Canada; Ehlinger M., Dosch J., Moser T.
(Presented by: Etienne Blain Paré, MD, CM, FRCPC, dABR)
Objective: To describe the radiologic appearance and clinical correlates of cases of osteolysis of the femoral neck in an
attempt to further understanding about this uncommon pathology
Material and Methods: 2 musculoskeletal radiologists and a musculoskeletal radiology fellow retrospectively reviewed 9
cases of osteolysis of the femoral neck. Radiologics studies were reviewed by consensus, including: radiographs (n=19),
CT (n=4), MRI (n=1) and bone scintigraphy (n=2). Formal pathological evaluations were available for 2 cases.
Results: Osteolysis of the femoral neck was found in six females and three males ranging in age from 53 to 78 years
(average, 67.6 years; median, 68 years). All patients presented with complaints of hip pain, 3 of which had acute
symptoms, while the rest had progressive symptoms and impairment. All but one cases were found to have bone
deposition in adjacent hip muscles. Bone scintigraphy showed mild uptake. MRI and CT confirmed bone deposition in
adjacent tissues and true osteolysis of the femoral neck with relative sparing of the articular surfaces.
Conclusion: Osteolysis of the femoral neck is a poorly understood and seldom reported pathological process, frequently
occurring in patient with underlying comorbidities. More research is needed, but we suspect an underlying fracture
associated with micromotion and synovitis to be closely associated. Potential differential etiologies would include
post−traumatic, crystal arthropathies and infection.
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Musculoskeletal Ultrasound Workshop:
Shoulder
Monday, March 18, 2013
1:00 p.m. – 3:00 p.m.
Location: Bandera
Co-Moderators/Organizers: Jon A. Jacobson, MD, Yoav Morag, MD
Instructors: Meg Chiavaras, MD, PHD, Joseph Craig, MB, ChB, Gina DiPrimio, MD,
David Fessell, MD, Katrina Glazebrook, MB, ChB, Kenneth Lee, MD, Suzanne Long, MD,
Jonathan Luchs, MD, Mihra Taljanovic, MD, Corrie Yablon, MD
Ultrasound Workshop: Shoulder
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Musculoskeletal Ultrasound Workshop: Shoulder
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Musculoskeletal Ultrasound Workshop: Shoulder
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Musculoskeletal Ultrasound Workshop: Shoulder
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Musculoskeletal Ultrasound Workshop: Shoulder
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Musculoskeletal Ultrasound Workshop: Shoulder
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Musculoskeletal Ultrasound Workshop: Shoulder
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